Department of Veterans Affairs Issues Final Rule on Reimbursement for Ambulance Services and Other Special Modes of Transportation

Written by Meghan Winesett on . Posted in Executive, Government Affairs, Reimbursement, Uncategorized, Veterans Affairs.

On February 16, 2023, the Department of Veterans published in the Federal Register the final rule to revise the payment methodology for beneficiary travel by ambulance and other so-called “special modes of transportation. The changes contained within the final rule were first included in a November 5, 2020 proposed rule.

The final rule will become effective on February 16, 2024.

Relevant Background

The VA currently pays for beneficiary travel under certain circumstances.  To be eligible for reimbursement, the veteran must meet certain eligibility criteria.  Specifically, the veteran must be traveling either: (i) for care at a VA health facility or (ii) for care at a non-VA facility that has been previously approved by the VA.  The veteran must also meet one of the following additional criteria:

  1. The veteran must have a VA disability rating of 30% or higher;
  2. The veteran must be traveling for treatment of a service-related condition (if their VA disability rating is less than 30%);
  3. The veteran receives a VA pension;
  4. The veteran has an income below the maximum annual VA pension rate;
  5. The veteran cannot otherwise afford to pay for their travel; or
  6. The veteran is traveling for one of the following reasons: (i) to obtain a VA compensation and pension exam, (ii) to obtain a VA service dog, or (iii) to obtain VA-approved transplant care.

Beneficiary travel covers all modes of transportation, including transportation by private vehicle, common carriers (e.g., taxi, livery, and public transportation), mass transit, etc.  Beneficiary travel also covers so-called “special modes of transportation,” which includes air and ground ambulance services, wheelchair vans services, and stretcher vans services.

The rules governing the payment for beneficiary travel services at set forth in 38 C.F.R. § 70.30.

Subpart (a)(4) sets forth the payment methodology for the reimbursement of special modes of transport, and simply provides that payment is based on “[t]he actual cost of a special mode of transportation.  In the context of ambulance services, this has historically been interpreted to mean the ambulance provider’s full billed charges.

Provisions of Final Rule 

Under the final rule, the VA would revise its existing payment methodology for beneficiary travel by ambulance and other special modes of transportation to no longer reimburse providers for their actual costs, and to instead base reimbursement on:

  1. For ground and air ambulance services, the lesser of: (i) the actual charge for ambulance transportation (i.e., the provider’s billed charges) or (ii) the amount determined under the Medicare Ambulance Fee Schedule.
  2. For other special modes of transportation (i.e., ambulette, wheelchair van, or stretcher van), the lesserof: (i) the provider’s actual charge, (ii) the applicable Medicaid rate in the state where the provider is domiciled (using the lowest Medicaid rate where the provider is domiciled in multiple states), or (iii) the applicable Medicaid rate in the state where the transport occurred (or the lowest Medicaid rate if the transport occurred in more than one state). Note: the revised regulations provide that if none of the states involved has a “posted rate,” the VA would continue to pay the provider’s full billed charges

The revised payment methodology for non-ambulance special modes of transport is intended to be temporary.  In its proposed rule, the VA indicated that it would use this payment methodology for a minimum of 90 calendar days after a final rule was posted in the Federal Register.  This period of time was intended to allow the VA to gather payment data.  If the VA believes that it gathered sufficient payment data during this initial 90-day period, it indicated that it would develop a new payment methodology “using the lowest possible rate.”  If the VA determined that it did not have sufficient payment data after the initial 90-day period, it would extend the proposed payment methodology for additional 90-day periods as needed until it believed it had sufficient data.  The VA indicated that it did not anticipate needing more than 18 months from the effective date of the final rule to gather sufficient payment data to implement a new payment method

OMB PHE Update | May 11

Written by AAA Staff on . Posted in Executive, Government Affairs, Legislative, Regulatory.

January 30, 2023
(House Rules)

STATEMENT OF ADMINISTRATION POLICY
H.R. 382 – A bill to terminate the public health emergency
declared with respect to COVID-19
(Rep. Guthrie, R-KY, and 19 cosponsors)

H.J. Res. 7 – A joint resolution relating to a national emergency
declared by the President on March 13, 2020
(Rep. Gosar, R-AZ, and 51 cosponsors)
The COVID-19 national emergency and public health emergency (PHE) were declared by the Trump Administration in 2020.  They are currently set to expire on March 1 and April 11, respectively.  At present, the Administration’s plan is to extend the emergency declarations to May 11, and then end both emergencies on that date.  This wind-down would align with the Administration’s previous commitments to give at least 60 days’ notice prior to termination of the PHE.

To be clear, continuation of these emergency declarations until May 11 does not impose any restriction at all on individual conduct with regard to COVID-19.  They do not impose mask mandates or vaccine mandates.  They do not restrict school or business operations.  They do not require the use of any medicines or tests in response to cases of COVID-19.

However, ending these emergency declarations in the manner contemplated by H.R. 382 and H.J. Res. 7 would have two highly significant impacts on our nation’s health system and government operations.

First, an abrupt end to the emergency declarations would create wide-ranging chaos and uncertainty throughout the health care system — for states, for hospitals and doctors’ offices, and, most importantly, for tens of millions of Americans.  During the PHE, the Medicaid program has operated under special rules to provide extra funding to states to ensure that tens of millions of vulnerable Americans kept their Medicaid coverage during a global pandemic.  In December, Congress enacted an orderly wind-down of these rules to ensure that patients did not lose access to care unpredictably and that state budgets don’t face a radical cliff.  If the PHE were suddenly terminated, it would sow confusion and chaos into this critical wind-down.  Due to this uncertainty, tens of millions of Americans could be at risk of abruptly losing their health insurance, and states could be at risk of losing billions of dollars in funding.  Additionally, hospitals and nursing homes that have relied on flexibilities enabled by the emergency declarations will be plunged into chaos without adequate time to retrain staff and establish new billing processes, likely leading to disruptions in care and payment delays, and many facilities around the country will experience revenue losses.  Finally, millions of patients, including many of our nation’s veterans, who rely on telehealth would suddenly be unable to access critical clinical services and medications.  The most acutely impacted would be individuals with behavioral health needs and rural patients.

