AAA/NAEMT Request PSOB Coverage for All Medics During COVID-19

On April 9, the AAA and the National Association of Emergency Medical Technicians (NAEMT) sent a letter to U.S. Attorney General William Barr requesting the Department of Justice extend coverage under the Public Safety Officers’ Benefits (PSOB) program to all paramedics and EMTs during the COVID-19 national health emergency. While paramedics and EMTs employed by governmental and non-profit EMS agencies are currently eligible for the program, those employed by private for-profit organizations and on the front lines of responding to COVID-19 pandemic are not covered. Read Letter HERE.

AAA Sends Letter to Treasury Secretary Mnuchin on Paycheck Protection Program

Earlier today, the AAA sent a letter to Treasury Secretary Mnuchin asking that he use his discretionary authority to apply the same terms of the Paycheck Protection Program (PPP) to ambulance service organizations with 500 or more employees. The PPP, established by the CARES Act, is only available to businesses with 500 or fewer employees and provides more favorable loan terms based on the retention of employees. Read the letter HERE.

HHS Announces Release of Initial Tranche of CARES Act Provider Relief Funding

On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.  These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.  These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19.  Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”

On April 9, 2020, the Department of Health and Human Services (HHS) indicated that it would be disbursing the first $30 billion of relief funding to eligible providers and suppliers starting on April 10, 2020.  This money will be disbursed via direct deposit into eligible providers and supplier bank accounts.  Please note that these are outright payments, i.e., these are not loans that will need to be repaid. 

Who is Eligible to Receive Relief Fund Payments?

HHS indicated that any healthcare provider or supplier that received Medicare Fee-For-Service reimbursements in 2019 will be eligible for the initial allocation.  Payments to practices that are part of larger medical groups will be sent to the group’s central billing office (based on Medicare enrollment information).  HHS indicated that billing organizations will be identified by their Taxpayer Identification Numbers (TINs).

Are There Any Conditions to Receipt of this Funding?

Yes.  As a condition to receiving relief funding, a healthcare provider or supplier must agree not to seek to collection out-of-pocket payments from COVID-19 patients that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.

How is the Amount of Relief Funding an Entity will Receive Determined?

HHS indicated that the amounts healthcare providers and suppliers will receive will be based on their pro-rata share of total Medicare FFS expenditures in 2019.  HHS indicated that Medicare FFS payments totaled $484 billion in 2019.

Providers and suppliers can estimate their initial relief payment amount by dividing their 2019 Medicare FFS reimbursement by $484 billion, and then multiplying that “ratio” by $30 billion.  Note: payments from Medicare Advantage plans are not included in the calculation of a provider’s/supplier’s total 2019 Medicare payments.

As an example, HHS cited a community hospital that received $121 million in Medicare payments in 2019.  HHS indicated that this hospital’s ratio would be 0.00025.  That amount is then multiplied by $30 billion to come up with its initial relief fund payment of $7.5 million.

The AAA has created a CARES Act Provider Relief Calculator
that you can use to estimate your initial relief payment.  |
USE DOWNLOADABLE EXCEL CALCULATOR►

Do I Need to do Anything to Receive Relief Funds?

No.  You do not need to do anything to receive your relief funding.  HHS has partnered with UnitedHealth Group (UHG) to disburse these monies using the Automated Clearing House (ACH) system.  Payments will be made automatically to the ACH account information on file with UHG or CMS.

Providers and suppliers that are normally paid by CMS through paper checks will receive a check from CMS within the next few weeks.

How Will I Know if I Received My Relief Funds?

The ACH deposit will come to you via Optum Bank.  The payment description will read “HHSPayment.”

Do I Need to do Anything Once I Receive My Relief Funds?

Yes.  You will need to sign an attestation statement confirming relief of the funds within 30 days.  These attestations will be made through a webportal that HHS anticipates opening the week of April 13, 2020.  The portal will need to be accessed through the CARES Act Provider Relief Fund webpage, which can be accessed by clicking here.

You will also be required to accept the Terms and Conditions within 30 days.  Providers and suppliers that do not wish to accept these terms and conditions are required to notify HHS within 30 days, and then remit full repayment of the relief funds.  The Terms and Conditions can be reviewed by clicking here.

How will HHS Distribute the Remaining $70 Billion in Relief Funds?

HHS has indicated that it intends to use the remaining relief funds to make targeted distributions to providers in areas particularly impacted by the COVID-19 outbreak, rural providers, providers of services with lower shares of Medicare reimbursement or who predominantly serve Medicaid populations, and providers requesting reimbursement for the treatment of uninsured Americans.

COVID-19 Relief Payments Begin Today

AAA ADVOCATES FOR COVID-19 RELIEF FOR AMBULANCE SERVICES

COVID-19 Relief Payments Begin Today

Beginning today, ambulance service suppliers and providers should start automatically receiving an allocation of payments from the Public Health and Social Emergency Fund. According to the Department of Health and Human Services (HHS), an initial distribution of $30 billion of the funds appropriated through the CARES Act will be distributed to Medicare providers and suppliers over the next week. The Fund was appropriated at $100 billion but not all the funds will be distributed as direct payments to providers and suppliers.

HHS is determining the amount of individual payments based on the proportion of the 2019 Medicare payments to the provider or supplier compared to total outlays for Medicare fee-for-service that year of $484 billion. The AAA estimates a total of approximately $265 million will be distributed to ground ambulance services in the initial round of payments. While the initial payments are a good start, the AAA is pushing for ambulance services to receive ten times that amount in initial relief.

The AAA had advocated for funding in the CARES Act for ambulance services and on April 6, the AAA sent HHS Secretary Azar a letter requesting that ambulance service providers and suppliers receive $48,000 per registered ambulance for financial relief from the impact of the COVID-19 pandemic. The AAA is pushing for a similar amount within future economic stimulus packages as well as several other proposals for legislative and regulatory relief.

On Monday, the AAA will be issuing a Call To Action to its members focusing on four of the provisions on our below list.

