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Talking Medicare: A Good Thing Poorly Explained

Written by Brian Werfel on . Posted in Medicare, Regulatory, Talking Medicare.

On April 13, 2018, CMS released two Transmittals, Transmittal 243 and Transmittal 4021, and a related MedLearns Matter Article (MM10550). Collectively, these documents clarify Medicare’s coverage of ambulance transportation of SNF residents in a stay not covered by Part B, but who have Part B benefits, to the nearest supplier of medically necessary services that are not available at the SNF. This clarification relates to both the ambulance transport to the site of medical care, and the return trip.

In order to properly understand the clarification, it is helpful to review Medicare’s coverage of ambulance transportation provided to SNF residents. At the onset, it is important to note that Medicare draws a distinction between the first 100 days of a beneficiary’s SNF stay, and any subsequent days of the same stay. The first 100 days are commonly referred to as the “Part A Period.” Under current Medicare rules, all ambulance transportation provided during the Part A Period is the financial responsibility of the SNF, unless a specific exemption applies. Outside the Part A Period, Medicare’s coverage rules generally mirror the rules applicable to ambulance transports that originate at the patient’s residence. However, there is an exception that relates to transportation to and from therapeutic or diagnostic sites (i.e., those facilities identified with the “D” modifier). This clarification relates to transportation to and from diagnostic sites.

Medicare rules are clear that transportation of an SNF resident outside the Part A Period for the purpose of receiving medically necessary care that could not be provided at the SNF will be covered to the extent the ambulance transportation was both medically reasonable and necessary. This is true regardless of the type of facility to which the patient is transported. In this context, the term “reasonable” refers to the costs of transporting the patient to the site of medical care. Where it is cheaper to bring the patient to the service (e.g., an MRI or CT scan), Medicare will cover the service. Where it is cheaper to bring the service to the patient (e.g., certain minor procedures), Medicare rules indicate that the transportation would not be covered.

In other words, once an SNF resident is outside the Part A Period, Medicare will cover a medically necessary ambulance transport to a diagnostic site provided that it is cheaper to transport the patient to that site than to transport the equipment needed to provide care to the SNF.

As you can imagine, determinations as to the reasonableness of a particular service can be quite subjective. Moreover, these determinations can typically only be made on a case-by-case basis, i.e., it is extremely difficult for Medicare Administrative Contractors to make such decisions without seeing the ambulance trip report and other supporting documentation. As a result, CMS has historically given its MACs broad discretion to make these determinations.

The MACs have elected to utilize this discretion in various ways. Some MACs have essentially elected to rely upon the ambulance provider to make such determinations prior to submitting the claims. These MACs have therefore elected not to implement front-end edits for such claims.

Other MACs have elected to issue an initial denial, and handle reasonableness determinations through the appeals process. These MACs do so by implementing edits into their claims processing system that automatically deny claims submitted with the “ND” modifiers. However, because Medicare coverage rules indicate that transportation from anywhere to an SNF may be covered, these MACs do not have a corresponding edit to deny claims submitted with the “DN” modifiers.

The result is various inconsistencies in the ways claims for these situations are handled. Depending on the MAC jurisdiction in which you operate, a claim for an ambulance transport from an SNF to a diagnostic site (“ND”) for a beneficiary outside the Part A Period may be paid or denied. For those of you that operate in jurisdictions where the MAC denies this claim, you may also see the return trip either paid or denied. Note: if the transportation to the diagnostic site is denied as not being “reasonable,” the return trip should be denied as well.

It is these inconsistencies that CMS is addressing. Essentially, CMS is instructing those MACs that use claims processing edits to deny the “ND” transport to remove those edits. The practical effect is to force the MACs to use some other criteria to determine whether the roundtrip is reasonable (and, therefore, covered by Medicare Part B).

Please note that the coverage rules and clarification summarized above applies only to therapeutic and diagnostic facilities. It does not apply to ambulance transportation to and from a physician’s office. With the narrow exception of emergency ambulance transportation to a physician’s office as an interim stop on the way to a hospital, such transportation has always been and remains a non-covered service.

While I believe the change is, on net, a positive one for the industry, I would caution against reading too much into this clarification. CMS is not indicating that these transports will be covered in all instances. CMS is simply saying that, with respect to the initial processing of claims, it is willing to sacrifice some potential accuracy for the sake of greater national consistency. CMS in not restricting its MACs from using other means to make reasonableness determinations, e.g., the use of development requests, prepayment review, etc. While it is reasonable to assume that most MACs will elect not to utilize these tools, only time will tell if that is indeed what comes to pass. In the meantime, I am going to enjoy one of those rare instances where CMS used common sense, and removed an additional burden on our industry.