Second, the end of the public health emergency will end the Title 42 policy at the border.  While the Administration has attempted to terminate the Title 42 policy and continues to support an orderly lifting of those restrictions, Title 42 remains in place because of orders issued by the Supreme Court and a district court in Louisiana.  Enactment of H.R. 382 would lift Title 42 immediately, and result in a substantial additional inflow of migrants at the Southwest border.  The number of migrants crossing the border has been cut in half, approximately, since the Administration put in place a plan in early January to deter irregular migration from Venezuela, Cuba, Nicaragua, and Haiti.  The Administration supports an orderly, predictable wind-down of Title 42, with sufficient time to put alternative policies in place.  But if H.R. 382 becomes law and the Title 42 restrictions end precipitously, Congress will effectively be requiring the Administration to allow thousands of migrants per day into the country immediately without the necessary policies in place.

The Administration strongly opposes enactment of H.R. 382 and H.J. Res. 7, which would be a grave disservice to the American people.
* * * * * * *

 

This statement is online here: https://www.whitehouse.gov/wp-content/uploads/2023/01/SAP-H.R.-382-H.J.-Res.-7.pdf

###

NACIDD & NACSD | Public Meetings 4/1 & 4/6

Written by AAA Staff on . Posted in Executive, Regulatory.

From ASPR on March 31, 2022

The National Advisory Committee on Seniors and Disasters (NACSD) and the National Advisory Committee on Individuals with Disabilities and Disasters (NACIDD) will soon host public meetings of these two advisory committees.

The next NACIDD meeting takes place on Friday, April 1 from 11:30 a.m. to 2:30 p.m. ET and the next NACSD meeting is on Wednesday, April 6 from 11:00 a.m. to 2:00 p.m. ET.

Join board members, distinguished guests, federal leaders, and other experts to discuss the challenges, opportunities, and priorities in meeting the unique health needs of older adult populations and people with disabilities during and after disasters and public health emergencies.

Advanced registration for these meetings is required and can be accessed, along with additional meeting agendas and public information, through the online event pages for the NACIDD and NACSD.

The agendas for each of the next meetings include time to hear from the public. The floor will be open to hear as many relevant comments as possible. To learn how to request a speaking time, please visit each committee’s event page. You can send questions about the NACSD to NACSD@hhs.gov and questions about the NACIDD to NACIDD@hhs.gov.

HHS PRF | EMS Funding Letter to Secretary Becerra

Written by AAA Staff on . Posted in Executive, Finance, Government Affairs, Regulatory.

Download PDF Letter

March 24, 2022

The Honorable Xavier Becerra
Secretary of Health and Human Services
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201

Dear Secretary Becerra:

Ground ambulance service organizations and fire departments continue to struggle financially from the enduring economic effects of the COVID-19 public health emergency (PHE). Our respective members face sharp increases in the costs of fuel, equipment, medical supplies, and staffing as we deal with a severe shortage of paramedics and emergency medical technicians (EMTs) which has been an issue for years but exacerbated by the pandemic. We implore you to help ensure communities around the country have access to 9-1-1 emergency and non-emergency ground ambulance services through the remainder of the PHE and beyond with an infusion of $350 million from returned and/or unspent money in the Provider Relief Fund (PRF).

We greatly appreciate the funding that ground ambulance service organizations and fire departments have already received from the PRF. The funds have been a lifeline for many of our respective members and their ability to continue to serve their communities. However, as the Phase 4 distribution of funds demonstrated, more funding is needed for ground ambulance services. Our members indicate the funds they received in Phase 4 covered approximately 50% of their lost reimbursement and increased costs from July 1, 2020, to March 31, 2021, whereas previous distributions were closer to 88%. We therefore respectfully request an immediate distribution of $350 million or 10% of the annual Medicare expenditure on ground ambulance services.

We request that the funds be distributed in a similar manner as the Tranche 1 distribution from the PRF. The automatic, across-the-board deposit of funding was especially helpful for small and rural ground ambulance service organizations. These rural organizations provide care in underserved areas and are often daunted even by an abbreviated application process. To ensure equity for all communities, we support universal direct deposit.

Additionally, we encourage HHS to make these payments based on the National Provider Identification (NPI) number of the ground ambulance service organization or fire department rather than Tax ID Number (TIN). In the case of moderate and large cities, many municipal departments may share a TIN while maintaining distinct NPIs. Providing these payments according to TIN may unintentionally comingle funds intended for different departments such as fire departments, public health departments, and local government-run hospitals or clinics.

The American Ambulance Association (AAA), International Association of Fire Chiefs (IAFC), International Association of Fire Fighters (IAFF), National Association of Emergency Medical Technicians (NAEMT), and National Volunteer Fire Council (NVFC) represent the providers of vital emergency and non-emergency ground ambulance services and the paramedics, EMTs and firefighters who deliver the direct medical care and transport for every community across the United States.

Our members take on substantial risk every day to treat, transport, and test potential COVID-19 patients, and play a vital role in providing vaccinations to individuals in their homes. Ground ambulance service organizations and fire departments, however, urgently need the additional

$350 million to help offset the increased costs and lower reimbursement resulting from our vital response to the pandemic.

Thank you in advance for your consideration of this request.

Sincerely,

American Ambulance Association

International Association of Fire Chiefs

International Association of Fire Fighters

National Association of Emergency Medical Technicians

National Volunteer Fire Council

FAIR Health | Ground Ambulance Services in the United States

Written by AAA Staff on . Posted in Balance Billing, Executive, Finance, Legislative, News, Press, Private Insurance, Regulatory, State-Level Advocacy.

