MAC Novitas March 2016 Updates to Ambulance Services

On March 4, Novitas Solutions, Medicare Administrative Contract managers for several jurisdictions, asked AAA to share the following information with ambulance services.

March 4, 2016 – Letter to Ambulance Providers | March 4, 2016 – Letter to Beneficiaries

Jurisdictions Covered By Novitas

  • The Medicare Administrative Contract (MAC) Jurisdiction L (JL), which spans Pennsylvania, New Jersey, Maryland, Delaware and Washington D.C.;
  • The Medicare Administrative Contract (MAC) Jurisdiction H (JH), which spans Colorado, Oklahoma, New Mexico, Texas, Arkansas, Louisiana, Mississippi, Indian Health Service (IHS) and Veterans Affairs (VA); and
  • The payment processing for the Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens contract, as authorized under Section 1011 of the 2003 Medicare Modernization Act.

Boustany (R-LA 3rd) Introduces the Timely Payment for Veterans’ Emergency Care Act

On March 3, 2016, Congressman Charles W. Boustany, Jr., MD, republican representative of Louisana’s 3rd district, introduced the Timely Payment for Veterans’ Emergency Care Act. According to data obtained by Boustany from the VA’s Chief Business Office, the VA has a nationwide emergency claims payment backlog of over $788 million.

When the VA fails to pay these medical bills on time, veterans’ credit ratings are put at risk.

Read more about Representative Boustany’s proposed solution on his website.

Share With Your Team: Substance Abuse Resources

Find out how AAA’s LifeWorks Employee Assistance Program, automatically covers all member organizations’ employees, can help your staff that is struggling with addiction.

Download our Substance Abuse PDF, then share electronically with employees. Articles covered include:

  • If You Suspect an Employee Has a Substance Abuse Problem
  • Recognizing a Substance Abuse Problem and What to Do
  • Drug and Alcohol Abuse: Warning Signs
  • Prescription Drug Abuse
  • Quick Facts About Alcohol Abuse
  • Support Groups for Family and Friends of Substance Abusers
  • What to Do If You Suspect a Co-Worker Has a Substance Abuse Problem
  • What is Reasonable Suspicion?
  • How to Help Someone Getting Past Resistance to Drug and Alcohol Treatment
  • Treating Addiction
  • How to Use the Employee Assistance Program
  • and many more!

Download Substance Abuse PDF

As always, you and your team can call our dedicated hotline, 1-800-929-0068, 24/7 to set appointments for FREE IN-PERSON COUNSELING in your area. Learn more on our AAA Employee Assistance Program page (membership required.)

FDA Issues First Responder Drug Dispenser Guidance

In accordance with the Drug Supply Chain Security Act of 2013, the FDA issued regulations last year to require drug dispensaries to build an electronic system to identify and track the distribution of drugs. Many small dispensaries do not have the ability currently to electronically trace small quantities of drugs. The AAA became concerned that hospital and other small dispensers would no longer provide first responders with critical drugs in fear of not being compliant with the new regulations. The AAA joined a coalition of dispensaries, pharmacists and others that also had concerns with the new regulations.

As a result of the efforts of the coalition and the AAA, we were able to delay enforcement of the requirements until today, March 1. The AAA then worked directly with the FDA to educate them about the unique nature that small dispensaries sometimes play in restocking certain ambulance service providers. Upon learning of these transactions, the FDA shared our concerns and worked quickly to release the guidance.

The guidance states that the FDA will not take action against drug dispensaries in providing drugs to first responders if the dispensary follows certain basic recording keeping policies. The agency will also not take any action against the first responder. The guidance is entitled “Requirements for Transactions with First Responders under Section 582 of the Federal Food, Drug, and Cosmetic Act — Compliance Policy Guidance for Industry“.

Musings on 2014 Medicare Payment Data…Part 2

Brian S. Werfel, AAA Medicare Consultant

Every year, the Centers for Medicare and Medicaid Services (CMS) releases data on Medicare payments for the preceding year. The 2015 Physician/Supplier Procedure Master File (PSP Master File) was released in late November 2015. This report contains information on all Part B and DME claims processed through the Medicare Common Working File with 2014 dates of service.

In last month’s post, I focused on total Medicare spending. This month, I want to shine the spotlight on Medicare’s payment for ambulance transports to and from dialysis.

It is no secret that the federal government has long viewed dialysis transports with suspicion. In 1994, the HHS Office of the Inspector General (OIG) issued a report citing dialysis transports as an area of concern. In a 2013 report, the OIG cited the dramatic increase in the volume of dialysis transports since the implementation of the Medicare Ambulance Fee Schedule as evidence that the Medicare ambulance benefit is vulnerable to fraud and abuse. Dialysis transports were also featured heavily in the OIG’s 2015 report on questionable billing practices.  A 2013 report by the Medicare Payment Advisory Commission (MedPAC) noted that the utilization of BLS non-emergency transports, dialysis in particular, had grown faster than the utilization of other ambulance levels of service.

The Numbers Don’t Lie…

According to statistics provided by the U.S. Department of Health and Human Services, the population of ESRD patients increased by 85% from 2002 to 2011. Over that same period of time, the OIG noted that the number of covered ambulance transports to and from dialysis increased by more than 269%. In other words, while the ESRD population has grown steadily over time, an increasing number of those patients are transported to and from their dialysis appointments by ambulance.

Medicare payment data confirms this. In 2007, Medicare paid a total of $445.8 million for dialysis transports. In 2014, Medicare paid $717.1 million for dialysis, an increase of 60.86%. The increase is even more dramatic when you consider that Congress mandated a permanent 10% reduction in Medicare’s payments for dialysis transports furnished on or after October 1, 2013. Without that reduction, Medicare’s payments for dialysis would have been closer to $800 million in 2014, an increase of nearly 80%. Over that same period of time, total Medicare payments for ambulance increased by only 27.08%.

Between 2007 and 2014, Medicare’s payments for ambulance services increased by approximately $1.06 billion, with dialysis transports accounting for $354 million. In other words, approximately one-third of the total increase in Medicare spending on ambulance is attributable to dialysis.

If you focus only on BLS non-emergency transports, the impact of dialysis is even more striking. In 2014, Medicare paid $1.139 million for BLS non-emergency transports (not counting mileage). This is almost essentially unchanged from the $1.131 million it spent in 2010. However, during that same period, payments for BLS non-emergency transports to dialysis increased from $513.7 million to $558.4 million. Put another way, if you remove transports for dialysis, Medicare’s payments for BLS non-emergency transports (and non-emergency transports in general) actually declined over the past five years.

In its 2013 report on ambulance utilization, the OIG noted that dialysis transports had increased to 19% of all covered ambulance transports in 2011, up from 9% in 2002. Note: in 2014, dialysis transports had dropped to 17.1% of all covered transports, suggesting we may start to see the pendulum shifting back a bit.

Our industry may ultimately look back on 2013 as a tipping point. That year marked the first time that the total volume of BLS non-emergency transports to and from dialysis exceeded the number of BLS non-emergency transports to or from places other than dialysis.

But They don’t Tell the Full Story Either…

While the overall trend has been upwards, the increase in dialysis transports is not a national phenomenon. Rather, this increase is largely confined to a handful of states.

As noted above, Medicare’s payments for dialysis transports increased by approximately $45 million between 2010 and 2014. During that same period, Medicare’s payments for dialysis transports in New Jersey increased by $50.7 million. You read that right, if you exclude New Jersey, total Medicare payments for dialysis would have declined nationwide. If you have ever asked: “Why was New Jersey selected to be one of the initial 3 states for the prior authorization program?”, you have your answer.

Other states that saw significant increases over that period include:

State 2010 Dialysis Payments 2013 (2014)

Dialysis Payments

California $87.7 million $106.0 million
Georgia $25.5 million $69.9 million (2014)
Illinois $13.5 million $19.3 million (2014)
Louisiana $4.0 million $6.4 million
Michigan $12.7 million $17.5 million
New York $23.5 million $30.1 million (2014)
South Carolina $51.1 million $62.4 million
Virginia $25.3 million $30.2 million
West Virginia $7.9 million $9.9 million (2014)

If your state is not one of the ones listed above, chances are Medicare’s payments for dialysis are lower today than they were 5 years ago. This includes a number of states and/or territories that, historically, have been recognized as having a so-called “dialysis problem.” For example, total payments for dialysis have declined in Texas from $86.7 million in 2010 (itself a significant reduction from 2007) down to $53.8 million in 2014. This is likely the result of ongoing enforcement efforts in the state, including a moratorium on the enrollment of new ambulance providers. Pennsylvania, also selected to be part of the initial prior authorization program, saw payments for dialysis transports drop to $39.2 million in 2014, down from $62.6 million in 2010.

As I look at this data, two thoughts come to mind. The first is that, to the extent you agree that there is a problem with dialysis transports (and I am one of those that does), it is clear that the problem is largely confined to a handful of states.

The second is that our overall perspective on our industry may need to change. Traditionally, we have viewed the industry through the prism of “emergency” vs. “non-emergency.” And there are valid operations reasons to distinguish between these two categories. However, I can’t help but wonder if that worldview isn’t overly simplistic these days. Maybe we need to start viewing our industry as having three components, emergencies, non-emergencies, and dialysis.


AAA members, submit a Medicare question to Brian! Not yet a member? Learn more.

American Ambulance Association and Journal of Emergency Medical Services Announce Collaboration

Press Release

For Immediate Release


Amanda Riordan
Membership Director
American Ambulance Association

A.J. Heightman, MPA, EMT-P
Journal of Emergency Medical Services

Baltimore, MD, February 25, 2016 – The American Ambulance Association (AAA) and the Journal of Emergency Medical Services (JEMS) today announced a collaboration to bring robust content and educational offerings to AAA members in the emergency medical services (EMS) and medical transportation industry.

AAA members will now receive complimentary access to EMS Insider gated content covering key EMS topics for top-level decision-makers. Additionally, JEMS will provide in-depth journalistic coverage, as the exclusive media partner, of AAA’s events and initiatives, including the Stars of Life EMS personnel recognition program.

“We are excited to bring innovative EMS Insider content and high-quality event coverage to our members,” said American Ambulance Association executive vice president Maria Bianchi. “We look forward to working with the JEMS team to shine light on the AAA Stars of Life who do so much for their communities.”

JEMS is pleased to collaborate with the American Ambulance Association,” said A.J. Heightman, editor-in-chief of JEMS and EMS Insider. “AAA members are EMS leaders, and we look forward to providing additional content that will support their efforts to provide expert care to patients while driving operational excellence.”

To kick off the partnership, AAA will exhibit at EMS Today Conference and Exposition|The JEMS Conference 2016 in Baltimore, February 25–27, accompanied by top leaders from the member community. JEMS will in turn serve as the official media partner of AAA’s Stars of Life in Washington, D.C. April 11–13, bringing fresh visibility to the EMS heroes honored there. The collaboration will carry through the 2016 AAA Annual Conference and Tradeshow and EMS Today Conference and Exposition|The JEMS Conference 2017 in Salt Lake City, UT, with additional content and networking opportunities for AAA members to be developed over time. “This is just the beginning,” said JEMS’s A.J. Heightman.

About the American Ambulance Association (AAA)

Founded in 1979, the American Ambulance Association represents hundreds of ambulance services across the United States that participate in emergency and nonemergency care and medical transportation. AAA’s advocacy, member resources, educational offerings, and publications support excellence in pre-hospital care, an essential part of the public healthcare system.

About the Journal of Emergency Medical Services (JEMS)

As “The Conscience of EMS,” JEMS leads the industry in providing the EMS advanced provider, instructor and administrator with clinical breakthroughs, product reviews, continuing education and more. JEMS is backed by the strength of PennWell, a media and information company with 130 print and online magazines and newsletters, 60 conferences and exhibitions on six continents, and an extensive offering of books, maps, websites, research products, digital media, and database services.

About PennWell Corporation

Founded in 1910 in Tulsa, Oklahoma, PennWell Corporation is a privately held and highly diversified business-to-business media and information company that provides quality content and integrated marketing solutions for the following industries:  Oil and gas, electric power generation and delivery, hydropower, renewable energy, water and wastewater treatment, waste management, electronics, semiconductor manufacturing, optoelectronics, fiber-optics, aerospace and avionics, LEDs and lighting, fire and emergency services, public safety, and dental.

PennWell publishes over 130 print and online magazines and newsletters, conducts 60 conferences and exhibitions on six continents, and has an extensive offering of books, maps, websites, research and database services.  PennWell Public Safety, a PennWell business located in La Jolla, CA, produces public safety products and services including JEMS (Journal of Emergency Medical Services),, Law Officer Magazine, EMS Today Conference and Exposition, and other products.

In addition to PennWell’s headquarters in Tulsa, Oklahoma, the Company has major offices in Nashua, New Hampshire; London, England; Houston, Texas; San Diego and Mountain View, California; Fairlawn, New Jersey; Moscow, Russia; and Hong Kong, China.

– END –

Calculating Excess Mileage

The American Ambulance Association receives many questions from members for our expert consultants. Starting in February 2016, we will share responses to common questions on our blog. Have a more complex question? Contact an AAA expert directly.
Medicare | Human Resources & Operations | Labor Relations

Ask An AAA Expert: Ambulance Service Needs Some Direction on Mileage

[dropcap1]Q:[/dropcap1] Our service operates in a large metropolitan area. Within the city limits is a major university medical center. This hospital operates the only Level 1 Trauma Center within 100 miles. It is also the only hospital to offer interventional cardiology services and certain other advanced services within a 50-mile radius. As a result, patients from outlying areas are frequently transferred to this hospital. As the medical center’s contracted ambulance provider, we are often asked to transport patients long distances back to their towns of origin, either to their residences or to a skilled nursing centers (SNF). There are approximately a half a dozen SNFs located within a short distance (approximately five miles) of the hospital. Can you help us determine whether all of the mileage for these long distance transports will be covered by Medicare? If all of the mileage is not covered, can you help us determine the portion of the mileage that would be covered?

[dropcap1]A:[/dropcap1] In this inaugural edition of Ask the Medicare Consultant, we tackle one of the more difficult aspects of Medicare billing: how to determine the number of covered miles for long-distance hospital discharges.

The starting point for answering this question is to recognize that Medicare’s coverage rules will differ depending upon whether the patient is: (1) being returned to his or her residence, (2) is being returned to an SNF where he or she previously resided, or (3) is being transported to an SNF for an initial admission.

Where the patient is being returned to a residence (or a SNF at which they were previously admitted as a resident), Medicare’s coverage rules are relatively straightforward. Section 10.3.1 of Chapter 10 of the Medicare Benefit Policy Manual provides that:

“Ambulance service from an institution to the beneficiary’s home is covered when the home is within the locality of such institution, or where the beneficiary’s home is outside the locality of such institution, but the institution, in relation to the home, is the nearest one with appropriate facilities.”

For these purposes “locality” means the area surrounding the hospital from which patients would normally travel to that hospital for medical care. See Section 10.3.5 of Chapter 10 of the Medicare Benefit Policy Manual. Therefore, to the extent the patient’s residence falls within the “catchment area” of the hospital, the Manual makes clear that all of the mileage back to the patient’s residence will be covered.

To the extent the patient’s residence falls outside the hospital’s catchment area, the test is whether that hospital was the nearest appropriate facility (in relation to the patient’s residence) for the treatment of the patient’s medical condition.

Consider a patient that went to his local hospital with a complaint of chest pain, and who was ultimately diagnosed with a major cardiac blockage requiring bypass surgery. The patient was then transferred to the university medical center for that surgery (the only facility offering interventional cardiology within a 50-mile radius). The patient is now ready to be discharged back to his residence, a distance of 45 miles.

In this instance, the patient’s residence falls outside the catchment area of the medical center. However, the medical center was the nearest appropriate facility for the treatment of the patient’s medical condition. Accordingly, all of the mileage to this patient’s residence would be covered.

Unfortunately, it can sometimes be difficult to apply this test in practice, because the patient’s medical condition does not always manifest itself while at home. For example, what if this cardiac patient did not reside in the area, but rather was in the area visiting a son or daughter? Let’s further assume that the patient actually resided a few hundred miles away, in another major urban center (e.g., Chicago).

The university medical center would clearly not be the nearest appropriate facility when measured in relation to the patient’s home. Therefore, at the onset, it is clear that there is some non-covered mileage. The question then becomes, “how many miles?”

The test indicates that the covered mileage is the mileage from the patient’s residence to the nearest appropriate facility for that treatment. For these purposes, let’s also assume that there is a hospital that offers interventional cardiology located 10 miles from the patient’s residence. Therefore, in this example, the first 10 miles would be covered, and the remaining mileage would be non-covered.

A good rule of thumb: if all of mileage from the patient’s residence to the university medical center would have been covered (whether or not the patient actually traveled to that facility by ambulance), then all of the mileage back to that residence will also be covered.

The test for discharges to a SNF for an initial admission is a bit more complicated. The starting point is Section 10.3 of Chapter 10 of the Medicare Benefit Policy Manual, which provides that “only mileage to the nearest appropriate facility equipped to treat the patient is covered.”

In the original question, it was indicated that there were a number of SNFs located within a short distance of the university medical center. For the purposes of convenience, let’s assume that the nearest SNF is located across the street from the hospital, the next closest is located one mile away, the next closest is located two miles away, etc.

Thus, if the patient is transported to the SNF across the street, the entire mileage would be covered.

If the patient was transported to the next closest SNF, we cannot determine whether all of the mileage is covered without first determining whether the closer SNF had a bed available on that date. Note: a facility is not considered an “appropriate facility” if it does not have an available bed at the time of the transport. In other words, if the closer SNF had a bed on that date, then only the mileage to that SNF would be covered. The extra mileage, approximately 9/10ths of a mile, would not be covered. If, however, that closer facility did not have a bed available at the time, then the SNF to which the patient was transported would be the “nearest appropriate facility,” and all of the mileage would be covered.

Now imagine that the patient was taken the SNF two miles from the hospital. To properly calculate the covered mileage, we would need to know whether: (1) the SNF across the street had a bed available and (2) whether the SNF 1 mile from the hospital had a bed available).

[quote_left]“Does CMS really expect me to call one or more SNFs on every hospital discharge?”[/quote_left]And so on and so on…

At this point, you are probably asking yourself, “How can I possibly know if each of these closer SNFs had a bed available on that date? Does CMS really expect me to call one or more SNFs on every hospital discharge?”

The short answer: Yes, a literal interpretation of the Medicare coverage rules would require you to make those phone calls.

It goes without saying that this sort of process would be burdensome. Depending on the actual miles traveled, it may not even be possible to identify each and every closer SNF. For example, the original question alludes to transports of 50 or more miles. There could be dozens of SNFs located within a shorter distance. Calling each and every one of them is simply impractical.

In a perfect world, the hospital staff would notify you at the time they schedule the call that the patient is being transported beyond the nearest appropriate facility. However, in order to notify you, the hospital would have to know whether the nearby SNFs had a bed available on that date. The only way they could know that information would be to have called themselves. But why would the hospital call? The hospital likely gave the patient a choice, i.e., you can do your rehab in a nearby SNF or you can elect to go to an SNF in your hometown where you can be closer to your friends and family. As you would expect, the patient then elected to go closer to home.

So what to do?

One solution used by a number of ambulance providers is to draw a circle around the hospital that incorporates a sufficient number of SNFs so that they can be reasonably confident that there would be an available bed on any given day. In the original example, let’s assume that is the six SNFs located within five miles of the hospital. These ambulance providers have elected not to question any mileage below this threshold. Instead, they will bill up to five miles for coverage without any questions. These providers then assume that anything over that five-mile threshold is going to be excess mileage, which will need to be billed to the patient.

Please note that I am not suggesting that the first five miles would always be covered. Rather, these providers are engaged in a cost/benefit analysis. They are balancing the chances of having some portion of those five miles disallowed during a Medicare audit against the time and effort involved in calling each of these SNFs.

Please also keep in mind that this mileage circle would vary based on the local geography. In some areas, you may need to go out to 10, 20, or even 30 miles before you can incorporate a sufficient number of SNFs so that you can be assured that at least one would have an available bed on any given date. Of course, the larger the circle, the greater the potential that you may end up billing for substantial amounts of non-covered mileage. Thus, the decision to adopt a mileage parameter is one that should be made in consultation with your legal advisors.


Have a Medicare billing question? Do you suspect other AAA members are struggling with the same issues? If so, please let us know.


CMS Publishes Medicare Fee-for-Service Provider & Supplier Lists

Earlier today, AAA representatives participated on an invitation-only stakeholder call in which CMS announced the availability of two new public data sets. The first data set shows through an interactive map the availability and use of services provided to Medicare beneficiaries by ground ambulance suppliers and home health agencies. The second data set is a list of Medicare fee-for-service (FFS) providers and suppliers currently approved to bill Medicare. CMS just released the two data sets to the public.

The first data set, the Moratoria Provider Services and Utilization Data Tool, includes interactive maps and a data-set that shows national, state, and county-level provider and supplier services and utilization data that can be used by CMS to determine which geographic and health service areas might be considered for a moratorium on new provider and supplier enrollments. The data provides the number of Medicare providers and suppliers servicing a geographic region, identifies moratoria regions at the state and county levels, and identifies the number of people with Medicare benefits who use a specific health service in that region. The data can also be used to reveal service levels related to the number of providers and suppliers in a geographic region. Utilization data and geographic regions for these services can be easily compared using interactive maps.

You can access the Moratoria Provider Services and Utilization Data Tool at:
The provider/supplier enrollment data set can be accessed at:

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