Also Adds Dollars to the Provider Relief Fund to Support Rural Providers and Suppliers
March 10, 2021
Moments ago, the House of Representatives joined the Senate in passing “The American Rescue Plan.” Among the many provisions, this legislation includes waiver authority to allow the Medicare program to reimburse for ground ambulance services provided during the COVID-19 public health emergency when the beneficiary has not been transported under certain circumstances. It also increases the Provider Relief Fund by $8.5 billion, targeting the money to rural providers and suppliers, including ground ambulance services.
The American Ambulance Association (AAA) worked diligently with Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) to reimburse ground ambulance services when they provide health care services to a beneficiary, but because of the pandemic the beneficiary was not transported. CMS concluded and communicated in a Frequently Asked Question (FAQ) that the Social Security Act requires the beneficiary to be transported in order for Medicare to reimburse the ground ambulance provider or supplier for the care provided.
To address this problem during the pandemic, Sens. Catherine Cortez Masto (D-NV) and Bill Cassidy (R-LA) introduced S. 149 that would allow CMS to waive the statutory provision creating the barrier to reimbursement during the pandemic. More specifically, it would allow CMS to reimburse ground ambulance services responding to a 9-1-1 or equivalent emergency call even when the beneficiary is not transported when a community-wide EMS protocol prohibiting the transport is in place. Reps. Cindy Axne (D-IA), John Larson (D-CT), and Bruce Westerman (R-AR) introduced the companion bill, H.R. 1609, in the House.
The Senate included S. 149 in “The American Rescue Plan Act of 2021,” which passed the Senate 50-49 on March 6. This amended version passed the House along party lines earlier today and the President is expected to sign the bill into law before March 14.
CMS must exercise its authority under the waiver for the provision to be implemented. The AAA has already begun working with CMS to urge it to act as quickly as possible and we are coordinating this effort with the International Association of Fire Chiefs, International Association of Fire Fighters, National Association of EMTs, National Volunteer Fire Council and the Congressional Fire Services Institute.
In addition to the waiver allowing for reimbursement for treatment in place, the final bill includes $8.5 billion additional dollars for the Provider Relief Fund directed to rural health care providers and suppliers. The funds can be used for health care related expenses and lost revenues that are attributable to COVID–19. To be eligible for a payment, an eligible rural health care provider or supplier must be enrolled Medicare or Medicaid and submit to the Secretary an application that includes a justification statement, documentation of the expenses or losses, the tax identification number, assurance required by the Secretary, and any other information the Secretary requires. The expenses and losses cannot have been reimbursed from another source or another source cannot already be obligated to reimburse.
“The American Rescue Act” marks an important step forward for ground ambulance organizations who have been on the front line of the pandemic and offers important relief recognizing the unique and essential role these organizations play in community response to the pandemic.
For more information on the provisions of the bill that impact ground ambulance services, please sign up for the webinar on “The American Rescue Plan and EMS” scheduled for this Friday, March 12, at 2:00 pm (eastern).
It appears that members of Congress on the House Ways & Means, Energy & Commerce, and Education & Labor Committees along with the Senate Health, Education, Labor, & Pensions Committee have reached a compromise agreement that will allow “surprise” billing legislation to be considered for passage before the end of the year. While the details of the legislation have yet to be unveiled, the American Ambulance Association has learned that it is likely to include provisions related to ground ambulance service and air ambulance service providers and suppliers.
Earlier legislation moved forward by the House Education & Labor Committee included a requirement for the Administration to create a Federal Advisory Committee to review ways to increase transparency around fees and charges for ground ambulance services and to better inform consumers about their treatment options. We believe that this language will be included in the compromise, but that there may be an opportunity to suggest modifications to make it more balanced and fairer in terms of the charge of the Committee and the types of individuals and organizations who will be selected to participate on it. The AAA is recommending that the Advisory Committee have at least a year to study and report on issues related to balance billing by ground ambulance service providers and suppliers, including the role of local and state governments in EMS systems amongst other considerations. It is also important that the Committee members include representatives from all types, sizes, and geographical areas of ground ambulance service providers and suppliers, as well as state EMS officials, and paramedics and EMTs.
It is likely that if the congressional leadership agree to move this legislation forward, it would be attached to the end of the year packages that may also include COVID-19 relief, Medicare extenders, and the annual spending bills.