From FAIR Health in February 2022

“Currently, no federal law protects consumers against “surprise” bills from out-of-network ground ambulance providers. Some state and local governments regulate ground ambulance surprise billing practices; however, such laws may not apply to all health plans or ambulance providers in an area. Because of the substantial policy interest in ground ambulance services, FAIR Health drew on its vast database of private healthcare claims to illuminate multiple aspects of such services across the nation, including utilization, costs, age, gender, diagnoses and differences across states.”

Download PDF Report

Statement for House Ways & Means Hearing on America’s Mental Health Crisis

Written by Shawn Baird on . Posted in Employee Wellness, Executive, Government Affairs, Legislative, Operations, Professional Standards, Regulatory.

Committee on Ways and Means

U.S. House of Representatives Hearing on “America’s Mental Health Crisis”

Statement of Shawn Baird, President, American Ambulance Association

February 2, 2022

Chairman Neal, Ranking Member Brady, and members of the Committee, on behalf of the members of the American Ambulance Association (AAA), I greatly appreciate the opportunity to provide you with a written statement on America’s Mental Health Crisis. Simply put, America’s hometown heroes who provide emergency medical services and transitional care need the Congress to recognize the significant stress and trauma paramedics and emergency medical technicians (EMTs) have experienced as a result of this pandemic. The AAA urges members of Congress not to forget these heroes and to expressly include all ground ambulance service personnel in efforts to address America’s Mental Health Crisis.

Emergency medical services (EMS) professionals are ready at a moment’s notice to provide life-saving and life-sustaining treatment and medical transportation for conditions ranging from heart attack, stroke, and trauma to childbirth and overdose. These first responders proudly serve their communities with on-demand mobile healthcare around the clock. Ground ambulance service professionals have been at the forefront of our country’s response to the mental health crisis in their local communities. Often, emergency calls related to mental health services are triaged to the local ground ambulance service to address.

While paramedics and EMTs provide important emergency health care services to those individuals suffering from a mental or behavioral health crisis, these front-line workers have been struggling to access the federal assistance they need to address the mental health strain that providing 24-hour care, especially during a COVID-19 pandemic, has placed on them. We need to ensure that there is equal access to mental health funding for all EMS agencies, regardless of their form of corporate ownership so that all first responders can receive the help and support they need.

EMS’s Enhanced Role in the Pandemic

As if traditional ambulance service responsibilities were not enough, paramedics and EMTs have taken on an even greater role on the very front lines of the COVID-19 pandemic. In many areas, EMS professionals lead Coronavirus vaccination, testing, and patient navigation. As part of the federal disaster response subcontract, EMS personnel even deploy to other areas around the country to pandemic hotspots and natural disasters to bolster local healthcare resources in the face of extraordinarily challenging circumstances.

Mental & Behavioral Health Challenges Drive Staffing Shortages on the Front Line

Myriad studies show that first responders face much higher-than-average rates of post- traumatic stress disorder[1], burnout[2], and suicidal ideation[3]. These selfless professionals work in the field every day at great risk to their personal health and safety—and under extreme stress.

Ambulance service agencies and fire departments do not keep bankers’ hours. By their very nature, EMS operations do not close during pandemic lockdowns or during extreme weather emergencies. “Working from home” is not an option for paramedics and EMTs who serve at the intersection of public health and public safety. Many communities face a greater than 25% annual turnover[4] of EMS staff because of these factors. In fact, across the nation EMS agencies face a 20% staffing shortage compounded by near 20% of employees on sick leave from COVID-19. This crisis-level staffing is unsustainable and threatens the public safety net of our cities and towns.

Sadly, to date, too few resources have been allocated to support the mental and behavioral health of our hometown heroes. I write today to ask for Congressional assistance to help the helpers as they face the challenges of 2022 and beyond.

Equity for All Provider Types

Due to the inherently local nature of EMS, each American community chooses the ambulance service provider model that represents the best fit for its specific population, geography, and budget. From for-profit entities to municipally-funded fire departments to volunteer rescue squads, EMS professionals share the same duties and responsibilities regardless of their organizational tax structure. They face the same mental health challenges and should have equal access to available behavioral health programs and services.

Many current federal first responder grant programs and resources exclude the tens of thousands of paramedics and EMTs employed by for-profit entities from access. These individuals respond to the same 911 calls and provide the same interfacility mobile healthcare as their governmental brethren without receiving the same behavioral health support from

Federal agencies. To remedy this and ensure equitable mental healthcare access for all first responders, we recommend that:

  • During the current public health emergency and for at least two years thereafter, eligibility for first responder training and staffing grant programs administered by the U.S. Department of Health and Human Services (such as SAMHSA Rural EMS Training Grants and HHS Occupational Safety and Health Training Project Grants) should be expanded to include for-profit entities. Spending on training and services for mental health should also be included as eligible program
  • Congress should authorize the establishment of a new HHS grant program open to public and private nonprofit and for-profit ambulance service providers to fund paramedic and EMT recruitment and training, including employee education and peer-support programming to reduce and prevent suicide, burnout, mental health conditions and substance use
  • Any initiatives to fund hero pay or death benefits for first responders should be inclusive of all provider models—for-profit, non-profit, and

The rationale for the above requests is twofold. First, ensuring the mental health and wellness of all EMS professionals—regardless of their employer’s tax status—is the right thing to do.

Second, because keeping paramedics and EMTs employed by private ambulance agencies who are on the frontlines of providing vital medical care and vaccinations during this pandemic is the smart thing to do.

Thank you for considering this request to support ALL of our nation’s frontline heroes. They are ready to answer your call for help, 24/7—two years into this devastating pandemic, will Congress answer theirs?