Priority Access for EMS to PPE and COVID-19 Testing

  • Recognition by FEMA, HHS (USPHS), CDC of need for priority access to personal protection equipment (PPE) and COVID-19 testing for EMS
  • Non-governmental EMS being eligible to apply directly to FEMA for PPE under the Public Assistance Grants and waive applicant match for all emergency response providers

EMS Services Coverage and Reimbursement for COVID-19 Response

  • Waiver for Medicare coverage of treatment in place and loosing of signature requirements
  • 20% increase, similar to hospitals, for emergency and non-emergency ambulance services in treating and transporting COVID-19 patients
  • SCT reimbursement level for COVID-19 transports and waive hospital-to-hospital limitation on SCT

EMS System Financial Sustainability in Response to COVID-19

  • Grant program under HHS specific to EMS for reimbursement of costs resulting from response to COVID-19 and lost revenue. Payment of $48,000 per registered ambulance to each ambulance service provider and supplier.
  • Expand Paycheck Protection Program to ambulance service organizations with 500 or more employees
  • Fuel tax relief for ground ambulance services

The AAA greatly appreciates the work of our members on the front lines of treating, transporting and testing patients with COVID-19 and we will continue to push for help for you.

CARES Act Provider Relief Fund

President Trump is providing support to healthcare providers fighting the COVID-19 pandemic. On March 27, 2020, the President signed the bipartisan CARES legislation that provides $100 billion in relief funds to hospitals and other healthcare providers on the front lines of the coronavirus response. This funding will be used to support healthcare-related expenses or lost revenue attributable to COVID-19 and to ensure uninsured Americans can get testing and treatment for COVID-19.

Immediate infusion of $30 billion into healthcare system

Recognizing the importance of delivering funds in a fast and transparent manner, $30 billion is being distributed immediately – with payments arriving via direct deposit beginning April 10, 2020 – to eligible providers throughout the American healthcare system. These are payments, not loans, to healthcare providers, and will not need to be repaid.

Who is eligible for initial $30 billion

  • All facilities and providers that received Medicare fee-for-service (FFS) reimbursements in 2019 are eligible for this initial rapid distribution.
  • Payments to practices that are part of larger medical groups will be sent to the group’s central billing office.
    • All relief payments are made to the billing organization according to its Taxpayer Identification Number (TIN).
  • As a condition to receiving these funds, providers must agree not to seek collection of out-of-pocket payments from a COVID-19 patient that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.
  • This quick dispersal of funds will provide relief to both providers in areas heavily impacted by the COVID-19 pandemic and those providers who are struggling to keep their doors open due to healthy patients delaying care and cancelled elective services.

How are payment distributions determined

  • Providers will be distributed a portion of the initial $30 billion based on their share of total Medicare FFS reimbursements in 2019. Total FFS payments were approximately $484 billion in 2019.
  • A provider can estimate their payment by dividing their 2019 Medicare FFS (not including Medicare Advantage) payments they received by $484,000,000,000, and multiply that ratio by $30,000,000,000. Providers can obtain their 2019 Medicare FFS billings from their organization’s revenue management system.
  • As an example: A community hospital billed Medicare FFS $121 million in 2019. To determine how much they would receive, use this equation:
    • $121,000,000/$484,000,000,000 x $30,000,000,000 = $7,500,000

What to do if you are an eligible provider

  • HHS has partnered with UnitedHealth Group (UHG) to provide rapid payment to providers eligible for the distribution of the initial $30 billion in funds.
  • Providers will be paid via Automated Clearing House account information on file with UHG or the Centers for Medicare & Medicaid Services (CMS).
    • The automatic payments will come to providers via Optum Bank with “HHSPAYMENT” as the payment description.
    • Providers who normally receive a paper check for reimbursement from CMS, will receive a paper check in the mail for this payment as well, within the next few weeks.
  • Within 30 days of receiving the payment, providers must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. The portal for signing the attestation will be open the week of April 13, 2020, and will be linked on this page.
  • HHS’ payment of this initial tranche of funds is conditioned on the healthcare provider’s acceptance of the Terms and Conditions – PDF, which acceptance must occur within 30 days of receipt of payment.  If a provider receives payment and does not wish to comply with these Terms and Conditions, the provider must do the following: contact HHS within 30 days of receipt of payment and then remit the full payment to HHS as instructed.  Appropriate contact information will be provided soon.

Is this different than the CMS Accelerated and Advance Payment Program?

Yes. The CMS Accelerated and Advance Payment Program has delivered billions of dollars to healthcare providers to help ensure providers and suppliers have the resources needed to combat the pandemic. The CMS accelerated and advance payments are a loan that providers must pay back. For more information from CMS, click here.

How this applies to different types of providers

All relief payments are being made to providers and according to their tax identification number (TIN). For example:

  • Large Organizations and Health Systems: Large Organizations will receive relief payments for each of their billing TINs that bill Medicare. Each organization should look to the part of their organization that bills Medicare to identify details on Medicare payments for 2019 or to identify the accounts where they should expect relief payments.
  • Employed Physicians: Employed physicians should not expect to receive an individual payment directly. The employer organization will receive the relief payment as the billing organization.
  • Physicians in a Group Practice: Individual physicians and providers in a group practice are unlikely to receive individual payments directly, as the group practice will receive the relief fund payment as the billing organization. Providers should look to the part of their organization that bills Medicare to identify details on Medicare payments for 2019 or to identify the accounts where they should expect relief payments.
  • Solo Practitioners: Solo practitioners who bill Medicare will receive a payment under the TIN used to bill Medicare.

Priorities for the remaining $70 billion

The Administration is working rapidly on targeted distributions that will focus on providers in areas particularly impacted by the COVID-19 outbreak, rural providers, providers of services with lower shares of Medicare reimbursement or who predominantly serve the Medicaid population, and providers requesting reimbursement for the treatment of uninsured Americans.

Ensuring Americans are not surprised by bills for COVID-19 medical expenses

The Trump Administration is committed to ensuring that Americans are protected against financial obstacles that might prevent them from getting the testing and treatment they need from COVID-19.

  • As announced in early April, a portion of the $100 billion Provider Relief Fund will be used to reimburse healthcare providers, at Medicare rates, for COVID-related treatment of the uninsured.
    • As a condition, providers are obligated to abstain from “balance billing” any patient for COVID-related treatment.
  • The Families First Coronavirus Response Act requires private insurers to cover an insurance plan member’s cost-sharing payments for COVID-19 testing.
  • President Trump has also secured commitments from private insurers, including Humana, Cigna, UnitedHealth Group, and the Blue Cross Blue Shield system to waive cost-sharing payments for treatment related to COVID-19 for plan members.
Content created by Assistant Secretary for Public Affairs (ASPA)
Content last reviewed on April 9, 2020

Senate Passes Economic Stimulus Package Several Provisions Help Ambulance Services!

