Preliminary Calculation of 2020 Ambulance Inflation Update

Section 1834(l)(3)(B) of the Social Security Act mandates that the Medicare Ambulance Fee Schedule be updated each year to reflect inflation. This update is referred to as the “Ambulance Inflation Factor” or “AIF”. The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Starting in calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi-factor productivity index (MFP). The MFP reduction may result in a negative AIF for any calendar year. The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule. For the 12-month period ending in June 2019, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased by 1.65%. CMS has yet to release its estimate for the MFP in calendar year 2020. However, assuming CMS’ projections for the MFP are similar to last year’s projections, the number is likely to be in the 0.6% range. Accordingly, the AAA is currently projecting...

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New SNF Consolidated Billing Edits: FAQs

On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that it stated would better identify ground ambulance transports that were furnished in connection with an outpatient hospital service that would be bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime. Unfortunately, the implementation of these new edits has been anything but seamless. Over the past few weeks, I have received numerous phone calls, texts, and emails from AAA members reporting an increase in the number of Medicare claims being denied for SNF Consolidated Billing. This FAQ will try to explain why you may be seeing these denials.  I will also try to provide some practical solutions that can: (1) reduce the number of claims denied by the edits and (2) help you collect from the SNFs, when necessary. Please note that, at the present time, there is no perfect solution to this issue, i.e., there is nothing that you can do to completely eliminate these claim denials.  The solutions discussed herein are intended only to minimize the disruption to your operations caused by these denials.   I am new to Medicare ambulance billing. Can you explain what the SNF Consolidated Billing...

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ET3 Model Application Portal Now Open

Emergency Triage, Treatment and Transport (ET3) Model Application Portal is Now Open! On August 5, 2019, the Center for Medicare and Medicaid Innovation (CMMI) announced that it had opened its Request for Application (RFA) Online Portal. The Online Portal can be found on the ET3 Model website. The Online Portal can also be accessed directly by clicking here. As a reminder, CMMI will be hosting a webinar about the Online Portal on Thursday, August 8, 2019.  This webinar will take place from 12:00 p.m. to 1:30 p.m. EDT. If you are interested in participating in this webinar, you can register by clicking here....

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CMMI Releases Preview of ET3 RFA

On May 22, 2019, the Center for Medicare and Medicaid Innovation (CMMI) released a preview of the Request for Applications (RFAs). This documentation will be used by ambulance providers and suppliers to apply for inclusion as “Participants” in the Emergency Triage, Treat, and Transport (ET3) pilot program. Webinar: Learn More About the RFA June 13, 2019 | 2:00 PM Eastern Speakers: Brian Werfel, Kathy Lester, Rebecca Williamson, Asbel Montes $99 for Members | $198 for Non-Members Relevant Background On February 14, 2019, CMMI announced the creation of a new 5-year pilot program designed to give participating EMS agencies greater flexibility to address the needs of Medicare beneficiaries following a 911 call. The ET3 model would create a new payment model under which participating EMS agencies will be eligible for Medicare reimbursement for: (1) transportation to alternative treatment destinations and (2) treatment at the scene. At the time, CMMI indicated that it anticipated starting the ET3 model in early 2020. To that end, CMMI anticipated soliciting Requests for Participation in the Summer of 2019. Participation in this pilot program is voluntary. Regardless of whether an ambulance provider or supplier participates in the pilot program, payment for ambulance transportation currently covered under...

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New SNF PPS Edits Highlight the Importance of Facility Agreements

On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that are intended to better identify ground ambulance transports that are furnished in connection with an outpatient hospital service that is properly bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime. These edits work by comparing the ambulance claim to the associated outpatient hospital claim.  Hospital claims were already subject to CWF edits designed to identify outpatient hospital services that should be bundled to the SNF.  These hospital edits operate by referencing a list of Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes that correspond to outpatient hospital services that are expressly excluded from SNF Consolidated Billing.  Hospital claims for outpatient services that are submitted with one of these excluded codes bypass the existing CWF edits, and are then sent to the appropriate Medicare Administrative Contractor for further editing and payment.  Hospital claims submitted without one of these codes are denied for SNF Consolidated Billing. The new ambulance edits will extend these process one step further.  The ambulance claim will be associated with the outpatient hospital claim on the same date.  To the extent that hospital claim...

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Summary of March 28, 2019 Ambulance ODF

The Centers for Medicare and Medicaid Services (CMS) held its latest Open Door Forum on Wednesday, March 28, 2019.  As with past Open Door Forums, CMS started the call with the following announcements: Ambulance Cost Data Collection – CMS reminded the industry that the Bipartisan Budget Act of 2018, enacted on February 9, 2018, requires CMS to create a new cost data collection system by December 31, 2019. Emergency Triage, Treat, and Transport Model – A representative from the Innovation Center within CMS provided an overview of the “Emergency Triage, Treat, and Transport Model” or “ET3.” This is a 5-year pilot program intended to provide ambulance providers with greater flexibility to handle low-acuity 911 calls, by providing Medicare payment for: (a) ambulance transportation to alternative treatment destinations and (b) treatment at the scene. The CMS representative indicated that CMS is in possession of data that suggests that 16% of emergency ambulance transports to a hospital emergency department could have been resolved by transporting the patient to an alternative treatment site, e.g., an urgent care center. CMS estimates that had all of these patients elected to receive care in the lower-acuity setting, it would have saved the Medicare Program approximately $560 (more…)

HHS OIG Issues Advisory Opinion on Community Paramedicine

HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions. The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions. Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include...

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Update on New SNF Edits

CMS Set to Implement New Common Working File Edits to Identify Ambulance Services Provided in Connection with Outpatient Hospital Services that should be bundled to the SNF under Consolidated Billing. In a Member Advisory issued last week, the AAA provided an update on a series of new Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019.  In our discussion of the implementation specifics, we attempted to answer the question of what would happen when an ambulance claim is submitted prior to the receipt of the associated hospital outpatient claim, and where the associated hospital claim eventually hit Medicare’s system. Specifically, we indicated as follows: “The Transmittal contains further instructions that the CWF be updated to identify previously rejected ambulance claims upon receipt of an associated hospital claim for the same date of service that contains an Exempted Code.  Once identified, the Shared System Maintainer (SSM) is supposed to adjust the previously rejected or denied ambulance claim.  At this point, the nature of that “adjustment” is...

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