As reported in various media outlets, on December 1 the Center for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) voted 13-1 to recommend that health care providers, expressly including EMS personnel, be prioritized to receive the COVID-19 vaccines during Phase 1a of the vaccine distribution plan. The complicating factor is that State and local governments have the final say in whether these recommendations are incorporated into their own distribution plans. Thus, we encourage all AAA members to engage actively with their State and local governments to urge the adoption of the CDC recommendation. The AAA has developed a toolkit for members to use in reaching out to their state and local government officials.
The AAA has been engaging with ACIP and other federal policy makers to urge them to prioritize EMS in the vaccine distribution plan. On November 19, the AAA submitted a comment letter to the ACIP advocating that the advisory committee specifically include EMS personnel in their recommendation of groups in the first phase of receiving the vaccination. Even though States and local governments will create their own list, having EMS listed in Phase 1a CDC recommendations is a critically important step toward influencing the State and local process.
During its second emergency meeting in less than a month, ACIP met to develop recommendations on the prioritization of vaccines, given that it will be impossible to provide access to everyone in the United States immediately after the vaccines are approved. In both virtual meetings, Committee members noted the importance of EMS personnel having access to the vaccine in the very top tier for prioritization. Other health care personnel on this list are defined as hospitals, long-term care facilities, outpatient clinics, home health care, pharmacies, and public health. The Phase 1a tier also includes residents of nursing homes, assisted living facilities, and other residential care settings, given that approximately 40 percent of all COVID-19 deaths have occurred in these settings. The final recommendation approved states:
When a COVID-19 vaccine is authorized by FDA and recommended by ACIP, vaccination in the initial phase of the COVID-19 vaccination program (Phase 1a) should be offered to both 1) health care personnel§ and 2) residents of long-term care facilities.
Health care personnel are defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials.
Long-term care facility residents are defined as adults who reside in facilities that provide a variety of services, including medical and personal care, to persons who are unable to live independently.
The CDC plans to publish this recommendation in the Morbidity Mortality Weekly Report as well.
The only controversial issue related to whether long-term care facility residents should receive the vaccine given the limited information available about its effectiveness and safety in these populations.
Because President Trump has indicated that State and local governments do not have to follow the CDC recommendations, it is critically important that AAA members work closely with their State and local governments to ensure that the CDC recommendations with regard to EMS are adopted by them as well. The AAA has posted a tool kit on our website to help our members provide the necessary information to their State and local governments as they are making these decision.
ACIP will continue to evaluate the distribution prioritization for Phase 1b, which will likely be non-health care essential workers, and Phase 1c, which will include adults with high-risk medical conditions and adults 65 years or older.
by Kathy Lester, J.D., M.P.H.
As the American Ambulance Association (AAA) reported yesterday, President Trump issued an Executive Order (EO) “An America-First Healthcare Plan.” The EO includes several provisions, including related to drug importation generally and for insulin specifically. It also includes statements that indicate if the Congress does not act before the end of the year, the President will have the Department of Health and Human Services (HHS) “take administrative action to prevent a patient from receiving a bill for out-of-pocket expenses that the patient could not have reasonably foreseen.” It does not mention ground ambulances.
In addition to suggesting action if the Congress does not pass legislation, the EO also states that within 180 days, the Secretary will update the Medicare.gov Hospital Compare website to inform beneficiaries of hospital billing quality, including:
The narrative related to balance billing (surprise coverage) reads as follows:
My Administration is transforming the black-box hospital and insurance pricing systems to be transparent about price and quality. Regardless of health-insurance coverage, two‑thirds of adults in America still worry about the threat of unexpected medical bills. This fear is the result of a system under which individuals and employers are unable to see how insurance companies, pharmacy benefit managers, insurance brokers, and providers are or will be paid. One major culprit is the practice of “surprise billing,” in which a patient receives unexpected bills at highly inflated prices from providers who are not part of the patient’s insurance network, even if the patient was treated at a hospital that was part of the patient’s network. Patients can receive these bills despite having no opportunity to select around an out-of-network provider in advance.
On May 9, 2019, I announced four principles to guide congressional efforts to prohibit exorbitant bills resulting from patients’ accidentally or unknowingly receiving services from out-of-network physicians. Unfortunately, the Congress has failed to act, and patients remain vulnerable to surprise billing.