Moments ago, the U.S. Senate passed an economic stimulus package in response to the coronavirus (COVID-19) outbreak. The House is expected to consider the legislation in the next few days. As a result of the efforts of the AAA and our members who are also on the front line of the response to COVID-19, we were able to improve the final package.

The package includes several provisions that will provide urgent financial assistance and resources to ambulance service organizations and our employees. The provisions are consistent with requests made by the AAA, although they target a broader constituency consistent with much of the rest of the stimulus package.

The provisions in the package related to our requests are as follows:

Stimulus Package Provisions

Health Care Provider Provisions

  • $100 Billion Grant Program: Direct funding to public entities, Medicare or Medicaid enrolled suppliers and providers, and for-profit entities and not-for-profit entities as the Secretary may specify to reimburse for health care related expenses or lost revenues that are attributable to coronavirus. Ambulance service suppliers and providers will file applicants for funding with the Department of Health and Human Services.
  • Sequestration Delay: Suspension of the 2% sequestration cut in Medicare funding for ambulance service and other providers and suppliers. The suspension would begin May 1 and end December 31, 2020 with sequestration then extended from 2029 to 2030.
  • Telehealth: Authorizes the Secretary to waive any of the current requirements in statute for telehealth services during the emergency.

Business Provisions

  • Payroll Tax Deferral: Employers including ambulance service organizations starting upon enactment of the legislation will defer payment of their 6.2% share of the payroll tax through December 31, 2020. Half of the tax will be due by the end of 2021 and the second half by the end of 2022.
  • Small Business Loans: Provides $350 billion in loans under the Payment Protection Program for employers including ambulance service organizations with 500 or fewer employees. Loans available up to $10 million per employer.

Emergency Responder Provisions

  • $45 Billion Disaster Relief Fund: Grants made available under the FEMA Public Assistance Program to state and local governments to address the recovery from COVID-19 including reimbursement for medical response, PPE and backfilling positions. The funding highlights the critical need for access by emergency responders to PPE and other resources. For-profit ambulance service organizations would be eligible for funding through their state or local government. If your organization faces an issue with government officials as to eligibility, please provide them the FEMA Fact Sheet: Public Assistance for Ambulance Services which in 2009 the AAA had successfully encouraged FEMA to issue.
  • $3.5 Billion Child Care Grants: Provides funding for childcare programs for essential workers including emergency responders such as paramedics and EMTs.

Not all of the provisions the AAA had advocated for inclusion in the package were addressed in some way. This is likely not the last legislative package that the Congress develops to combat COVID-19 and we will advocate for our provisions to be included in future packages. We will also continue to push these issues through regulatory and other legislative efforts as outlined below.

Regulatory and Additional Legislative Efforts

Coverage of Treatment in Place and Alternative Destination

On March 11, the AAA sent a letter to CMS Administrator Seema Verma asking the agency to wave regulatory restrictions for treatment in place and transport to alternative destinations and for Medicare to cover these services related to potential COVID-19 cases. CMS had initially indicated they do not think they have the authority to wave the restrictions under the 1135 Waiver, but the AAA is continuing to work with CMS to provide payment for these services when provided to Medicare beneficiaries.  A press release from the House Republican leadership suggests that this issue is being addressed.

Employee Tax Credit for EMS Training and Uniforms

While the stimulus package includes reimbursement for training and equipment for first responders, it did not include the specific request for an above-the-line tax credit for paramedics and EMTs for training and uniforms paid by the employee. Earlier this year, AAA representatives had met with staff of Congressman Suozzi (D-NY), who sponsored the tax credit language which passed the House late last year, on how we can press the Senate to consider the provision. The AAA will continue to work with Congressman Suozzi on other opportunities to pursue the tax credit.

Federal Benefits during COVID-19 for All Paramedics and EMTs

Several paramedics and EMTs who worked for private ambulance service organizations lost their lives on September 11, 2001, while responding to the aftermath of the attacks on the World Trade Center. Then-Attorney General John Ashcroft extended Public Safety Officers Benefits (PSOB) to the surviving family members of those paramedics and EMTs. The AAA is sending a letter to Attorney General William Barr asking him to provide the same consideration for paramedics and EMTs responding to the COVID-19 outbreak.

The AAA Will Keep Fighting

We will continue to press the Congress and federal agencies for help to ensure ambulance service organizations and our paramedics and EMTs serving on the front lines of the COVID-19 pandemic have the necessary resources and financial assistance to serve their communities.

We greatly appreciate the efforts of all of our members who contacted their members of Congress in support of relief and resources for ambulance services

AAA members can register for our free members-only webinar here

URGENT – CALL TO ACTION Congress Still Negotiating Stimulus Package Ambulance Specific Relief Not Yet Included: Act Now!

None of the proposals offered so far on an economic stimulus package to address the impact of COVID-19 include our specific provisions to provide ambulance relief! Negotiators on a final package failed to reach an agreement over the weekend. There is still time to influence the final outcome! Please write to your members of Congress!

There are provisions in the packages that would help businesses, first responders and Medicare providers and suppliers. However, the AAA is advocating for specific help for ambulance services with the prioritization of COVID-19 resources, coverage of services, as well as direct financial assistance. The Congress has heard directly from the AAA about our requests and they need to hear from their constituents about assistance to your operations. If you have not yet contacted your members of Congress, please do so today!

Please e-mail today the health aides for your members of Congress!

It will take you only a few minutes per congressional office to email a letter. Just follow these steps.

1. USE LETTER TEMPLATE: CLICK HERE to access a draft letter. Please customize your letter including the cities and towns you serve, if you are sending to the office of a Senator or Representative and any additional details as to services you are providing during the COVID-19 outbreak and the financial impact on your operation.

2. LOOK UP HEALTH STAFFER AND EMAIL ADDRESS: CLICK HERE to access a list of the name of the health staffer and email address for all congressional offices.

