MedPAC Issues June 2016 Report to the Congress

MedPAC Issues June 2016 Report to the Congress with Chapter on Improving Efficiency and Preserving Access to Emergency Care in Rural Areas

Medicare Payment Advisory Commission (MedPAC or the Commission) has issued its June 2016 Report to the Congress.   The June report includes recommended refinements to Medicare payment systems and identifies issues affecting the Medicare program, broader changes in health care delivery, and the market for health care services.

Chapter 7 focuses on preserving access to emergency care in rural areas.  The Commission recognizes that access to inpatient and emergency services in rural areas is threatened because of the dwindling populations.  Declining populations can lead to fewer hospital admissions and reduced efficiencies that can create financial and staff problems for hospitals.  The Report notes that “[d]eclining volume is a concern because low-volume rural hospitals tend to have worse mortality metrics and worse performance on some process measures.” In addition, “low-volume CAHs have the difficult job of competing with each other for a shrinking pool of clinicians who want the lifestyle of operating an outpatient practice during the day, covering inpatient issues that arise at night, and covering the emergency department.”

Under current policies, most rural hospitals are critical access hospitals (CAHs).  They receive a cost-based payment for providing inpatient and outpatient services to Medicare beneficiaries.  To receive these payments, a hospital must maintain acute inpatient services.  In rural areas, many small towns do not have a sufficient population to support such a model.  Yet eliminating these services would mean giving up the supplemental payments that their hospitals receive through the CAH cost-based payment model.

The hospital prospective payment system serves as the payment model for other hospitals.  Rural providers receive supplemental payments, which are also linked to providing inpatient services.

MedPAC highlights the concerns with cost-based payment models:

  • Cost-based payments do not direct payments toward isolated hospitals having the greatest financial difficulty, but rather reward hospitals in high-income areas with higher non-Medicare margins by providing them with higher Medicare payments.
  • Cost-based payments encourage providers to expand service lines with high Medicare and private-payer shares rather than primarily focus on services that are needed on an emergency basis.
  • Cost-based models reduce the incentive for hospitals to control their costs, which can lead to unnecessary growth in capital costs, despite declining volumes.

In light of these challenges, MedPAC sets forth a two of options that would give isolated rural hospitals the option of converting to an outpatient-only model while maintaining their special payment arrangements.  These models seek to ensure access to essential services:

  • Establishing a 24/7 emergency department model; and
  • Adopting a clinic with ambulance services model.

Under the 24/7 emergency department model, the hospital would be paid under the outpatient prospective payment rates and would receive an annual grant/fixed payment from Medicare to cover the standby costs associated with 24/7 emergency services.  The current supplemental payments would be redirected to support this annual grant/fixed payment amount.  If a hospital chose to use inpatient beds as skilled nursing facility (SNF) beds, it would be reimbursed under the Medicare SNF prospective payment system.  The hospital could be required to use the fixed payment for emergency standby capacity, ambulance service losses, telehealth capacity, and uncompensated care in the emergency department.

Under the clinic and ambulance model, hospitals could convert their existing inpatient facilities into primary care clinics.  These clinics would be “affiliated” with an ambulance service.   Medicare would pay the prospective rates for primary care visits and ambulance transports.  Medicare would provide an annual grant/fixed payment to support the capital costs of having a primary care practice, the standby costs of the ambulance service, and uncompensated care costs.

The Commission recognizes that the “low population density would also make it difficult to retain primary care providers and support an ambulance service.”  It could also be difficult to describe the exact level of primary care and ambulance access that is required to receive the fixed Medicare payment.

MedPAC reiterates its position that “supplemental payments beyond the standard PPS rates should be targeted to isolated rural providers that are essential for access to care.”  Thus, it states that a program to support stand-alone emergency departments should be limited to facilities that are a minimum distance in road miles from the nearest hospital.


Spotlight: SSM Health Cardinal Glennon Children’s Hospital STARS Program

The Special Needs Tracking & Awareness Response System (STARS), was founded just over two years ago at SSM Health Cardinal Glennon’s Children’s Hospital in St. Louis, Missouri. The team at Cardinal Glennon realized that they needed to do something to address the growing number of children in the U.S. with special health care needs, many of whom are at a higher risk for repeated ambulance transports.