In the absence of congressional action, my Administration has already taken strong and decisive action to make healthcare prices more transparent. On June 24, 2019, I signed Executive Order 13877 (Improving Price and Quality Transparency in American Healthcare to Put Patients First), directing certain agencies — for the first time ever — to make sure patients have access to meaningful price and quality information prior to the delivery of care. Beginning January 1, 2021, hospitals will be required to publish their real price for every service, and publicly display in a consumer-friendly, easy-to-understand format the prices of at least 300 different common services that are able to be shopped for in advance.
We have also taken some concrete steps to eliminate surprise out‑of-network bills. For example, on April 10, 2020, my Administration required providers to certify, as a condition of receiving supplemental COVID-19 funding, that they would not seek to collect out-of-pocket expenses from a patient for treatment related to COVID-19 in an amount greater than what the patient would have otherwise been required to pay for care by an in-network provider. These initiatives have made important progress, although additional efforts are necessary.
Not all hospitals allow for surprise bills. But many do. Unfortunately, surprise billing has become sufficiently pervasive that the fear of receiving a surprise bill may dissuade patients from seeking appropriate care. And research suggests a correlation between hospitals that frequently allow surprise billing and increases in hospital admissions and imaging procedures, putting patients at risk of receiving unnecessary services, which can lead to physical harm and threatens the long-term financial sustainability of Medicare.
Efforts to limit surprise billing and increase the number of providers participating in the same insurance network as the hospital in which they work would correspondingly streamline the ability of patients to receive care and reduce time spent on billing disputes.
The AAA will continue to advocate for the resources necessary to sustain life-saving mobile healthcare.
CMS Clarify in Guidance that EMS Personnel Are Not Required To Be Tested under Skilled Nursing Facility Testing Interim Final Rule
The Centers for Medicare & Medicaid Services (CMS) have issued guidance clarifying the types of personnel who are subject to the testing requirements when entering a Skilled Nursing Facility (SNF) in the Interim Final Rule with Comment (IFC) on Additional Policy and Regulatory Revisions in Response to the COVID– 19 Public Health Emergency. The new guidance memo states:
Entry of Health Care Workers and Other Providers of Services
Health care workers who are not employees of the facility but provide direct care to the facility’s residents, such as hospice workers, Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technicians, radiology technicians, social workers, clergy etc., must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened. We note that EMS personnel do not need to be screened so they can attend to an emergency without delay. We remind facilities that all staff, including individuals providing services under arrangement as well as volunteers, should adhere to the core principles of COVID-19 infection prevention and must comply with COVID-19 testing requirements.
CMS issued this guidance at the request of the American Ambulance Association (AAA) to address concerns our members had raised about some SNFs misinterpreting the requirements. The guidance is also consistent with AAA’s interpretation of the IFC. As we indicated in an earlier Member Advisory, the IFC requires SNFs to test certain individuals for COVID-19 before they enter the facility. Specifically, it applies to employees, consultants, and contractors of a skilled nursing facility (SNF). It does not apply to vendors, suppliers, attending physicians, family, or visitors. Providers, such as medical directors and hospice, that are under a contract or consultants to a SNF are subject to the rule. EMS personnel do not come within the scope of the IFC.
Even though the testing requirements of the IFC do not extend to ground ambulance services that do not have a contractual relationship with a SNF, the AAA supports the efforts of all of our members to follow the World Health Organization and Centers for Disease Control and Prevention Guidelines to have EMT and paramedics use full Personal Protective Equipment (PPE) when they are engaging with any patient, not only those in SNFs. We also want to recognize the best practices of many members who have worked with SNFs to establish outdoor locations where the SNF personnel, when possible, can bring a patient out of the building to transfer the patient to the ambulance. These and other examples of safe practices can help control the spread of COVID-19, which is the paramount concern.
The Centers for Medicare & Medicaid Services (CMS) has announced that the first performance period for the Emergency Triage, Treat, and Transport (ET3) Model will begin on January 1, 2021. As we reported previously, CMS delayed the start of ET3 Model, consistent with its delaying or pausing other payment models, because of the COVID-19 public health emergency (PHE).
To start this effort, CMS has indicated that it will post a revised Participation Agreement (PA) to the ET3 Model Portal by mid-October 2020. Participants must upload signed PAs to the ET3 Model Portal by December 15, 2020. CMS will also post an Implementation Plan Template (IPT). Participants must submit their IPT CMS by November 15, 2020 to allow CMS to review and accept the IPT prior to beginning their participation in the Model.