3. SEND E-MAILS TO STAFFERS: Copy and paste the email address of the health staffer and copy and paste the letter as the body of the e-mail and send.

While the Congress may not include all of our requests in this stimulus package, there are likely to be future legislative vehicles in which the AAA will continue to press for passage of additional relief for ambulance service organizations and personnel.

URGENT – CALL TO ACTION Contact Congress Today About COVID-19 Ambulance Relief!

The Congress and Administration are currently in negotiations to finalize an economic stimulus package to address the impact of COVID-19. As reported previously, the AAA has been pressing for the prioritization of COVID-19 resources and coverage of services, as well as financial assistance, for ambulance services organizations. Negotiations are expected to wrap up this weekend.

Please e-mail today the health aides for your members of Congress!

It will take you only a few minutes per congressional office to email a letter. Just follow these steps.

1. USE LETTER TEMPLATE: CLICK HERE to access a draft letter. Please customize your letter including the cities and towns you serve, if you are sending to the office of a Senator or Representative and any additional details as to services you are providing during the COVID-19 outbreak and the financial impact on your operation.

2. LOOK UP HEALTH STAFFER AND EMAIL ADDRESS: CLICK HERE to access a list of the name of the health staffer and email address for all congressional offices.

3. SEND E-MAILS TO STAFFERS: Copy and paste the email address of the health staffer and copy and paste the letter as the body of the e-mail and send.

While the Congress may not include all of our requests in this stimulus package, there are likely to be future legislative vehicles in which the AAA will continue to press for passage of additional relief for ambulance service organizations and personnel.

AAA Pushing Ambulance COVID-19 Relief

Over the past several days, the AAA has been pushing the Congress and the Administration to provide immediate financial and other relief to ambulance service organizations and their employees. EMS personnel are often the first medical professionals to come into contact with patients with COVID-19. But our members are running low on personal protection equipment and other supplies necessary to respond to the pandemic.

AAA members are providing vital medical services beyond the traditional stabilizing and transporting of patients for which they need to be reimbursed. Our members are also seeing a decrease in both emergency and non-emergency transport call volume as Americans are opting to forgo medically necessary trips to the emergency department and as elective procedures are postponed. It is important that Congress understands the short and long-term implications of our response to COVID-19 and provides critical financial relief.

To help our members in their time of need as they respond to the COVID-19 pandemic, the AAA has been advocating that Congress needs to include in the stimulus package they are developing several provisions to help ambulance service organizations. The provisions include providing ambulance service organizations priority access to PPE, authorizing CMS to waive Medicare policy and reimburse for treatment in place, reimbursing ambulance services for additional costs incurred in responding to COVID-19, suspending the payroll tax and providing all paramedics with coverage under the Public Safety Officers’ Benefit (PSOB) and a tax credit for training and uniforms.

For the details of our requests of the Congress, please access our position paper.

While the Congress is working on its third stimulus package which it is expected to complete in the next few days, it is likely not to be the last. With this package moving so quickly, the AAA has been working with a targeted list of AAA members in the states and districts of key policymakers to the negotiations. We will be issuing in the near term a Call To Action to the entire AAA membership with the request for everyone to contact their members of Congress with our list of requests. We hope you will answer the call.

The AAA will continue over the next weeks and months to push the Congress and Administration on our requests to help ambulance service organizations. Thank you for your support.

Permanent Medicare Ambulance Relief Bill Introduced in House

Moments ago, Congresswoman Terri Sewell (D-AL) and Congressman Devin Nunes (R-CA) introduced the Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2019 (H.R. 4938). Congressmen Peter Welch, (D-VT), Markwayne Mullin (R-OK), and Earl Blumenauer (D-OR) are original cosponsors of the legislation. Thank you to the bill sponsors for their continued support!

H.R. 4938 would help stabilize current and future Medicare reimbursement of ambulance services and set the stage for future reform of the Medicare ambulance fee schedule. If passed, this bill would:

  • Make Medicare Add-ons Permanent – Current temporary 2 percent urban, 3 percent rural, and super rural bonus payments would be made permanent.
  • Expand Prior Authorization Pilot Program Nationwide – To address fraud and abuse with the transportation of dialysis patients by ambulance, the bill expands the Centers for Medicare & Medicaid Services (CMS) national prior authorization program for repetitive non-emergency basic life support (BLS) dialysis transports. CMS has not yet exercised its authority to expand this successful pilot program nationwide. While CMS is considering exercising its authority to extend the program nationwide in a recent proposed rule, it has not made a final determination yet.
  • Provide Regulatory Relief – Amend requirements under the 855 form to make change notifications less burdensome.
  • Protect Access to Ambulance Services in Rural and Low Population Density Areas – Protect access to ambulance services in rural and super-rural areas, by establishing a policy to protect low volume areas and a process for CMS to review changes in the rural or super-rural status of an area after the next census occurs.

The AAA has worked diligently to get this legislation introduced and we are excited to share this news with the membership. We would like to thank all the AAA members who have worked closely with their elected representatives to get this legislation introduced. In the coming weeks, the AAA will be asking members to contact their Members of Congress to voice their support of this legislation.

If you have any questions, please contact Tristan North (tnorth@ambulance.org) or Aidan Camas (acamas@ambulance.org).

Update on AAA Legislative Priorities

The American Ambulance Association has been working hard to accomplish the legislative goals of the membership in the 116th Congress. The AAA would like to take this opportunity to provide an update on what we have accomplished thus far in the 116th Congress.

Balance/Surprise Billing

Balance/surprise billing is a hot button issue that recently came into the spotlight at the start of the 116th Congress. With the President’s announcement calling for Congress to pass legislation that would end surprise billing for patients, there has been an increase in Congressional action on the issue including introduced legislation, discussion drafts and hearings in all committees of jurisdiction. The AAA has been working tirelessly with the Congressional committees of jurisdiction to educate Members and staff on the unique characteristics of EMS systems and that it would be inappropriate to apply the same restrictions on balanced billing to ground ambulance services.

The AAA has formed a working group comprised of AAA member volunteers that have worked on policy and messaging on balance billing. The working group has submitted comments to the Energy and Commerce Committee and Senate HELP committees advocating that the ambulance industry is unique from other stakeholders, and as such, should be looked at differently. Ambulance service providers and suppliers are required by law to treat and transport all patients, regardless of their ability to pay and are heavily regulated at the local level. The AAA has been working to communicate these factors that place the ambulance industry in a different situation than many other stakeholders.