Please do not hesitate to contact American Ambulance Association Senior Vice President of Government Affairs, Tristan North, at tnorth@ambulance.org or 202-486-4888 should you have any questions.

  • Prevalence of PTSD and common mental disorders amongst ambulance personnel: A systematic review and meta-analysis. Soc Psychiatry Psychiatr 2018;53(9):897-909.
  • ALmutairi MN, El Mahalli AA. Burnout and Coping Methods among Emergency Medical Services Professionals. J Multidiscip Healthc. 2020;13:271-279. Published 2020 Mar 16. doi:10.2147/JMDH.S244303
  • Stanley, I. H., Hom, M. A., & Joiner, T. E. (2016). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and Clinical Psychology Review, 44, 25–44. https://doi.org/10.1016/j. cpr.2015.12.002
  • Doverspike D, Moore S. 2021 Ambulance Industry Employee Turnover Study. 3rd Washington, DC: American Ambulance Association; 2021.

Application Period Extended for FY 2021 Assistance to Firefighters Grant (AFG) Program

Written by Meghan Winesett on . Posted in Executive, News, Uncategorized.

Please see the below notice from FEMA on the extension of the Assistance to Firefighter Grant (AFG) Program:

“FEMA has been working with the General Services Administration to resolve interface issues related to SAM.gov that were affecting some applicants’ ability to begin inputting their federal fiscal year (FY) 2021 Assistance to Firefighters Grant (AFG) Program applications into the FEMA GO System. Specifically, this issue included applicants that received error messages stating their organizations were not found and that their Unique Entity Identifier (UEI)/Electronic Funds Transfer (EFT) combination did not exist despite the applicants’ SAM.gov accounts being fully active.

As this issue is ongoing, the FY 2021 AFG Program application period will remain open until January 21, 2022 5:00 p.m. ET. All applicants will automatically be granted this extension. This ensures that applicants affected by the UEI/EFT issue will have sufficient time to complete the online application. The extension to the application period will not affect the award timeline. In the meantime, FEMA continues to strongly encourage applicants to review the FY 2021 AFG Program Notice of Funding Opportunity and the associated tools posted on the FEMA website here: FY 2021 Assistance to Firefighters Grant (AFG) Application Guidance Materials | FEMA.gov. In preparation for application submission, applicants may also draft their narratives separately and cut and paste them into the appropriate areas of FEMA GO once the SAM.gov interface issue is resolved. The questions that are asked in the narrative section may be found in the FY 2021 AFG Program Narrative Get Ready Guide.

Fire Grants Help Desk: If you have questions about the NOFO or application process, call or email the Fire Grants Help Desk. The toll-free number is 1-866-274-0960; the e-mail address for questions is firegrants@fema.dhs.gov.The Fire Grants Help Desk is open Monday – Friday, 8 a.m. – 4:30 p.m. ET. “

 

5th Circuit Lifts Injunction on CMS Mandatory Vaccine Requirement for Half of U.S.

Written by Scott Moore on . Posted in Executive, Human Resources, Judicial.

On December 15, 2021, the United States Court of Appeals for the Fifth Circuit issued a ruling which modifies an earlier court national injunction related to the CMS mandatory vaccination rules.  In the latest ruling, the court upheld the injunction issued by the United States District Court for the Eastern District of Missouri as it applied to the fourteen (14) plaintiff states, Louisiana, Montana, Arizona, Alabama, Georgia, Idaho, Indiana, Mississippi, Oklahoma, South Carolina, Utah, West Virginia, Kentucky, and Ohio.  However, it overturned the lower court’s expansion of that injunction to other, non-plaintiff states, in the injunction.  Meaning that between the 5th and 8th Circuit Court rulings, the CMS mandatory vaccination injunction only applies to the following 24 states:

5th Circuit Plaintiffs: Louisiana, Montana, Arizona, Alabama, Georgia, Idaho, Indiana, Mississippi, Oklahoma, South Carolina, Utah, West Virginia, Kentucky, Ohio

8th Circuit Plaintiffs: Missouri, Nebraska, Arkansas, Kansas, Iowa, Wyoming, Alaska, South Dakota, North Dakota and New Hampshire.

States not covered by the CMS mandatory vaccination injunction:

California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Vermont, Virginia, Washington, and Wisconsin

This decision, follows another mandatory vaccine related decision issued by the United States Court of Appeals for the Eleventh Circuit which criticized the Louisiana court for expanding the CMS vaccine mandate nationwide given that a Florida District Court had already refused to issue an injunction and because it felt that it was likely that the mandate was likely authorized under current CMS rules.

What does this mean for employers?

If you are an employer in one of the states not covered by an injunction, you should consult with any covered healthcare facility that your organization performs services under contract. These covered healthcare facilities will be required to mandate vaccination for their staff and for any contractor staff that interacts with their employees or patients.  Additionally, they will be seeking proof that your staff is vaccinated against COVID-19, unless they have a protected medical or religious accommodation.

Employers should have already taken the initial steps toward compliance with the CMS mandatory vaccination rules, including having a list of all employees with their vaccination status.  Additionally, employers should have an established policy related to mandatory vaccination and a procedure for requesting and processing an exception/accommodation requests. Lastly, healthcare institutions may independently institute mandatory vaccination rules for their employees and can require this of anyone entering their facility, including EMS staff.

We will continue to keep you post as these cases proceed through the legal system. These facilities may still independently require your staff to be vaccinated. If your organization has questions or need assistance deciphering or preparing for these requirements, please contact the AAA by emailing hello@ambulance.org.

 

 

 

HRSA Announces Distribution of Phase 4 General Distribution Funds

Written by Brian Werfel on . Posted in Executive, Government Affairs, Uncategorized.

The Health Resources & Services Administration (HRSA) has announced that it will begin distributing Phase 4 General Distribution Payments on Thursday, December 16, 2021.  According to HRSA, approximately 75% of all Phase 4 applications have now been processed.  HRSA indicated that the remaining 25% of applications require additional review under its risk mitigation and cost containment safeguards.

HRSA further indicated that it began distributing American Rescue Plan (ARP) Rural Payments on November 23, 2021.  As of December 14, 2021, HRSA has indicated that it has processed approximately 96% of ARP applications.  The ARP allocated a total of $8.5 billion to health care providers who serve rural Medicare, Medicaid and CHIP patients.  HRSA indicated that it will distribute $7.5 billion of these funds in its initial distribution.

To the extent a provider was determined to be eligible for either a Phase 4 payment or an ARP Rural Payment, the provider will receive both an email notification and a paper letter with additional details on these payments.  This will include the individual amounts attributed to any subsidiary TINs submitted as part of their application.  To the extent HRSA determined that you were not eligible for a Phase 4 payment, the email notice will provide an explanation for why you were determined to be ineligible.  These email notices will be sent to the email address provided in the Phase 4 application.  Providers selected for additional review will receive email notification as soon as HRSA completes its review process, which it indicated would be completed in “early 2022.”

AAA members are encouraged to look for this email.  If you have not received an email notification, we would suggest that you check your spam filter, as several of our members have indicated that the email was flagged as “spam” by their email system. 

Notice on Ground Ambulance and Patient Billing Advisory Committee

Written by Tristan North on . Posted in Executive, Government Affairs, News, Regulatory.

The Centers for Medicare and Medicaid Services (CMS) has filed for publication in the Federal Register the Solicitation of Nominations Notice for the Ground Ambulance and Patient Billing (GAPB) Advisory Committee. The Notice is scheduled to be included in the Federal Register for tomorrow, Tuesday, November 23.

The Congress created the GAPB Advisory Committee as part of The No Surprises Act enacted last year and currently being implemented by the Departments of Health and Human Services, Labor and the Treasury. The American Ambulance Association, International Association of Fire Chiefs, International Association of Fire Fighters, National Association of Emergency Medical Technicians, and the National Volunteer Fire Council successfully advocated that the Congress take into consideration the unique characteristics of ground ambulance services when determining balance billing policy for our services. The Congress excluded ground ambulance services from the provisions of The No Surprises Act and created the GAPB Advisory Committee to address balance billing.

The AAA has identified candidates, including AAA President Baird, who we will be supporting for inclusion on the Advisory Committee who we believe are well-positioned to represent the AAA membership. Once formed, the Advisory Committee has 180 days in which to report its recommendations to the Congress. The directive of the Committee is to review options to “improve the disclosure of charges and fees for ground ambulance services, better inform consumers of insurance options for such services, and protect consumers from balance billing.” We will be keeping the AAA membership continually informed of the actions and deliberations of the GAPB Advisory Committee.

Should you have any questions regarding the GAPB Advisory Committee, please contact AAA Senior Vice President of Government Affairs Tristan North. He can be reached at tnorth@ambulance.org.

It’s Time for EMS to Apply for HHS Provider Relief Fund Tranche 4!

Written by AAA Staff on . Posted in Executive, Finance, Legislative, Regulatory, Reimbursement.

Recorded October 8, 2021 | Free to All | Speaker: Asbel Montes

The deadline for Provider Relief Fund (PRF) applications is 11:59 PM October 26, 2021. If your EMS agency has not yet applied for funds, the American Ambulance Association strongly encourages you to do so! We are happy to answer member questions, just email hello@ambulance.org. Remember, Amber cost data collection software (www.emsamber.com) access is included with your AAA membership and has a PRF module to help you with your application. If you are an AAA member and need help accessing Amber, email shilker@ambulance.org. HRSA is also hosting a technical assistance webinar for PRF applications on October 13, 2021.

Congressional Letter on the EMS Workforce Shortage

Written by AAA Staff on . Posted in Executive, Human Resources, Legislative, Recruitment & Retention, Regulatory.

October 1, 2021

The Honorable Nancy Pelosi
Speaker of the House
U.S. House of Representatives
Washington, DC 20515

The Honorable Kevin McCarthy
Minority Leader
U.S. House of Representatives
Washington, DC 20515

The Honorable Charles Schumer
Majority Leader
United States Senate
Washington, DC 20510

The Honorable Mitch McConnell
Minority Leader
United States Senate
Washington, DC 20510

Dear Speaker Pelosi, Majority Leader Schumer, Minority Leader McConnell & Minority Leader McCarthy,

Our paramedics and emergency medical technicians (EMTs), as well as the organizations that they serve, take on substantial risk every day to treat and transport patients that call 9-1-1. But our nation’s EMS system is facing a crippling workforce shortage, a long-term problem that has been building for more than a decade. It threatens to undermine our emergency 9-1-1 infrastructure and deserves urgent attention by the Congress.

The most sweeping survey of its kind — involving nearly 20,000 employees working at 258 EMS organizations — found that overall turnover among paramedics and EMTs ranges from 20 to 30 percent annually. With percentages that high, ambulance services face 100% turnover over a four- year period. Staffing shortages compromise our ability to respond to healthcare emergencies, especially in rural and underserved parts of the country.

The pandemic exacerbated this shortage and highlighted our need to better understand the drivers of workforce turnover. There are many factors. Our ambulance crews are suffering under the grind of surging demand, burnout, fear of getting sick and stresses on their families. In addition, with COVID-19 halting clinical and in-person trainings for a long period of time, our pipeline for staff is stretched even more.

The challenge is to make sure that the paramedics and EMTs of the future know that EMS is a rewarding destination. Many healthcare providers have extensive professional development resources, but that simply does not exist for EMS. COVID-19 has put additional pressures on the health care system and added another layer of complexity to the emergency response infrastructure.