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

Congress Passes Ambulance Medicare Add-Ons

Written by Mark Postma on . Posted in Legislative, Medicare, Reimbursement.

 

It is my pleasure to share with you that—just minutes ago—Congress passed the 5 year extension of the Medicare ambulance add-ons. The extension was part of the two-year budget deal reached by congressional leaders and passed by the Senate early this morning and then shortly thereafter by the House. The ambulance provisions in the final deal differ from the provisions passed earlier this week by the House in one key area – the collection of ambulance cost data. This means that we are truly in the endzone of the add-on payment extension process.

While we ask your continued patience as we jump through one last procedural hoop, I am confident that the add-ons will be back in effect as soon as the President signs the legislation. In today’s deeply divided political climate, I am proud of what we have accomplished through collaboration as an association and industry.

Here are the specifics of the final package:

  • 5 year extension of the ambulance Medicare add-ons through December 31, 2022, retroactive to January 1, 2018.
  • AAA’s preferred method of Cost data collection that provides flexibility to the Secretary of HHS in developing the system. Consultation with the industry is required so that it strikes the appropriate balance between obtaining meaningful data while not overly burdening or onerously penalizing the ambulance services.
  • The penalty for failing to report required data would be a reduction in payment up to 10% for the year following the year in which the data should have been submitted. AAA objected to the house proposed penalty of up to a year of Medicare payments clawback or withholding of payments. A clause is included to wave the penalty in cases of hardship.
  • A “pay-for” for the 5-year extension of the add-ons with a 13% cut to non-emergent dialysis transports – the AAA had objected to the offset and pushed for a cut targeted to just those entities which abuse the dialysis transport benefit. We were successful in reducing the initial cut from 22% to 13%. The AAA is actively working on other pay-for options that would replace the 13% cut with something targeting dialysis fraud and abuse.

Next Steps

All that remains to bring the add-ons into effect retroactively to January 1, 2018 are a few administrative formalities and the signature of the President, who has indicated his support of the agreement. Given the government shutdown, we are cautiously optimistic that this will proceed quickly. However, bumps are always a possibility—we will keep you informed! (Follow AAA on Twitter at @amerambassoc or Facebook for instant updates.)

Thank You

This week’s tremendous progress would not have been possible without months of effort by AAA volunteer leaders, advocacy experts, and staff, as well as support from our key champions in Congress.

I’d like to personally thank the AAA Government Affairs Committee, including Chair Jamie Pafford-Gresham and Vice Chair Shawn Baird, as well as the entire AAA Board for their hundreds of hours of hard work on this issue. We are all truly grateful for your dedication to moving mountains to find sustainable funding for EMS.

Last but certainly not least, thank you to the dozens of state ambulance associations and thousands of individual members who wrote letters to their Members of Congress in support of the add-ons. We truly couldn’t have made it this far without your support.

Again, thank you, and please stay tuned for final updates!

Mark Postma
President
American Ambulance Association
“Representing EMS in America”

House Passes Ambulance Medicare Add-Ons

Written by Mark Postma on . Posted in Legislative, Medicare, Reimbursement.

Moments ago, the U.S. House of Representatives passed legislation which includes a five-year extension of the Medicare ambulance add-ons. The House voted 245 to 182 to pass a Continuing Resolution (CR) to fund the federal government beyond the current expiration date of February 8. The CR included a package of Medicare provider extenders including an extension of the temporary Medicare ambulance add-ons.

The ambulance provisions in the CR include the following:

  • A five-year extension of the temporary Medicare ambulance increases of 2% urban and 3% rural to base and mileage rates and 22.6% to the base rate in super rural areas. The extension would be retroactive to January 1, 2018 and expire on December 31, 2022.
  • The requirement for ambulance service suppliers to submit cost reports. The language is based on H.R. 3729 as reported by the House Ways and Means Committee but with new language providing the CMS Administrator with the discretion to apply a payment suspension or overpayment as the penalty for suppliers that do not submit timely, accurate and complete data after the initial two years.
  • To offset the cost of the add-ons extension, a further reduction of 13% in Medicare reimbursement for BLS non-emergency transports to and from dialysis centers. The initial reduction was 22% but the AAA was able to help lower the estimated cost of the add-ons and thus lower the percentage of the offsetting cut.

The CR now goes to the Senate for its consideration. The Senate is likely to act tomorrow, February 7.

We will keep you posted of new developments. Thank you for your continued support of the American Ambulance Association.

Mark Postma
President
American Ambulance Association
“Representing EMS in America”

President’s Perspective: January 2018

Written by Mark Postma on . Posted in Annual Conference & Tradeshow, Legislative, Medicare, Member-Only, Stars of Life.

Dear Fellow AAA Members,

Happy New Year from the American Ambulance Association!

This year promises to bring new challenges and opportunities for ambulance services. As your association, AAA, its experts, and the whole member community will be there to support you every step of the way.

Advocacy Update

If you’ve missed your recent member advocacy emails, you may be wondering “What is going on with the add-ons?!” I’d like to address this first and foremost.

Despite the best efforts of the American Ambulance Association and other industry stakeholders, the temporary Medicare ambulance increases expired December 31. However, please rest assured that the AAA lobbying team, volunteer leadership, and staff are working tirelessly around-the-clock to advocate for this critical EMS revenue.

The good news is that the end may be in sight. However, we must remain engaged, active, and unified as an industry to carry this effort through in the face of the today’s contentious and unpredictable political climate.

Republicans and Democrats in the House and Senate are working toward a long-term extension of the Children’s Health Insurance Program (CHIP).  As part of these negotiations, the House and Senate are working through the details of a Medicare provider extender package. Thanks to the work of our lobbying team and countless Hill visits, phone calls and letters by dedicated AAA members and our supporters on Capitol Hill, both the House and Senate proposals include five-year extensions of the ambulance increases retroactive to January 1, 2018.

We are cautiously optimistic that Congress will include CHIP in the next Continuing Resolution (CR) on or around January 19. Depending on the outcomes of last-minute discussions, the Medicare provider extender package may be attached to the CHIP bill or moved forward separately shortly thereafter.  However, of course, Congress in 2018 is predictably unpredictable: we ask for your patience, and your continued confidence that AAA is doing everything possible on this issue.

To support this effort, AAA joined forces with other healthcare industry groups to send a letter to Congress urging them to pass the larger Medicare provider extender package. The AAA has also made the case to Congress that it must act now on the ambulance extension as ambulance service providers and suppliers are first responders and cannot afford to hold claims for prolonged periods of time. Congress must therefore move immediately to ensure that our nation’s health care safety net is not put at risk. We pointed out that submitting claims with the increases paid retroactively could result in long delays in providers and suppliers getting the additional funds, an unacceptable risk for an EMS network made up primarily of small providers. As a last resort, we have asked that if Congress cannot address a Medicare provider extender package by January 19 that they pass a short-term extension of the ambulance increases to sustain our operations.

The AAA is also working with congressional offices and committees of jurisdiction to implement a workable system for collecting cost data from ambulance service providers and suppliers and on an offset focused on reducing reimbursement just for those entities which abuse the dialysis transport benefit. The reality is that ambulance services will have to report their costs to the federal government. However, AAA will work to ensure that the system implemented is fair and does not place undue burden on ambulance services or subject ambulance services to standards and penalties that are not applied to other Medicare providers.

While we believe we may be approaching the endzone on the extender renewals, we must continue to push Congress to do what is right for EMS. Now, more than ever, we need you to add your voice to those of AAA, state-level ambulance associations, and thousands of your peers. Please take a moment today to send Congress your message of support for the Medicare ambulance add-ons—it takes just two clicks. Write a letter now>

Our advocacy team will continue to provide frequent updates as we work to keep this issue at the forefront.

Stars of Life

Despite the challenges on the Hill, I look forward to seeing many of you in Washington, DC in June at Stars of Life. Stars recognizes EMS providers from across the nation who have served their communities with great distinction. The Stars, accompanied by their executive-level Hosts, meet with legislators to shine a light on the importance of ambulance services to our healthcare network. Nominate your Stars today, and help AAA celebrate the best in EMS! (Early bird registration rates end March 31.)

Renew Your Support of AAA

Has your organization renewed its AAA membership? Your continued support is critically important as AAA fights for fair ambulance reimbursement. Membership also include benefits such as free use of the Savvik Buying Group, complimentary CISM and EAP-based counseling for your employees, and access to industry experts on Medicare, operations, and HR.

If you have already renewed, please accept our most sincere thanks. If you have not yet submitted payment for this year’s membership, I encourage you to renew online or reach out to staff at info@ambulance.org for assistance.

AAA Annual Conference & Trade Show

The 2017 AAA Annual Conference was an overwhelming success. In addition to powerful industry-centric presentations on leadership, reimbursement, and operations, this year’s AAA Annual Conference & Trade Show featured three inspiring keynotes—Steven M.R. Covey, Mel Robbins, and Dr. Zubin “ZDoggMD” Damania. Additionally, we honored AMBY Award winners and those who responded to the tragic Route 91 shootings. Check out the photo album for AAA 2017 on our Facebook page.