CMS plans to provide additional guidance, including: an Orientation Overview fact sheet, Billing and Payment fact sheets, Model Participation During the PHE fact sheet, a Who’s Who fact sheet, and an ET3 Model Portal User Guide. These documents will be available to participants through the ET3 Model Portal during the next several weeks.
The re-engagement on the ET3 Model prior to the end of the PHE is something that the American Ambulance Association (AAA) has supported in discussions with CMS. While it does not address some of the gaps in reimbursement and treatment that our members are seeing nationwide, for those who are participating in the model, it will be an enormous benefit.
The AAA also continues to work with CMS to identify new models that will allow other ground ambulance providers and suppliers to participate in innovative models, even though there were not able to meet the ET3 participation requirements.
The Centers for Medicare & Medicaid Services (CMS) has released printable version of the ground ambulance data collection instrument and an expanded FAQ. Both updated documents address some of the more common questions that CMS has heard over the past months, many of which the American Ambulance Association raised. Importantly, CMS announces through the FAQs the registration process will begin December 2021.
The topics covered in the FAQs include:
Question: Will the modification listed in the COVID-19 Emergency Declaration Blanket Waiver issued by CMS on May 15, 2020 allow ground ambulance organizations selected in year 1 the option to continue with their current data collection period that started in early 2020 or choose to select a new data collection period starting in 2021? [Added 7/31/2020]
Examples of Data Collection and Reporting Periods for a Ground Ambulance Organization with Accounting Period not based on a Calendar Year:
The same principles apply to similar cases, for example when the other entity is a hospital, non-profit organization, or other type of entity.
The Centers for Medicare & Medicaid Services (CMS) has released the Physician Fee Schedule Proposed Rule for Calendar Year (CY) 2021 which has traditionally included proposed changes to the Ambulance Fee Schedule for the same year. The American Ambulance Association (AAA) has confirmed with CMS that the reason there are no references to the Ambulance Fee Schedule in the Proposed Rule is because the temporary add-ons were built into the regulations themselves. Thus, the governing regulations already indicate that the temporary add-on payments for ground ambulance transports are effective for services furnished through December 31, 2022. The regulations are at 42 CFR §414.610 (c)(1)(ii) and 42 CFR §414.610 (c)(5)(ii).
The Proposed Rule also seeks to extend or make permanent several of the telehealth waivers CMS has implemented during the public health emergency. Because CMS does not believe it has the authority to reimburse ambulance providers or suppliers for services provided without transportation also occurring, these waivers have not applied to ground ambulance. However, we will review these provisions of the rule closely to identify potential opportunities to include ground ambulance providers and suppliers in these policies.
As we recently reported, CMS announced that it will be delaying the implementation of the statutorily mandated ambulance data collection system. CMS has released a new set of Frequently Asked Questions (FAQs) clarifying the delay. In sum, ambulance organizations selected to provide cost data for 2020 will now be required to report 2021 data in Year 2. CMS will also add a new set of ambulance organizations for Year 2 reporting as well. This means that twice as many ambulance organizations will be reporting 2021 data in Year 2 and there will be no data reported for 2020. Any organization selected that does not report data will be subject to the 10 percent penalty, unless an exception applies. In addition to addressing concerns about reporting during the pandemic, the FAQs suggest that CMS is concerned that 2020 data “may not be reflective of typical costs and revenue associated with providing ground ambulance services.”
The complete list of these questions, as well as previous ambulance FAQs for COVID-19 on Medicare Fee-for-Service (FFS) Billing can be found here. The new data collections are below.
1. Question: CMS requires selected ground ambulance organizations to collect cost, revenue, utilization, and other information through the Medicare Ground Ambulance Data Collection System. The collected information will be provided to MedPAC, which is required to submit a report to Congress on the adequacy of Medicare payment rates for ground ambulance services and geographic variations in the cost of furnishing such services. Will the data collection and reporting requirements for the Medicare Ground Ambulance Data Collection System be delayed due to COVID-19?
Answer: Yes. CMS has issued a blanket waiver: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration- waivers.pdf due to the PHE for the COVID-19 pandemic. CMS is modifying the data collection period and data reporting period, as defined at 42 CFR §414.626(a), for ground ambulance organizations that were selected by CMS to collect data beginning between January 1, 2020, and December 31, 2020 (Year 1).
Under this modification, these ground ambulance organizations can select a new data collection period that begins between January 1, 2021, and December 31, 2021; collect the necessary data during their selected data collection period; and submit the data during the data reporting period that corresponds to their selected data collection period.
CMS is modifying this data collection and reporting period to increase flexibilities for ground ambulance organizations that would otherwise be required to collect data in 2020–2021 so that they can focus on their operations in support of patient care.
As a result of this modification, ground ambulance organizations selected for year 1 data collection and reporting will collect and report data during the same period of time that will apply to ground ambulance organizations selected by CMS under §414.626(c) to collect data beginning between January 1, 2021, and December 31, 2021 (year 2) for purposes of complying with the data reporting requirements described at §414.626.
For additional information on the Medicare Ground Ambulance Data Collection System, please visit the Ambulances Services Center website at
2. Question: Will the 10 percent payment reduction still apply to ground ambulance organizations that are now required to collect and report data under the modified data collection and reporting period but do not sufficiently report the required data?
Answer: Yes. The 10 percent payment reduction described at 42 CFR §414.610(c)(9) will still apply if a ground ambulance organization is selected to collect and report data under the modified data collection and reporting timeframe, but does not sufficiently submit the required data according to the modified timeframe and is not granted a hardship exemption. The payment reduction will be applied to payments made under the Medicare Part B Ambulance Fee Schedule for services furnished during the calendar year that begins following the date that CMS provides written notification that the ground ambulance organization did not submit the required data.
3. Question: The modification states that the ground ambulance organizations that were selected by CMS to collect data beginning between January 1, 2020, and December 31, 2020 (year 1) can select a new continuous 12-month data collection period that begins between January 1, 2021, and December 31, 2021. Do the ground ambulance organizations that were selected in year 1 have an option to continue with their current data collection period that started in early 2020 or choose to select a new data collection period starting in 2021?
Answer: No. The ground ambulance organizations that were selected for year 1 do not have an option and must select a new data collection period that begins in 2021. CMS cannot permit this option because the data collected in 2020 during the PHE may not be reflective of typical costs and revenue associated with providing ground ambulance services. New: 6/16/20
4. Question: Does the guidance mean that there will be no data reporting in 2021 and that both the ground ambulance organizations that were selected for year 1 and the ground ambulance organizations that will be selected for year 2 will collect and report data during the same time periods?
Answer: Yes. Under the modification, ground ambulance organizations that are selected for year 1 will not collect data in 2020. These ground ambulance organizations will select a new data collection period that begins in 2021 and must submit a completed Medicare Ground Ambulance Data Collection Instrument during the data reporting period that corresponds to their selected data collection period. As a result of the modification, year 1 and year 2 selected ground ambulance organizations will collect and report data during the same time periods. New: 6/16/20
CMS has issued a blanket waiver modifying the data collection period for the ground ambulance services that were selected to report in Year 1. Under the current law, these organizations would have been required to collect data beginning January 1, 2020, and through December 31, 2020. The waiver allows these organizations to select a new continuous 12-month data collection period that begins between January 1, 2021 and ends December 31, 2021. This modification means that such organizations will collect and report data during the same time period as the ground organizations that CMS will select for Year 2 of the cost collection program.
From the summary of the waiver, it appears that organizations will have the choice of submitting data in Year 1 or Year 2. CMS has not moved the timeline for any other data collection year, so there is the potential for a substantial number of organizations to report in Year 2, which would increase the amount of data available.
The AAA has supported the data collection system to make sure that CMS and the Congress have valid and reliable data to support maintaining the geographic add-ons to the Medicare Ambulance Fee Schedule and to support efforts to address the chronic underfunding of the Medicare Ambulance Fee Schedule.
The complete FAQ is below and also available at: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf (on page 29).
“CMS is modifying the data collection period and data reporting period, as defined at 42 CFR § 414.626(a), for ground ambulance organizations (as defined at 42 CFR § 414.605) that were selected by CMS under 42 CFR § 414.626(c) to collect data beginning between January 1, 2020 and December 31, 2020 (year 1) for purposes of complying with the data reporting requirements described at 42 CFR § 414.626. Under this modification, these ground ambulance organizations can select a new continuous 12-month data collection period that begins between January 1, 2021 and December 31, 2021, collect data necessary to complete the Medicare Ground Ambulance Data Collection Instrument during their selected data collection period, and submit a completed Medicare Ground Ambulance Data Collection Instrument during the data reporting period that corresponds to their selected data collection period. CMS is modifying this data collection and reporting period to increase flexibilities for ground ambulance organizations that would otherwise be required to collect data in 2020- 2021 so that they can focus on their operations and patient care.”
“As a result of this modification, ground ambulance organizations selected for year 1 data collection and reporting will collect and report data during the same period of time that will apply to ground ambulance organizations selected by CMS under 42 CFR § 414.626(c) to collect data beginning between January 1, 2021 and December 31, 2021 (year 2) for purposes of complying with the data reporting requirements described at 42 CFR § 414.626.”
CMS Relaxes Physician Certification Statement Signature Requirements During Public Health Emergency for COVID-19
By Kathy Lester, J.D., M.P.H.
The Centers for Medicare & Medicaid Services (CMS) has released guidance that recognizes the difficulty ambulance service providers and suppliers may have during the COVID-19 Public Health Emergency (PHE) in obtaining a physician certification statement (PCS) signed by a physician or other authorized professional. The question and answer below indicates that CMS (and its contractors by extension) will not deny claims during a future medical audit even if there is no signature for non-emergency ambulance transports, absent an indication of fraud or abuse. Ambulance service providers and suppliers should indicate in the documentation that a signature was not able to be obtained because of COVID-19. The AAA advises completing the PCS form and then indicating if a physician, or other appropriate personnel, has not signed it by writing “COVID-19 Public Health Emergency” on the signature line. CMS also reminds providers and suppliers that medical necessity still needs to be met.
The American Ambulance Association has been advocating for CMS to ease its restrictions on signature requirements during the COVID-19 PHE. The FAQ posted by CMS is consistent with our recommendations.
The specific Q&A is below:
Q. For ambulance services that require a physician, or, in lieu of that, certain non-physician personnel, to sign and certify that a non-emergency ambulance transport is medically necessary, are these signature requirements not required during the COVID-19 PHE?
A. We understand that in certain situations during the COVID-19 PHE it may not be feasible to obtain the practitioner signature. Therefore, for claims with dates of service during the COVID- 19 PHE (January 27, 2020 until expiration), CMS will not review for compliance with appropriate signature requirements for non-emergency ambulance transports during medical review, absent indication of fraud or abuse. Ambulance providers and suppliers should indicate in the documentation that a signature was not able to be obtained because of COVID-19. However, we note that Medicare Part B covers ambulance transport services only if they are furnished to a Medicare beneficiary whose medical condition is such that other means of transportation are contraindicated, and the beneficiary’s condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.
The full Q&A document can be accessed here.
The Centers for Medicare and Medicaid Services (CMS) promulgated an interim final rule with comment period (IFC) entitled “Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.” Consistent with the recommendations the AAA made to CMS, for the duration of the public health emergency (PHE), the IFC allows ground ambulance service providers and suppliers to transport patients both on an emergency or non-emergency basis to any destination that is equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished. In related guidance, CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic, waived patient signature requirements, and is pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model. The policies of the IFC are effective retroactively to March 1, 2020.
On March 11, the AAA sent CMS a letter specifically requesting for the agency to waive during the COVID-19 pandemic the regulatory restrictions that prevent coverage for transport to alternative destinations. Separately, the AAA has been pressing CMS to provide relief from signature requirements. The AAA had also been working with CMS to lifting of these restrictions and others to eliminate barriers the current Medicare regulations in responding to the COVID-19 crisis.
Paying for Transports to Alternative Destinations. During the duration of the crisis, CMS has expanded the list of destinations for which Medicare covers ambulance transportation to include all destinations, from any point of origin, that are equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished.
These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH) or skilled nursing facility (SNF), community mental health centers, federal qualified health clinic (FQHCs), rural health clinics (RHCs), physicians’ offices, urgent care facilities, ambulatory surgery centers (ASCs), any location furnishing dialysis services outside of an ESRD facility when an ESRD facility is not available, and the beneficiary’s home.
This expanded list of destinations applies to medically necessary emergency and non-emergency ground ambulance transports of beneficiaries during the PHE for the COVID-19 pandemic. The IFC does not waive the medically necessary requirements for ground ambulance transport of a patient in order for an ambulance service to be covered.
The AAA is working closely with CMS to confirm that patients who require isolation meet the medical necessity requirements.
Suspension of Audits and Relief on Patient Signatures. In guidance released separately, CMS indicates that it is suspending nearly all audits of providers and suppliers for the duration of the PHE.
CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.
CMS also indicates in this guidance that a beneficiary’s signature will not be required for proof of delivery, as it relates to durable medical equipment services, during the PHE. In a follow-up exchange with CMS, the AAA has confirmed that this policy of not requiring a beneficiary’s signature also applies to ground ambulance providers and suppliers. The AAA has requested that this clarification for ground ambulances also be provided in a written FAQ.
Pause in the Non-Emergency Prior Authorization Model. CMS has paused the claims processing requirements for the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model, effective March 29 until the end of the PHE. During this pause, claims for repetitive, scheduled non-emergent ground ambulance transports for the COVID-19 pandemic in States in which the model operates will not be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period. During the pause, the MAC will continue to review any prior authorization requests that have already been submitted, and ambulance suppliers may continue to submit new prior authorization requests for review during the pause. Claims that have received a provisional affirmative prior authorization decision and are submitted with an affirmed unique tracking number (UTN) will continue to be excluded from future medical review. Following the end of the PHE for the COVID-19 pandemic, the MACs will conduct postpayment review on claims otherwise subject to the model that were submitted and paid during the pause.
Telehealth Services. While CMS does not provide authority for ambulance organizations to bill directly for telehealth services, it does modify for the duration of the PHE the “direct supervision” requirements to allow physicians enter into a contractual arrangement with an entity that provides ambulance services to allow the physician to use the ambulance organization’s personnel as auxiliary personnel under a leased agreement. Under such circumstances, the provider or supplier would seek payment for any services it provided from the billing physician and would not submit claims to Medicare for such services directly.
Ongoing work of the AAA. The rule does not address two critical issues: (1) reimbursement for treatment in place and (2) direct reimbursement for telehealth services. The AAA will continue to work with CMS and the Congress to address these issues that are critical to meeting the needs of patients and your community during the epidemic.
CMS announced at the end of last week that it is expanding its Accelerated Payment Program. The goal of the program is to address cash flow problems arising from the public health emergency. The program functions as a short-term loan with no interest.
To qualify for advance/accelerated payments the provider/supplier must: (1) Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/supplier’s request form; (2) Not be in bankruptcy; (3) Not be under active medical review or program integrity investigation; and (4) Not have any outstanding delinquent Medicare overpayments.
Qualified providers/suppliers will be asked to request a specific amount using an Accelerated or Advance Payment Request form provided on each MAC’s website. Most providers and suppliers will be able to request up to 100% of the Medicare payment amount for a three-month period. All non-hospital Part A providers and Part B suppliers will have 210 days from the date of the accelerated or advance payment was made to repay the balance.
The provider/supplier can continue to submit claims as usual after the issuance of the accelerated or advance payment; however, recoupment will not begin for 120 days. Providers/ suppliers will receive full payments for their claims during the 120-day delay period. At the end of the 120-day period, the recoupment process will begin and every claim submitted by the provider/supplier will be offset from the new claims to repay the accelerated/advanced payment. Thus, instead of receiving payment for newly submitted claims, the provider’s/supplier’s outstanding accelerated/advance payment balance is reduced by the claim payment amount. This process is automatic.
The proposed rule sets the foundation for the data collection system for ground ambulances. It proposes a stratified random sample method, that is very similar to the one the AAA proposed via the work we commissioned through The Moran Company. We are working through the stratification categories, which are slightly different than those we identified.
CMS also proposes the cost and revenue data elements it plans to use. There are some details in the proposed rule text and others will be in the proposed tool that will be posted the CMS website today.
CMS also proposes the collection period and penalties for failing to report.
While the data collection provision was the key component for ground ambulance services, CMS also proposed changes to the PCS requirement sought by the AAA. CMS is proposing to reference the PCS also as non-physician certification agreements. The agency is further proposing to clarify that the focus is on the certification of the medical necessity provisions and the form of the certification statement is not prescribed. As part of the non-physician statement, CMS is proposing expanding the staff of you may sign the statement when an attending physician is unable to sign.