Public Safety Officers Death Benefit (PSOB)

The Public Safety Officers Death Benefit (PSOB), a one-time benefit paid to families of first responders killed in the line of duty, is an issue that the AAA has passionately advocated for over many years. In the 116th Congress, the AAA has secured introduction of legislation in the House of Representatives, H.R. 2887, the Emergency Medical Service Providers Protection Act. H.R. 2887 would extend the PSOB to first responders employed by private for-profit EMS agencies. The AAA was able to secure several commitments from Members of Congress to cosponsor the legislation during Stars of Life meetings in Washington, DC. In addition to taking action to move H.R. 2887 through the legislative process, the AAA will be engaging in an outreach campaign in the next few weeks.

Dialysis Off-Set Restructuring

The AAA has worked toward reintroduction of legislation to restructure the offset that was passed into law in the Bipartisan Budget Act of 2018 (H.R. 1892) in the 115th Congress. This offset included a total cut of 23% to the Medicare reimbursement for basic life support (BLS) non-emergency transports performed by all ambulance service suppliers and providers to and from dialysis centers. This cut served as an offset to the 5-year extension of Medicare add on payments that our industry worked hard to get extended.

The AAA has secured introduction of legislation in both the House and Senate. H.R. 3021 was introduced by Representatives LaHood (R-IL) and Sewell (D-AL) and S. 228 by Senators Cassidy (R-LA) and Jones (D-AL). If passed, this legislation would change the cut that is currently in place so that it applies specifically to companies conducting over 50% ESRD non-emergency transports. Those ambulance services with over 50% ESRD transports would get a cut of 29.5%, while those doing less would receive a 15.5% cut. The AAA will continue to work toward movement and passage of this legislation that would better distribute the reduction to those providers which do almost exclusively non-emergency dialysis transports and thus have a lower cost of providing services.

Medicare Priorities Bill

The AAA has crafted legislation that is specifically aimed at addressing major Medicare ambulance industry issues. The issues that will be included in future legislation include making Medicare ambulance add-ons permanent, implementing a prior-authorization program across the nation, allowing for transportation to alternative destinations, reducing regulatory burdens, and providing relief through maintaining many zip codes as rural following the next census. The AAA is working to get this Medicare priorities legislation introduced in the coming months so that we can get to work on solving these Medicare issues that impact our industry as a whole.

VA Legislation

Another priority that that the AAA has been diligently working toward getting introduced is Veterans Affairs (VA) legislation. The Veterans Reimbursement for Emergency Ambulance Services Act (VREASA) introduced by Congressman Tipton (R-CO) would provide veterans with reimbursement for emergency ambulance services when a Prudent Layperson would have a reasonable expectation that a delay in seeking immediate medical attention will jeopardize the life or health of the veteran. This legislation was introduced as a result of the VA consistently requiring all medical records be provided, including the records of treatment after the emergency service has taken place. Should those records show that it was not a life threatening emergency or a false alarm, the claim for reimbursement is being denied. The VA legislation would mandate that the VA apply the “prudent layperson” definition of emergency to determine coverage of ambulance claims.

The AAA is also working toward addressing two other issues with the VA to enforce more prompt payment by the VA and treating the VA as the first payor, similar to Medicare, as it is determined whether there is a different primary payor. The AAA has been working with Senators Collins and Tester on language help solve this ongoing and serious reimbursement issue.

In our next update, we will be reporting on the progress the AAA has made this year on regulatory issues.

Questions? Contact Us

If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support

House Introduces NEATSA Act Companion Bill (H.R. 3021)

House Introduces NEATSA Act Companion Bill (H.R. 3021)

The American Ambulance Association (AAA) is pleased to announce that, Congressman Darin LaHood (R-IL) and Congresswoman Terri Sewell (D-AL) have introduced H.R. 3021 the “Non-Emergency Ambulance Transportation Sustainability and Accountability Act of 2019” or “NEATSA Act.”

Last year, Congress included in the Bipartisan Budget Act of 2018 an offset to cover the cost of the 5 year extension of the add-ons. The offset cuts reimbursement for BLS non-emergency transports to and from dialysis centers by an additional 13%. This is on top of the preexisting 10% reduction. This legislation would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS non-emergency transports to and from dialysis centers.

H.R. 3021 is the reintroduction of H.R.6269 from last Congress. This legislation serves as a companion bill to the Senate version, S. 228 by Senator Cassidy (R-LA) and Senator Jones (D-AL) which was introduced in January 2019. The additional cut went into effect on October 1, 2018 and has since negatively impacted AAA members. As such, the AAA is grateful for the support of Congressman LaHood and Congresswoman Sewell in working with us to get this important legislation introduced.

The AAA has worked diligently to ensure the timely introduction of this legislation that will ultimately help protect vital ambulance services for end stage renal disease patients. The AAA is working to help pass this bill through the legislative process and we will keep members updated as this legislation moves through Congress.

House Introduces PSOB Bill (H.R. 2887)

The American Ambulance Association (AAA) is pleased to announce that Congressman Lee Zeldin (R-NY-01) and Congressman Thomas Suozzi (D-NY-03) have introduced H.R. 2887, the “Emergency Medical Services Providers Protection Act.” This piece of legislation would extend the Public Safety Officers’ Benefit (PSOB) to cover first responders who work for private providers. The PSOB Program provides death and education benefits to survivors of fallen law enforcement officers, firefighters, and other first responders, and disability benefits to officers catastrophically injured in the line of duty.

The AAA has advocated tirelessly for years that all first responders killed in the line of duty, should be eligible for this benefit regardless of who their employer is. Many of the nation’s first responders work for more than one EMS Agency. Local communities throughout the country decide which organization is best fit to provide high quality mobile healthcare to their community. For large parts of the country, privately run ambulance services have been providing high quality health care, and responding to the same natural disasters, incidents, etc. as their peers for decades.

It is common for Paramedics and EMTs to also work/volunteer as firefighters and vice versa. Currently, if a line of duty death occurs, whether first responders receive this benefit depends on which uniform they were wearing that day. A firefighter picking up an extra shift with a local ambulance service could end up being ineligible for this benefit if that company happens to be privately run. The AAA believes this legislation acknowledges the vital role that all first responders play in keeping our communities safe and healthy. If passed, this change would apply to injuries sustained on or after March 1, 2007.

The AAA thanks Congressman Zeldin and Suozzi for taking the lead on this critical issue. AAA members are encouraged to contact their representatives about co-sponsoring H.R. 2887. Full text of the Bill is not yet available online but can be read here. Please contact the AAA’s Government Affairs team if you have any questions.

Questions? Contact Us

If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

Member Update on Balance Billing

This morning Ruth Hazdovac and Aidan Camas of AAA staff and Kathy Lester, Esq, Healthcare Consultant to the AAA attended a briefing held by the House Energy & Commerce Committee on the issue of surprise/balance billing. At the briefing, staff for Chairman Frank Pallone (D-NJ) and Ranking Member Greg Walden (R-OR) announced that they would be releasing a bipartisan discussion draft, the No Surprises Act, which would “protect consumers from surprise medical bills and increase transparency in our health care system.”

As of now, ground and air ambulances are NOT included in the discussion draft. However, the committee is asking for comments on ground and air ambulance and recommendations on how to provide relief to the consumer in this area. The AAA has a Balance Billing Work Group that is hard at work developing a policy recommendation that will work for our members.

The House Ways and Means Health Subcommittee Chairman Lloyd Doggett also announced today that the Health Subcommittee will hold a hearing next week entitled “Hearing on Protecting Patients from Surprise Medical Bills.” AAA Staff will be at the briefing and provide a timely update to membership on any developments.

The AAA team will be submitting comments and policy recommendations based off the work of the Balance Billing Work Group to both the Energy & Commerce and Ways & Means Committee to ensure that the views of our members are well represented. We will also be reaching out to AAA members in the states of key policymakers on the Committees to submit comments, as well. The AAA will also provide members with key talking points in the event they are contact by their Members of Congress or their staff.

Questions? Contact Us

If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

Release: CMMI Announces Ambulance Innovative Payment Pilot Program

February 14, 2019

For Immediate Release
Contact Maria Bianchi
American Ambulance Association
202-802-9020
info@ambulance.org

CMMI Announces Ambulance Innovative Payment Pilot Program

Washington, DC – Today, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) announced the launch of the Emergency Triage, Treat and Transport (ET3) Model.  During the next five years, this model will test paying ambulance providers and suppliers when they transport beneficiaries to locations other than an emergency department, if the alternative location is more appropriate medically for the patient.  It will also test paying for health care services provided by qualified health care professionals or through telehealth at the scene even if the ambulance does not transport the patient.

While there are several important details yet to be released, this model appears to track the recommendations the American Ambulance Association, our members, and other industry partners have been working with CMS to implement.

“Over the last 7 years, the AAA and our members have been working to develop an innovative payment framework to modernize the Medicare ambulance benefit,” said AAA President Aarron Reinert. “We are pleased that CMS is taking this important step and look forward to working closely with Administrator Verma, Director Boehler and their teams on the details of the ideas announced today to ensure the appropriate implementation.”

Representatives of the American Ambulance Association also participated in the CMS announcement of this model today in DC.  Senior Department of Health and Human Services (HHS) officials including Secretary Alex Azar, CMS Administrator Seema Verma and CMMI Director Adam Boehler spoke at the event. AAA President-Elect Shawn Baird represented the AAA at the announcement.

While the details of the program are still under development and will be communicated through program guidance, a few general details were provided at the event.

The Emergency Triage, Treat and Transport (ET3) Model, would test two new ambulance payment methods. Under ET3, participating ambulance service providers or suppliers would be able to receive payment for:

  • treatment in place with a qualified health care practitioner, either on-the-scene or connected using telehealth; and
  • for unscheduled, emergency transport of Medicare beneficiaries to alternative destinations (such as 24-hour care clinics) other than destinations covered under current regulations (such as hospital EDs).

The program will be national in scope and thus open to all ambulance service suppliers and providers who meet the program requirements, which are still being finalized. The program will be voluntary so providers and suppliers who chose not to participate can continue to be paid under current policy. CMS anticipates releasing applications for the program this summer and an anticipated start date for the program in early 2020.

While seeing the specific details of the program will be crucial, we are very pleased that CMMI is announcing its commitment today to test multiple innovative payment models for ambulance service providers and suppliers. The AAA and our volunteer leaders and members have been working in a collaborative manner with other EMS organizations for the last 5 years to develop an evidence-based, data-driven structural framework to support the adoption of innovative payment models for ambulance emergency and non-emergency services. In 2016, the AAA issued a joint statement with NAEMSP, NAEMSO, and NAEMT outlining this framework. During the last two year, the AAA has worked closely with the Congress, CMS and the CMMI to seek the implementation of this framework. To encourage as broad an adoption as possible, we have focused on achieving these goals through the regulatory process.

The AAA is committed to the development and implementation of innovative payment models.  It is critical that they be designed in a manner that will ensure their success. Adoption of the framework along with having the necessary data to establish reimbursement rates that reflect the cost of providing ambulance services will usher in a new era of ambulance services for not only Medicare beneficiaries, but also for all Americans. As part of the effort to modernize the ambulance benefit, ambulance service suppliers should be recognized as providers of health care services and not merely a transportation benefit. The days of merely driving patients to and from other providers are long gone.

We believe that our efforts and those of the Administration will help us achieve this exciting goal. The AAA supports expanding the destination site for 9-1-1 and similar calls, which is currently limited to hospital emergency departments. For some patients, it is more appropriate to take them to other types of facilities, such as rural health clinics, substance or behavioral health facilities, and inpatient psychiatric hospitals. Allowing ambulance services to use state and local protocols to help triage patients to the most appropriate setting will help address the opioid epidemic and better care for patients with behavioral health issues, as well as urgent low acuity medical conditions.

We want to thank the Congress and the groups at CMS and CMMI who began to lay the ground work for the next phase of innovative payment models last winter as well. We also greatly appreciate the efforts of other EMS representatives who worked with the CMMI to help push for the pilot program.

The AAA will continue to advocate for data and evidence-based changes to the Medicare ambulance fee schedule which allow ambulance service providers and suppliers to provide even better medical services to patients.

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About the American Ambulance Association
The American Ambulance Association, formed in 1979, represents 500 ambulance services across the United States that serve their communities with emergency medical services, interfacility mobile healthcare, and community paramedicine 24/7/365. The Association serves as a voice and clearinghouse for mobile healthcare, and views prehospital care as an essential part of the total public health care system.

Senate Introduces S. 228

Last year, Congress included in the Bipartisan Budget Act of 2018 an offset to cover the cost of the 5 year extension of the add-ons. The offset cuts reimbursement for BLS nonemergency transports to and from dialysis centers by an additional 13%. This is on top of the preexisting 10% reduction.

The AAA is pleased to announce that Senators Bill Cassidy (R-LA) and Doug Jones (D-AL) have recently introduced S. 228 which would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports to and from dialysis centers.

S. 228 is the reintroduction of S. 3619 from last Congress which served as a companion bill to the House version, the NEATSA Act (H.R.6269), by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) which was introduced in June 2018. AAA staff and volunteer leaders are working to get a House version of this legislation reintroduced shortly.

The additional cut went into effect on October 1, 2018 and negatively impacted AAA members. The AAA is working to help pass this legislation and we will keep members updated as this legislation moves through Congress.

Senate Introduces NEATSA Act Companion Bill (S. 3619)

Earlier this year, Congress included in the Bipartisan Budget Act of 2018 an offset to go along with the extension of the add-ons that will cut reimbursement for BLS nonemergency transports to and from dialysis centers by an additional 13%. This will be on top of the existing 10% reduction.

Senators Bill Cassidy (R-LA) and Doug Jones (D-AL) just introduced S. 3619 which would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports to and from dialysis centers. S. 3619 will serve as a companion Bill to the House version, the NEATSA Act (H.R.6269) by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) which was introduced in June 2018.

The additional cut went into effect on October 1 and impacted AAA members and the AAA are working to get this legislation passed. The AAA will be sure to keep members updated as this legislation moves through Congress.

Questions?: Contact Us

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

Rural Health Day Advocacy Update

Happy National Rural Health Day! Thank you to all of the ambulance service providers who work hard providing life-saving treatment in rural areas every day.

In part of our ongoing advocacy efforts, the AAA sent a letter today to the Rural Caucuses in the United States Senate and House of Representatives. Addressed to leadership of the caucuses, Sen. Pat Roberts (R-KS), Sen. Heidi Heitkamp (D-ND), Rep. Adrian Smith (R-NE), and Rep. Tim Walz (D-MN), this in-depth letter highlights the critical work that our members do every day around the country and raises important issues affecting the industry. Issues covered in the letter include:

Stabilizing the Ambulance Fee Schedule
  • Make the add-ons permanent and build them into the base rate
  • Use new data from the ambulance cost collection program to ensure reimbursement is adequate going forward
  • New data should be used to assess the problems with the current ZIP-code methodology for determining rural and super-rural services
Ambulance Fee Schedule Reform
  • Proposed alternative models for rural ambulance services
  • Encouraging Congress to look at alternative destination options for ambulance service providers
Recognizing Ambulance Services as Providers of Health Care
  • Moving non-fire-based ambulance services from suppliers to providers under Medicare

The letter also highlights some of the burdensome regulations facing ambulance service providers that the AAA has recommended Congress address through its Red Tape initiative. These include:

Removing Unnecessary Regulatory Burdens:
  • Reduce the burdens created by the Physician Certificate Statement
  • Simplify the 855B Ambulance Enrollment Form
  • Address burdensome requirements of the patient signature on claims and the strict application of the revocation of billing authority

This letter from the AAA to Congressional leaders is just one part of the AAA’s ongoing effort to educate Congress on the crucial role ambulance service providers play in America’s healthcare system. The AAA wants Congress to know that in many rural areas of the country, ambulances are the medical safety net, yet face extreme challenges to staying in business thanks to below cost reimbursement and burdensome regulations. The AAA will continue to pursue this list of priorities with our members next year and going forward.

Read the Full Letter

Again, Happy Rural Health Day to our members – thanks for all that you do!

If you have any questions about our letter or rural advocacy, please contact us:

Questions?: Contact Us

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

Statement on Ambulance Cost Data Collection

October 22, 2018

Contact: Amanda Riordan
Phone: 703-615-4492
Email: ariordan@ambulance.org

For Immediate Release

Statement on Cost Data Collection for Ambulance Services

WASHINGTON, DC—On October 17, the International Association of Fire Chiefs (IAFC), International Association of Fire Fighters (IAFF), and The Metropolitan Fire Chiefs Association released a joint statement discouraging fire-based providers from endorsing AAA’s proposed ambulance cost collection methodology. While we regret to learn that they do not believe that our method is appropriate for the segment of providers they represent, we respectfully disagree and invite open dialogue as our previous requests to discuss cost collection with the IAFF and IAFC were declined.

The American Ambulance Association membership is composed of ambulance providers of all types and sizes, ranging from non-profit, for-profit, volunteer, hospital-based, county-based, public utility models, and more. We represent 911 ambulance providers in major metropolitan areas, small 911 providers in rural America, and those who provide vital hospital-to-hospital interfacility mobile healthcare throughout the country. AAA encourages all ambulance providers to visit www.ambulancereports.org to learn about the extensive research, time, and thought devoted to ensure that our comprehensive recommendations accurately capture data for the full spectrum of providers.

“Regardless of an ambulance organization’s service model, we collectively serve our communities with round-the-clock mobile healthcare. The collection and analysis of accurate cost data for ambulance providers of all types is essential to the future of our industry. If adopted by CMS, AAA’s cost collection recommendations will demonstrate the value of the care that we provide to our patients, as well as open the door for the establishment of forward-thinking payment models that sustain operations and grow innovation. The American Ambulance Association welcomes discussion with fire and other stakeholders. Our door is always open,” said AAA President Aarron Reinert on Monday.

Medicare cost reporting is an exhaustive and extremely technical system that has been in place in other healthcare specialties for many years. While not all ambulance services are Medicare “providers of service,” it has long been clear to AAA that ambulance services would eventually be required to provide cost data to support Medicare reimbursement, especially for purposes of making the add-ons permanent and expanding the benefit to include innovative payment models, including mobile integrated health. As such, our ambulance cost collection leadership began in 2012 with the commission of an extensive independent research study to design a cost model that would be accurate, complete, and minimally burdensome to ambulance providers of all sizes, types, and models. The findings of this study were released in 2014 and form the foundation of AAA’s cost data collection system design.

Following extensive advocacy efforts led by the American Ambulance Association, the Bipartisan Budget Act of 2018 was passed into law in February of this year. This bill included language that extended the ambulance Medicare add-ons for five years. It also required that ambulance services begin collecting and reporting cost data to the Centers for Medicare & Medicaid Services (CMS) in 2020. CMS has the ability to determine certain aspects of how the data is collected as well as the data elements so AAA is working closely with this agency to advocate for the implementation of our survey-based model. It is also clear that given the Congressional instruction to use the cost collection data to assess Medicare rates, the data collection will be aligned with the costs Medicare has the statutory authority to reimburse, but not necessarily all costs suppliers may incur to support the non-healthcare aspects of their services.

It is essential that ambulance providers speak with one voice on this critically important issue.  Inconsistencies in reporting and failure to standardize costs allowable under the Medicare statute will result in data being eliminated and will threaten the sustainability of the program. As such, throughout this lengthy and intensive process, AAA leadership remains open to feedback and focused on the development of and advocacy for a cost collection system that encompasses all mobile healthcare provider types. Learn more at www.ambulancereports.org.

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About the American Ambulance Association (AAA)

The AAA was formed in 1979 in response to the need for improvements in emergency medical services and mobile healthcare. The American Ambulance Association represents hundreds of ambulance services across the United States who provide emergency and interfacility mobile healthcare. The Association serves as a voice and clearinghouse for ambulance services.

Talking Medicare: CMS Implements Further Dialysis Cuts

Talking Medicare: CMS Implements Further Cuts in Reimbursement for Dialysis Services; Medicare Payment Data Shows Continued Reduction in Overall Spending on Dialysis Transports, but Net Increase in Dialysis Payments in Prior Authorization States

On October 1, 2018, CMS implemented an additional thirteen (13%) cut in reimbursement for non-emergency BLS transports to and from dialysis. This cut in reimbursement was mandated by Section 53108 of the Bipartisan Budget Act of 2018. This on top of a ten (10%) cut in reimbursement for dialysis transports that went into effect on October 1, 2013. As a result, BLS non-emergency ambulance transports to and from dialysis that occur on or after October 1, 2018 will be reimbursed at 77% of the applicable Medicare allowable.

In related news, CMS has released its national payment data for calendar year 2017. This data shows a continued reduction in total Medicare payments for dialysis transports. Medicare paid $477.7 million on dialysis transports in 2017, down from $488.9 million in 2016. This continues a downward trend that has seen total payments decline from a high of more than $750 million in 2013 (see accompanying chart to the right). Not coincidentally, it was in 2013 that our industry saw its first reduction in Medicare’s payments for dialysis transports.

The payment reduction is partially the result of the reduction in the amounts paid for dialysis services. However, it is also reflective of an overall decline in the number of approved dialysis transports. For this, we can look primarily to the impact of a four-year demonstration project that requires prior authorization of dialysis transports in 8 states and the District of Columbia.

As a reminder, the original prior authorization states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress. The chart below shows total spending on dialysis in those states in the years immediately preceding the implementation of the prior authorization project up through 2017, the third year of the demonstration project. While the three states had very different trajectories prior to 2015, each showed a significant decrease in total payments for dialysis under the demonstration project.

However, it is the trajectory of these changes that I want to discuss in this month’s blog. In previous blogs, I discussed the impact of the particular Medicare Administrative Contractor on the outcomes under prior authorization. Specifically, I noted that, while dialysis payments dropped in each state, the decline was far more dramatic in the states administered by Novitas Solutions (NJ, PA) than in the South Carolina, which was administered by Palmetto GBA. This trend continued in the second year of the program, which saw prior authorization expanded into five additional states and the District of Columbia. Those states administered by Novitas (DE, MD) saw far greater declines than the states administered by Palmetto (NC, VA, WV).

Given these declines, the data from the third year is somewhat surprising. The states administered by Palmetto continued to see declines in total dialysis payments, with the only exception being West Virginia. However, in the states administered by Novitas, we saw total dialysis payments increase, particularly in New Jersey, which saw nearly a 33% increase in total dialysis payments.

Three years into the prior authorization program, it is starting to become clear that the two MACs have approached the problem of overutilization of dialysis transports using two different approaches. Palmetto appears to have adopted a slow-and-steady approach, with total payments declining in a consistent manner year after year. By contrast, Novitas adopted more of a “shock the system” approach, where it rejected nearly all dialysis transports in the first year, and has adopted a somewhat more lenient approach in subsequent years.

Key Takeaways

 Last year, I wrote that two years of data under the prior authorization program permitted two conclusions: (1) the implementation of a prior authorization process in a state will undoubtedly result in an overall decrease in the total payments for dialysis within that state and (2) the size of that reduction appears to be highly dependent on the Medicare contractor.

With an additional year of data, I think both conclusions remain valid, although I would revise the second to suggest that the initial reduction has more to do with the Medicare contractor. The evidence from the third year of the program suggests that the trends tend to equalize after the first few years. It is also possible that Novitas felt a more aggressive approach was needed in the first few years to address evidence of widespread dialysis overutilization in the Philadelphia metropolitan area.

This has potential implications beyond the demonstration project, as CMS looks towards a possible national expansion of the program. Among other issues, it suggests that the AAA must continue its efforts to work with CMS and its contractors on developing more uniform standards for coverage of this patient population.

What the AAA is Doing

The AAA continues to work on legislation that would restructure this cut to dialysis transport reimbursement. The AAA strongly supports the NEATSA Act (H.R.6269) introduced by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) that would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports. AAA members and the AAA are working to get a Senate companion bill introduced shortly. The goal of this legislation would be to have the restructured offset go into effect as soon as possible. Thank you to the dozens of AAA members who have already contacted their members of Congress voicing their support for this critical legislation.


Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com