As an EMT for over 18 years, Patricia Casey, the Missouri Coordinator of the STARS Program, knows how intimidating it can be for a first responder to walk into a home that in many ways may look like a hospital room. Children with special health care needs can require many different types of in home medical equipment that first responders are often not familiar with. The STARS Program aims to make the job of the first responders easier while making children with medical needs and their parents more comfortable with ambulances in case they need to be transported in one.

Cardinal Glennon works with local ambulance districts to enroll children with special medical needs in that district’s STAR Program. Once a child is registered in STARS, they are given a unique patient identification number and a home visit is scheduled with the patient and their family to compile pertinent medical history. Participating ambulance companies then create a book with all of the stars in their area so that their first responders have access to the medical information on the go. If a STAR needs to be transported, their caregiver can relay their STAR number to the dispatcher who will then let the first responders know. First responders can then look up crucial medical information about the STARS patient, so they can be better prepared when they arrive on scene.

Knowing that many medical devices in the homes of the STARS may be foreign to first responders, Cardinal Glennon’s staff provides free necessary trainings all around Missouri and now Illinois. Shelby Cox works as the Team Lead for EMS outreach, and Josh Dugal, RN, is the EMT-P STARS Coordinator for Illinois. Together with Casey, they help keep the program running smoothly. Each participating ambulance company appoints a STARS coordinator on their staff who will make biannual home visits and make sure the STARS medical information is up to date. Cardinal Glennon also sets up regular opportunities for STARS to visit their local first responders. Giving STARS the chance to get familiar with an ambulance and their local first responders prior to a medical emergency has been proven to help out both parties when an emergency occurs.

A paramedic who has responded to STARS calls explains that “the STARS system permitted me to have advanced medical knowledge before I walked through the door. There was no time lost backtracking to learn the patient’s history or baseline in the midst of a chaotic scene”. In addition to helping the first responders, the STARS program has been a huge reassurance to the parents of STARS whose children may often need medical assistance.

To learn more about Cardinal Glennon’s STARS program, visit their website or check them out on Facebook. Also check out Patricia Casey’s Article on the STARS Program which includes testimonials from both parents and first responders who have participated in the program.
Thanks to the entire team at Cardinal Glennon for your great work!

Do you know of other innovative programs being run by ambulance services? Share with the AAA so that we might feature those programs on the AAA Blog as well.

Boston Compliance and Billing Workshop

A Comprehensive Compliance Strategy: How to Structure Your Billing Office for Integrity, Accountability, and Profitability

Workshop Date: Thursday, September 29, 2016

The Comprehensive Compliance Strategy One-Day Workshop is intended to guide Patient Accounts Managers/Supervisors and lead billing staff on the need for a comprehensive compliance strategy. The workshop provides a hands-on “Deep Dive” format that will allow for in-depth discussion of your billing office operations. It is our goal to have attendees leave with actionable information on the reimbursement, compliance, and practical aspects of running a billing office. NAAC approved for 6.5 CEU hours.

$299 for individual members, $279 group rate (2 or more)NAAC_CEU_CAC_CACO_CAPO_LogoVector
$599 for non-members, $579 group rate (2 or more)



Spaulding Rehabilitation Hospital
300 First Street
Charlestown, MA

There is no event hotel for the workshop. However, there are several hotels less than 5 miles from Spaulding Rehabilitation Hospital for those needing overnight accommodations.  Two noteworthy and affordable hotels nearby are:










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9:00 am –Welcoming Remarks and State of the Union

The first session will cover a current state of the industry as it relates to fraud and abuse in the ambulance business, CMS and OIG practices, investigative trends and the need for payment reform. The session will identify those fraudulent and unintended billing errors that led to action by the oversight agencies. Also, was it much to do about nothing? We will an update on the ambulance industry’s transition to ICD-10.

10:30 am- Deep Dive-The Lion in Sheep’s Clothing-Properly Vetting Employees

This in-depth session will teach you how to develop a comprehensive background screening process for all staff members, both new hires and existing staff, particularly those handling ambulance claims. Attendees will learn what screening they should be performing on employees and the law on when they can and should run credit reports on those in financially sensitive positions. Attendees will leave with a checklist and tips to ensure they accurately document their processes.

11:45 am- Your Infrastructure- Establishing Partners Not Peddlers

An expose on establishing or improving upon vendor partnerships in the billing office, both from a compliance standpoint, as well as achieving the best type of partnerships for the EMS organization. The session will cover the use of indemnification clauses in the Business Associate Agreements, ensuring the vendor has a current Cyber Insurance Policy, out clauses for non-performance, GEO Screening for Vendor Employees (and their contractors!), and more. This session will cover advanced strategies like looking for partners, not peddlers, measuring net-back gain (vs. rate), using no obligation test files, comparing multiple vendor results, holding vendors accountable, interviewing negative and positive references, and more.

12:45 pm –Deep Dive – Raising the Bar:Patient Accounts Policies & Procedures Workgroup

This interactive breakout session, facilitated by both speakers, will address the compliance concerns brought forward by the attendees. During this session, we will identify and discuss policies and procedures that will standardize ambulance billing office practices as part of a larger compliance plan. This session will give services a list of recommended Patient Accounts Policies & Procedures that will provide protection from unintended errors.

2:15 pm Billing Office Efficiencies, Managing Payor Problems and Your Revenue Cycle

Brian Choate, with Solutions Group, will share some of his practical advice and step by step methods for having maximum reimbursement success.  From how to deal with VA claims, to how to make your data work for you, this is the session that will help you find solutions you can implement immediately.

3:45 pm Medicare Update

An invaluable overview of what you need to know regarding Medicare. Always pithy and delivered at a pace that holds your attention this session will give you the big picture for reimbursement. Brian will also cover court cases and the decisions that may surprise you. These real-life examples will help you avoid the common and the not so common pitfalls.

We’ll wrap up the day with Q&A with all our presenters



Scott Moore


Scott A. Moore, Esq. has been in the emergency medical services field for over 26 years.  Scott has held various executive positions at several ambulance services in Massachusetts.  Scott is a licensed attorney, specializing in Human Resource, employment and labor law, employee benefits, and corporate compliance matters.  Scott holds a certification as a Professional in Human Resources (PHR) and was the Co-Chair of the Education Committee for the American Ambulance Association (AAA) for several years.  Also, Scott is a Site Reviewer for the Commission on the Accreditation of Ambulance Services (CAAS).   Scott earned his Bachelor’s Degree in Psychology from Salem State College and his Juris Doctor from Suffolk University Law School.  Scott maintains his EMT and still works actively in the field as a call-firefighter/EMT in his hometown.  Scott is a member of the American Bar Association, the Massachusetts Bar Association, the Society for Human Resource Management, and the Northeast Human Resource Association.

Brian Werfel

3Brian S. Werfel, Esq. is a partner in Werfel & Werfel, PLLC, a New York-based law firm specializing in Medicare issues related to the ambulance industry. Brian is a Medicare Consultant to the American Ambulance Association, and has authored numerous articles on Medicare reimbursement, most recently on issues such as the beneficiary signature requirement, repeat admissions and interrupted stays. He is a frequent lecturer on issues of ambulance coverage and reimbursement.

Tristan North


Tristan North serves as the Senior Vice President of Government Affairs for the American Ambulance Association (AAA). Mr. North is a registered lobbyist with over 15 years of expertise and experience in government affairs. He joined AMG in 2002 and has been a lobbyist for the AAA since 1996. As the Senior Vice President of Government Affairs for the AAA, Mr. North oversees all aspects of the legislative and regulatory priorities of the Association before the Congress and Federal agencies. He is the lead lobbyist for the AAA and is responsible for shaping and implementing the public policy of the organization. Before joining AMG, Mr. North was Director of Government Affairs for the AAA at Hauck & Associates. Mr. North spent five years in the Government Affairs Division of Fleishman-Hillard representing the interests of health care and financial service clients before the Congress. For four of those years, Mr. North was a member of the Fleishman-Hillard team that represented the AAA on legislative and regulatory issues. Mr. North began his career in politics with the U.S. House of Representatives Committee on Financial Services where he worked as a professional staff member and investigator. While on the Committee, he was responsible for issues involving anti-counterfeiting efforts, the redesign of the currency and the review of the U.S. banking system. Mr. North graduated from Babson College in Wellesley, MA with a B.S. in Finance

Brian Choate

2Brian’s diverse background consists of 18 years of finance, technology, and revenue cycle. His passion for out-of-the-box thinking and innovation creates a perfect storm for challenging the status quo. Brian’s start in revenue cycle began in 2009 when creating a technology that uncovers billable insurance(s) for mis-classified self-pay accounts. Brian currently serves as faculty for the American Ambulance Association’s (AAA) Reimbursement Conferences and often speaks on reimbursement technologies at State and National EMS conferences.  When not working, Brian enjoys playing drums and spending time with his wife and three children, ages 17, 3, and 1.

Register Now
Please contact Desiree LaFont at or 703-610-9038 should you need any additional information.

AAA Issues Response to GAO Claims Report

On May 13, the Government Accountability Office (GAO) issued a report entitled “Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data“. In the report, the GAO recommended that CMS be provided legislative authority to allow Recovery Auditors to use prepayment claims reviews to address improper Medicare payments. CMS fortunately disagreed with the GAO on the recommendation and cited better options such as prior authorization to address potentially improper payments.

The AAA has now issued a Formal Statement in response to the GAO report noting the problems with prepayment claims review for ambulance services and promoting the better alternative of prior authorization for nonemergency BLS transports of dialysis patients. The statement is in follow up to our Member Advisory providing an in-depth review of the report. Please feel free to share the statement if you receive questions about the report.

On June 26, 2015, the AAA had participated in a conference call with the GAO officials conducting the report in which AAA representatives had pushed for recommendations in line with our statement. The AAA will continue to advocate for policies to address improper payments that address the issue but are also the least burdensome to AAA members and help ensure our ability to continue to provide high-quality emergency and nonemergency ambulance services to patients.

Webinar: Affordable Care Act in 2016

What are the ongoing challenges with the rollout of the Affordable Care Act and how are the current politics of the 2016 national elections influencing the future of health care reform? How will high deductible plans, enrollment numbers, court decisions and insurance plans pulling out of current exchanges impact health care delivery and more important; what will its potential impact be to ambulance services nationwide. Register for this webinar and hear directly from health care law expert, Kathy Lester, Esq., on how to prepare for your future in providing mobile health care to all regardless of ability to pay.


Webinar: Medicare for the Experienced Biller

In this follow-up to the Medicare 101 webinar, AAA Medicare Consultant Brian Werfel will explore some of the more complicated aspects of Medicare reimbursement. Topics will include:

– The ALS Assessment, and the steps a provider needs to take to effectively bill for the assessment
– The proper use of the ABN
– Strategies for maximizing Medicare reimbursement
– Strategies for managing prepayment reviews
– Appeal strategies

The webinar will conclude with a QA session, where participants can receive advice for specific issues they have encountered.


Webinar: Prior Authorization

In this webinar, AAA Medicare Consultant, Brian Werfel, Esq., will get you up to speed on the ongoing Medicare Demonstration Project for scheduled, repetitive non-emergency transports. From the underlying justifications for the demonstration project, to the implementation in the first three states and the recent expansion to additional states, attendees will be provided with the proper background to understand the goals of the program. Brian will also discuss the experience of ambulance providers in the initial states, including the challenges they faced in getting appropriate patients approved for continued transports. The last part of the webinar will discuss the proposed expansion to the rest of the nation in 2017, and will include specific tips for managing your repetitive patient population, to obtain the proper documentation, and to manage the prior authorization process. The goal is to give attendees the tools necessary to succeed in the new prior authorization world. The webinar will conclude with a Q&A period for attendees to get any specific questions answered.


Webinar: I Really Can’t Stay… Managing Employee Leave

Managing employee leaves can be a complex and challenging task which can expose employers to significant risk. This webinar will provide employers with a solid understanding of an employee’s right to protected leave and best practices for managing and tracking leave. This session will cover the notices employers should provide to employees, their rights related to employee benefits, and what an employer should do if they suspect an employee is abusing their leave rights.

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