I hope that you will join me and hundreds of our colleagues for networking, learning, and fun in Las Vegas at next year’s Annual event September 6–8. Early bird registration is open now!

Webcasts & Regional Workshops

AAA is working hard to make it easier than ever to educate your team. Join us in 2018 for a variety of live and on-demand webcasts as well as convenient regional workshops. Upcoming webinar topics include sexual harassment, CMS low volume settlements, and cybersecurity. This year, we are also proud to host one-day workshops in each of AAA’s five regions (calendar soon to be announced).

Thank You, Members!

I would like to give special thanks to the members who dedicate their time and thought to AAA’s board, committees, and task forces. We literally could not do it without you.

It continues to be my pleasure to serve these individuals, as well as the many other talented, dedicated healthcare professionals who make up the AAA membership. We deeply appreciate your continued support, participation, and unity. Thank you!

—POST!
Mark Postma—President
American Ambulance Association
Representing EMS in America

 

Alert: Medicare Increases Will Expire For Now: What You Need to Know

Written by Kathy Lester on . Posted in Advocacy Priorities, Government Affairs, Member Advisories, News, Reimbursement.

While the Congress succeeded in passing the Republican tax bill and keeping the federal government open with a short-term continuing resolution that included a temporary extension for the State Children’s Health Insurance Program (CHIP), it did not act upon the several Medicare extenders that expire on December 31, 2017. This extenders package includes the ambulance add-ons for urban, rural, and super-rural areas, as well as a moratorium on therapy caps, extenders for hospitals, and several other extenders important to other Medicare providers.

Despite the fact that the Congress left town, there is still strong bipartisan support for reinstating these extenders – including the ambulance extenders – early in January 2018. The most likely time frame will be for the extenders to be added to the next government funding legislation, which must be passed by January 19.

First, do not panic. As you may have already heard, CMS is telling providers and suppliers that the add-ons will expire at the end of the month. Technically that is true. The Agency is simply stating the obvious; but no one should imply from such statements that the Congress will not fix them or not make them retroactive. Historically, CMS has followed this pattern of indicating the add-ons have expired until legislation extending the add-ons has passed both chambers of Congress and the President has signed the bill into law.  CMS will make similar statements relative to the other Medicare extenders as well.

Second, prepare. To the extent you are able to do so, you may hold your claims. Medicare requires providers to files claims no later than 12 months after the date when the services were provided. (See Medicare: File a Claim; see also section 6404 of the Affordable Care Act). While this may not work for all claims, holding claims will reduce the number that would have to be reprocessed once the add-ons become law. If CMS believes at some point the legislation will pass, it may also break with its own precedent and indicate that has asked the contractors to hold claims for a short period of time as well. It did this in 2014 when it discovered errors in a final fee schedule rule. Once the claims are processed, so long as the add-ons have been extended by law, the add-on dollars will appear in the reimbursement amounts sent to providers and suppliers.

Third, retroactivity can be expensive, but CMS can mitigate the costs. CMS did this most recently in May of 2017. Then, CMS announced that it would implement the retroactive extension of a transitional payment for durable medical equipment suppliers by having the contractors automatically reprocess claims from the period when the transitional payment was made retroactive. This approach reduced the burden on providers and suppliers by eliminating the need to resubmit claims.

Despite the fact that there are ways to mitigate the problem, the American Ambulance Association (AAA) remains deeply concerned that the Congress did not extend the add-ons before they left for the holidays. We understand that for ambulance services across the country receiving timely payments from Medicare can be the difference between being able to make payroll or not. Having the dollars from the add-ons is also crucial to ensuring adequate cash flow. Therefore, while we advise you to think through your options and take the steps that best meet your needs and the needs of your employees, patients, partners, and businesses, we also ask that you reach out to the Congress and let them know how important it is to get the add-ons extended as early in January as possible. Make your voice heard by going to the AAA’s grassroots page. There you can send an email or reach out through social media to your Members of Congress.  We need everyone, including your employees, patients, and others who support high quality ambulance services, to reach out today.

Write to Your Members of Congress

The AAA will continue our direct efforts on Capitol Hill to make sure these add-ons are extended and overly burdensome new requirements are not placed on ambulance services. With your help, we can get the add-ons extended. For more information please visit https://ambulance.org/advocacy/.

Medicare Extender Update

Written by Mark Postma on . