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Summary of CMS Ambulance Open Door Forum of November 5, 2015

By David M. Werfel, Esq. | Updated November 6, 2015

On November 5, 2015, the Centers for Medicare and Medicaid Services (CMS) conducted its latest Ambulance Open Door Forum.  As usual, CMS started with announcements, which were as follows:

As required under the Medicare Access and CHIP Reauthorization Act (HR 2), the pilot program for prior authorization for non-emergency repetitive patients will be expanded to Delaware, the District of Columbia, Maryland, North Carolina, Virginia and West Virginia, effective January 1, 2016.  A Special Open Door Forum on the topic will be held by CMS on November 10, 2015 from 12:30 to 1:30 pm. (Link to PDF).

Payment Policies

On October 30, CMS released the final rule on changes in CY 2016 to the Medicare ambulance fee schedule.  The final rule will be published in the Federal Register on November 16, 2015.  The rule finalizes the following:

  • The 2% urban, 3% rural and 22.6% super rural adjustments have been extended through December 31, 2017.
  • Urban/Rural Designations – CMS will continue in 2016 and thereafter with the current geographic designations of urban and rural that were implemented on January 1, 2015. CMS also stated the Agency is further reviewing those zip codes which are a RUCA 2 or 3 and have a portion that include a rural census tract.  The Agency will issue possible changes in a proposed rule.  This review was requested by the AAA and should result in more urban zip codes being designated as rural.
  • Vehicle/Staff – For Medicare purposes, a BLS vehicle must include at least a driver and an EMT-Basic.  However, the vehicle/staff must also meet all state and local rules.

ICD-10 – CMS published an ambulance crosswalk from ICD-9 codes to ICD-10 codes.  Also, the condition codes list is only a guide and using one of the codes does not guarantee coverage.

Meeting at the AAA

  • Rogers spoke at the AAA Workshop on Prior Authorization held at the AAA headquarters on October 2.  He thanked the AAA for inviting him as a speaker.
  • Rogers mentioned one of the issues he discussed at the AAA headquarters was the transportation of psychiatric patients. Dr. Rogers indicated that his opinion is that when patients are in a “psychiatric hold”, that the psychiatric hold, by itself, does not constitute Medicare coverage for an ambulance.  He indicated that coverage would exist if there was IV, EKG, medications administered, etc., but that possible elopement was not enough for coverage.  Dr. Rogers’s statement was his individual opinion.  The AAA does not agree with that opinion and we will be following up with Dr. Rogers and CMS on the matter.
  • Rogers stated another issue discussed at the AAA headquarters was on the proper level of service being determined at the time of dispatch. He stated that it was his opinion that Medicare should reimburse for the level of service dispatched.

Healthcare Marketplace – individuals can apply for health coverage through the marketplace from November 1, 2015 to January 31, 2016 through

Medicare Open Enrollment – CMS announced the Open Enrollment period has begun for Medicare beneficiaries to select their plan.

The question and answer period followed the announcements.  As usual, several resulted in the caller being asked to e-mail their question to CMS.  Questions concerning the prior authorization program were asked but the callers were told the questions would be answered on the Special Open Door Forum for prior authorization that will be held on November 10.  Answers to questions asked were as follows:

  • Medicare does not cover an ambulance transport of a psych patient, as the patient can be transported safely by other means, such as by law enforcement.
  • When physicians and facilities do not provide records needed for prior authorization, the ambulance provider may have to choose discontinuing transportation of that patient.
  • The denial rate for ICD-10 codes is the same as it was for ICD-9 codes.
  • No solution was offered for situations where the SNF uses 911 to call for an ambulance that they know is not needed.
  • When Medicaid pays and takes back its payment more than a year after the date of service, due to the patient receiving retroactive Medicare eligibility, Medicare can be billed.

No date was given for the next Ambulance Open Door Forum, other than the November 10 date for the Special Open Door Forum on the expansion of prior authorization.

Novitas Issues Guidance for Ambulance Providers, Facilities and Beneficiaries Regarding Expansion of Prior Authorization Project for Repetitive Patients

September 17, 2015

Novitas Solutions, Inc. (Novitas) recently issued a series of guidance documents on the expansion of the prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project is currently operating in the states of New Jersey, Pennsylvania, and South Carolina.

The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. Law 114-10), enacted on April 16, 2015, requires that this program be expanded into the remaining states of MAC Regions L (Delaware, Maryland, and the District of Columbia) and M (North Carolina, Virginia, and West Virginia), effective January 1, 2016. The program will be further expanded to cover all remaining states starting on January 1, 2017.

Novitas is the Medicare Administrative Contractor for MAC Region L, and therefore will be responsible for implementing this program in Delaware, Maryland and the District of Columbia. These guidance documents are intended to educate ambulance services, health care professionals and facilities, and beneficiaries located in these states on the programs requirements.

Guidance Document for Ambulance Services

On August 17, 2015, Novitas issued a “Dear Ambulance Company” letter that provides guidance to ambulance companies on how the program will operate. As noted in the letter, participation is voluntary.

However, ambulance services that elect not to seek prior authorization for repetitive patients (defined as a patient that is transported by non-emergency ambulance for the same service either: (1) three or more times in a 10-day period or (2) once a week for three straight weeks) will find that claims for these patients will be subject to a prepayment review. For this reason, it is anticipated that most ambulance services will elect to seek prior authorization for their repetitive patient population.

The letter further summarizes the documentation requirements needed to request prior authorization for a patient. These include the submission of a prior authorization cover sheet (which can be found on Novitas’ website), a valid Physician Certification Statement (PCS) signed by the beneficiary’s attending physician within sixty (60) days of the requested first transport date, and all other medical records supporting medical necessity.

Novitas will review the submitted documentation and issue either a prior authorization covering all transports within a set date range, or a rejection. To the extent an application is rejected, the provider will be entitled to resubmit the application with additional documentation to support medical necessity.

Guidance Document for Health Care Professionals and Facilities

On August 24, 2015, Novitas issued a “Dear Healthcare Provider/Facility” letter that provides guidance to physicians, healthcare practitioners, and facilities on how the prior authorization project will operate. This letter includes bolded language that indicates that these individuals and facilities must provide certain records to the transporting ambulance service and/or the beneficiary. The letter specifically includes a statement that “[a]ttending physicians must provide a physician certification statement (PCS) and medical records that support medical necessity.” Members may want to download copies of this letter for distribution to physicians and facilities from which they may need to obtain PCS forms and other medical records.

Guidance Document for Beneficiaries

On August 20, 2015, Novitas issued a “Dear Medicare Beneficiary” letter that is intended to educate Medicare beneficiaries on the operation of the prior authorization project. The letter indicates that the pre-approval process is intended to allow the beneficiary to know whether his or her transports will be covered by Medicare prior to the provision of services. The letter indicates that either the beneficiary or the ambulance service can obtain a prior authorization, but notes that the ambulance provider will typically be the one submitting requests. Members may want to download copies of this letter for distribution to beneficiaries and their families.

AAA to hold Prior Authorization Workshop on October 2, 2015

The AAA will be holding a one-day workshop devoted exclusively to the prior authorization program. The workshop will take place on October 2, 2015 at the AAA Headquarters located in McLean, Virginia. This workshop will feature representatives from both Novitas and Palmetto (the MAC for Region M), who will be able to provide additional details on how the project will operate in their areas. Dr. William Rogers from the Centers for Medicare and Medicaid Services will also be in attendance to offer CMS’ perspective on this new program. This is a wonderful opportunity for CEOs and senior ambulance executives in the affected states to hear first-hand how this project will impact their ambulance services.

Spotlight: David Tetrault

David Tetrault
Farmington, MO, USA
Administrator/CEO, St. Francois County Ambulance District
Director, AAA Board, Region 4

Tell us a little about yourself, please.

I grew up in Jennings, Missouri, a small town in St. Louis County. I’m the baby of six kids—four brothers and a sister. I am very proud of my twin girls who just graduated from high school while simultaneously completing their associates degrees. They are now off to college to Rolla, Missouri, to finish their bachelors degrees. In addition to sharing time with my family and friends, I enjoy softball, camping, swimming, tennis, and walking.

How did you come to work in the industry? How long have you been involved?

David with some of his staff at a recent AAA workshop.
David with some of his team at a recent AAA workshop.

Years ago I was involved in part of the law enforcement arena called “Police Explorers”, primarily because my brother was a police officer. From there, I progressed through many different facets of law enforcement. The one thing that sticks out in my mind is that every time I was involved in an incident including a sick person or trauma, I really felt as if I would filling my calling. I could calm people and make them feel better, even when at that point I had only first responder training.

I have been involved with EMS for more than 30 years now, from my early days as a dispatcher, then up the ranks to Training Officer, then Manager, and now CEO/Administrator here in St. Francois County.

What do you enjoy most about your job?

I enjoy working with the public, people in our community, and my staff. They are my second family.

What is your biggest professional challenge?

Dealing with the younger spirited individuals coming into the world of EMS. Understanding the different challenges in funding, retention of our employee’s, the right mix of people and balancing the good/bad at the same time.

Making sure the Emergency Medical Services is not the forgotten one in the mix of Fire and Police. We all have a very important roles and the same amount of responsibility.

What is your typical day like?

My day typically starts with putting out fires and finishing my to do list from the previous day. Having 24/7 responsibility for a large program has its ups and downs—including sometimes getting called into work in the middle of the night. By sunrise, I have usually been up and on the highway for several hours. During typical office hours, I attend meetings and handle projects, budgeting, scheduling, and other tasks that need to be completed to keep our service operating. I also address any concerns or needs of the board of directors.

How has participation in AAA membership and advocacy helped your organization?

The American Ambulance Association has bridged the gap for me in my role as a service Administrator/CEO. AAA has many valuable resources, and provides me access to a vast network of ambulance services across the United States. My fellow AAA members as well as staff are always available to answer questions.

AAA has been the leader in ambulance services resources for many years, and they continue to strive to be the best in everything they offer. I enjoy the daily updates, and feel that the work AAA does with benchmarking and standands forms the backbone of the industry. The American Ambulance Association is truly a leader for EMS.


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