HRSA EMS Training Funding

Fortunately, there are immediate and long-term solutions. Although the provider relief funds are essential and helpful to address the challenges of the pandemic, we need funding for EMS that addresses paramedic and EMT training, recruitment, and advancement more directly. The Congress can provide specific direction and funds to the Health Resources and Services Administration (HRSA) to help solve this workforce crisis. Those funds can be used to pay for critical training and professional development programs. Some of our members have already begun offering programs and would benefit from additional funding support from HRSA. Funding public-private partnerships between community colleges and private employers to increase the applicant pool and training and employment numbers through grants could overcome the staffing deficit we face.

Paramedic and EMT Direct Pay Bump

In addition, more immediately targeting funds for EMS retention could address the shortage we are experiencing day to day. To help ambulance services retain paramedics and EMTs, we request funds through HRSA to be paid directly to paramedics and EMTs. These earmarked funds could be distributed to each state with specific guidance that the State Offices of EMS distribute the funds to all ground ambulance services using a proportional formula (per field medic).

COVID-19 Medicare Reimbursement Increase

With capitated payments by federal payors, there are limited funds to transfer into workforce initiatives. Increasing Medicare payments temporarily would be meaningful to compete with other employers and other jobs. This could help infuse additional funds into the workforce and create innovative staffing models that take into account hospital bed shortages and overflow.

Congressional Hearings on EMS Workforce Shortage

The workforce shortage crisis facing EMS spans several potential Committees of jurisdiction. This critical shortage is particularly felt in many of our rural and underserved communities. As Congress moves on the steps we have outlined above, we also urge you to organize hearings in the appropriate Committees to develop long-term solutions and focus the country’s attention on these urgent issues.

Thank you in advance for continuing to ensure that our frontline responders have the resources necessary to continue caring for our patients in their greatest moment of need, while maintaining the long-term viability of our nation’s EMS system.

Thank you for your consideration. Sincerely,

Shawn Baird
President
American Ambulance Association

Bruce Evans
President
National Association of Emergency Medical Technicians

Application Open: COVID-19 Provider Relief Funding

Written by AAA Staff on . Posted in Executive, Finance, Legislative, Regulatory.

From HHS on September 29, 2021

The Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), has announced a new application cycle for $25.5 billion in COVID-19 provider funding. Applicants will be able to apply for both Provider Relief Fund (PRF) Phase 4 and American Rescue Plan (ARP) Rural payments during the application process. PRF Phase 4 is open to a broad range of providers with changes in operating revenues and expenses. ARP Rural is open to providers who serve rural patients covered by Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
See a detailed list of eligible provider types here.
The application is open now and will close on October 26, 2021 at 11:59 p.m. ET. Providers who have previously created an account in the Provider Relief Fund Application and Attestation Portal and have not logged in for more than 90 days will need to first reset their password before starting a new application. In order to streamline the application process and minimize administrative burdens, providers will apply for both programs in a single application.
HHS recently hosted a briefing session to provide information about these upcoming funding opportunities – view the video here. HRSA will also host webinar sessions featuring guidance on how to navigate the application portal. Register now using the links below.
  • Thursday, September 30 from 3:00 – 4:00 p.m. ET
  • Tuesday, October 5 from 3:00 – 4:00 p.m. ET
  • Two additional webinars the weeks of October 11th and 18th (dates, times, and registration forthcoming)
 
Real time technical assistance is available by calling the Provider Support Line at (866) 569-3522, for TTY dial 711. Hours of operation are 8 a.m. to 10 p.m. CT, Monday through Friday.

HHS PRF Tranche 4 | Important Funding Opportunity for EMS Providers

Written by Scott Moore on . Posted in Executive, Finance, Legislative, Regulatory, Webinars.


Speaker: Scott Moore, Esq. | Share on Facebook
This funding opportunity will distribute $25.5 billion in additional Phase 4 General Distribution for EMS agencies and American Rescue Plan (ARP) payments for qualified rural providers who furnish services to Medicaid/CHIP and Medicare beneficiaries. It is critical for all #EMS providers to apply for this funding opportunity regardless of previous funding allocations. We have learned that many EMS providers did not apply for the Tranche 3 funding opportunity because they did not believe that they would be eligible to receive funds under the announced funding formula. Due to the limited number of applicants in Tranche 3, HRSA modified the formula and many who failed to apply would have received funds. We are recommending that all EMS agencies apply to receive the funding that they desperately need. The deadline for applying is 11:59 p.m. on October 26, 2021. There is no penalty for applying.

HHS: Availability of Add’l $25.5 Billion in COVID-19 Provider Funding

Written by Scott Moore on . Posted in Advocacy Priorities, Executive, Government Affairs, Legislative, Regulatory.

HHS Announces the Availability of $25.5 Billion in COVID-19 Provider Funding

This morning the Department of Health and Human Services (HHS) announced that it will be making $25.5 billion in new funding available for healthcare providers affected by the COVID-19 pandemic. The funding, available through the Health Resources and Services Administration (HRSA) will include $8.5 billion in American Rescue Plan Act (ARPA) resources for providers who serve rural Medicaid, Children’s Health Insurance Program (CHIP), or Medicare patients, and an additional $17 billion for Provider Relief Fund (PRF) Phase 4 for a broad range of providers who can document revenue loss and expenses associated with the pandemic.

Getting additional financial relief for ground ambulance service providers who are still struggling from the lost revenue and increased expenditures resulting from being on the frontlines of responding to the pandemic has been a top priority for the AAA. The AAA along with the International Association of Fire Chiefs, International Association of Firefighters, National Associations of EMTs and National Volunteer Fire Association have continually pressed HHS to release the remaining funds. We strongly encourage all AAA members to submit an application regardless of whether you have applied for previous rounds of funding.

Consistent with the requirements included in the Coronavirus Response and Relief Supplemental Appropriations Act of 2020, PRF Phase 4 payments will be based on providers’ lost revenues and expenditures between July 1, 2020, and March 31, 2021 (Q3 – Q4 2020 and Q1 2021). The PRF Phase 4 will reimburse smaller providers, who tend to operate on thin margins and often serve vulnerable or isolated communities, for their lost revenues and COVID-19 expenses at a higher rate compared to larger providers. PRF Phase 4 will also include bonus payments for providers who serve Medicaid, CHIP, and/or Medicare patients, who tend to be lower- income and have greater and more complex medical needs. HRSA will price these bonus payments at the generally higher Medicare rates to ensure equity for those serving low-income children, pregnant women, people with disabilities, and seniors.

Consistent with the focus of the ARPA, HRSA will make ARPA rural payments to providers based on the amount of Medicaid, CHIP, and/or Medicare services they provide to patients who live in rural areas as defined by the HHS Federal Office of Rural Health Policy. As rural providers serve a disproportionate number of Medicaid and CHIP patients who often have disproportionately greater and more complex medical needs, many rural communities have been hit particularly hard by the pandemic. Accordingly, ARP rural payments will also generally be based on Medicare reimbursement rates.

In the announcement, HHS stated that it would “expedite and streamline” the application process and minimize administrative burdens, providers will apply for both programs in a single application. HRSA will use existing Medicaid, CHIP and Medicare claims data in calculating payments. The application portal will open on September 29, 2021. HHS has stated that to ensure that these provider relief funds are used for patient care, PRF recipients will be required to notify the HHS Secretary of any merger with, or acquisition of, another health care provider during the period in which they can use the payments. They have stated that providers who report a merger or acquisition may be more likely to be audited to confirm their funds were used for coronavirus-related costs.

To promote transparency in the PRF program, HHS also released detailed information about the methodology utilized to calculate PRF Phase 3 payments. Providers who believe their PRF Phase 3 payment was not calculated correctly according to this methodology will now have an opportunity to request a reconsideration. HHS announced that additional details on the PRF Phase 3 reconsideration process will be released at a later date.

In addition, many of you attended the PRF Reporting Q&A AAA webinar yesterday with Asbel Montes, Brian Werfel, and Scott Moore.  HHS has acknowledged the challenges facing many providers across the country due to recent natural disasters and the Delta variant, HHS announced a final 60-day grace period to help providers come into compliance with their PRF Reporting requirements if they fail to meet the deadline on September 30, 2021. While the deadlines to use funds and the Reporting Time Period will not change, HHS will not initiate collection activities or similar enforcement actions for non-compliant providers during this grace period.

Members can access more information about eligibility requirements, the documents and information providers will need to complete their application, and the application process for PRF Phase 4 and ARP Rural payments by visiting the HRSA website.

The combined application for American Rescue Plan rural funding and Provider Relief Fund Phase 4 will open on September 29, 2021.  Like we have done with the previous rounds of HHS funding, we encourage all ambulance service providers to submit an application for this Phase 4 funding.  If you have questions regarding this or any COVID-19 related questions, please contact hello@ambulance.org.

CMS Releases Medicare COVID-19 Vaccine Data Analysis and PUF

Written by AAA Staff on . Posted in Emergency Preparedness, Executive, Patient Care, Regulatory.

From CMS on August 25, 2021

Today, the Centers for Medicare & Medicaid Services (CMS) released two new resources with information on Medicare beneficiaries on whose behalf at least one fee-for-service (FFS) claim for the administration of the COVID-19 vaccine has been submitted to the Medicare program.

First, we released a paper titled Assessing the Completeness of Medicare Claims Data for Measuring COVID-19 Vaccine Administration. This paper presents preliminary findings on the count of individuals ages 65 and older with at least one COVID-19 vaccine administration claim in the Medicare data compared to the count of people 65+ with at least one COVID-19 vaccine dose in the data reported by the Centers for Disease Control and Prevention (CDC). Using data as of June 4th, 2021, we estimate that CMS received a claim for COVID-19 vaccine administration for roughly half of Medicare beneficiaries who have received at least one COVID-19 vaccine dose as compared to the estimated counts based on adjusted CDC figures (17.5 million out of 36.6 million). As a result, we recommend that the public apply significant caution when analyzing COVID-19 vaccine administration trends using Medicare claims data.

Second, we released the Medicare COVID-19 Vaccine Public Use File (PUF) which presents a high-level and preliminary overview of Medicare utilization and spending information from Medicare FFS claims for the administration of the COVID-19 vaccine. The PUF shows that between December 11, 2020 and June 30, 2021, Medicare payments for administration of the COVID-19 vaccine were over $1.1 billion.  The PUF is based on Medicare FFS claims CMS received by August 6, 2021.

[Note: The Medicare FFS program is paying for COVID-19 vaccine administration on behalf of MA beneficiaries as well as for FFS beneficiaries receiving COVID-19 vaccinations in 2020 and 2021.]

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Provider Relief Fund Reporting Requirement Deadline is Approaching

Written by Brian Werfel on . Posted in Executive, Government Affairs, Legislative.

The American Ambulance Association wants to remind our members that the deadline to submit your initial report on your use of HHS Provider Relief Funds is fast approaching.  Any ambulance provider or supplier that received more than $10,000 in aggregate funds from the first two rounds of General Distribution funding will need to submit a report on their use of such funds by September 30, 2021.  This initial report will detail the expenditure of PRF funds through June 30, 2021.

Relevant Background

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.  An additional $75 billion was allocated as part of the Paycheck Protection Program and Health Care Enhancement Act, with subsequent legislation adding further amounts to this fund.  In total, the Provider Relief Fund (PRF) will distribute $178 billion to health care providers and suppliers to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.

To date, HHS has distributed approximately $148.4 billion through three rounds of General Distribution funds ($92.5 billion) and multiple smaller Targeted Distributions.  A portion of the PRF is also being used to reimburse health care providers for the costs of testing, treating, and vaccinating the uninsured.

Summary of Final Reporting Requirements

On June 11, 2021, HHS issued its final PRF Reporting Requirements.  Under these new guidelines, health care providers will be required to report for any “Payment Received Period” in which they received one or more PRF payments that, in the aggregate, exceed $10,000.  Providers meeting this threshold for any Payment Received Period will report on their use of such funds during the corresponding “Reporting Time Period.”

The following table sets forth the applicable Payment Received Periods and corresponding Reporting Time Periods.  The table also sets forth the deadline to use funds received within each Payment Receiving Period.

 

Period Payment Received Period Deadline for use of Funds Reporting Time Period
1 April 10, 2020 – June 30, 2020 June 30, 2021 July 1, 2021 – September 30, 2021
2 July 1, 2020 – December 31, 2020 December 31, 2021 January 1, 2022 – March 31, 2022
3 January 1, 2021 – June 30, 2021 June 30, 2022 July 1, 2022 – September 30, 2022
4 July 1, 2021 – December 31, 2021 December 31, 2022 January 1, 2023 – March 31, 2023

 

PRF payments received in the first two rounds of General Distribution funding will fall within the first reporting period.  PRF payments received in the third round of General Distribution funding will fall within either the second or third reporting periods, depending on when the funds were actually received.

As a result, ambulance providers and suppliers that received more than $10,000 in the aggregate from the first two rounds of General Distribution funding will need to submit an initial report during the 90-day period starting on July 1, 2021.  This initial report will detail all expenditures of PRF funds through June 30, 2021.

Ambulance providers and suppliers that received between $10,001 and $499,999 in aggregated PRF funds during each Payment Received Period are required to report on their use of such funds in two categories: (1) General and Administrative Expenses and (2) Health Care Related Expenses.  Ambulance providers and suppliers that received $500,000 or more in aggregated PRF funds during each Payment Received Period will be required to submit more detailed information for each of these general categories.

Specific Instructions Related to Reporting of Lost Revenues

The American Ambulance Association has received numerous questions from members regarding the appropriate methodology to report lost revenues attributable to the coronavirus.  Specifically, many members have inquired as to the appropriate methodology for calculating their lost revenues.

HHS has indicated that health care providers must report their lost revenues using one of three methodologies:

  1. The difference between actual patient care revenues;
  2. The difference between budgeted patient care revenues and actual patient care revenues; or
  3. An alternative methodology selected by the provider for estimating lost revenues.

Based on HHS guidance, it appears that the default methodology is to measure the difference between actual patient care revenues for each calendar quarter during the applicable period.  The provider will also be asked to further break down patient care revenues by applicable payer.  In basic terms, the first methodology will compare: (i) your actual calendar year 2019 patient care revenues to (ii) your actual calendar year 2020 patient care revenues.  The A.A.A. suggests that all members start by conducting this basic revenue analysis.  To the extent your lost revenues in 2020 equal or exceed (in combination with your increased expenses, if any) the total PRF funds received during the first Payment Received Period, no additional revenue analysis is required. 

In some instances, you may find that your actual revenue losses for calendar year 2020 do not fully offset the PRF funds received during the First Payment Received Period.  In that event, it may be beneficial to conduct a separate revenue analysis using the budgeted vs. actual methodology.  Note: you are only eligible to use this methodology to the extent you had a formal budget approved prior to March 27, 2020. 

This methodology is likely to be beneficial to ambulance providers or suppliers that, pre-pandemic, were projecting significant revenue growth in calendar year 2020.  For example, consider the case of a hypothetical “ABC Ambulance Service, Inc.”  ABC Ambulance had $1 million in patient care revenues in calendar year 2019.  However, in November 2019, the company signed an agreement to be the preferred provider of a major hospital system in its service area.  As a result, the company was projecting significant revenue growth in calendar year 2020.  Specifically, when it created its 2020 budget in December 2019, it projected that its patient care revenues would rise to $1.5 million in 2020.

When the pandemic hit in mid-March 2020, the company saw a significant slowdown in its transport volume.  Like many ambulance providers, it saw its transport volume rebound somewhat in the 3rd and 4th quarters of 2020.  As a result, it ended the year with $1.2 million in patient care revenues.

A revenue analysis using the default methodology would show an increase in revenues, i.e., its revenues increased by $200,000 over 2019.  However, its 2020 actual revenues were $300,000 less than it projected in its 2020 budget.  Using this second methodology, the company would be able to claim $300,000 in lost revenues to offset against its PRF funds.

Please note that any ambulance provider or supplier using this second methodology will be required to submit additional documentation with its initial PRF report.  Specifically, you will be required to submit a copy of the 2020 budget relied upon to show the lost revenue, together with an attestation from its CEO, CFO, or other authorized official attesting to the fact that this budget was formally established prior to March 27, 2020.

HHS will also permit ambulance providers or suppliers to utilize an alternative methodology created by the entity for calculating their lost revenues.  However, to utilize an alternative methodology, the provider or supplier will be required to submit additional documentation explaining not only the methodology, but also the justification for why this methodology was reasonable.  HHS has indicated that providers or suppliers electing to use an alternative methodology will face an increased risk of audit.  As a good rule of thumb, the use of an alternative methodology is likely to limited to situations where the EMS agency’s business is extremely seasonal, or where there was some major change in their operations during the 2020 calendar year (e.g., a partial sale of the company, a large acquisition, etc.).

Further Information Related to PRF Reporting

HHS updated its instructions for how ambulance providers and suppliers should complete their PRF Reporting obligations.  These updated instructions start on Page 4 of the Revised Reporting Requirements.

HHS also recently updated its Frequently Asked Questions (FAQs) associated with the PRF Reporting Program.

 

 

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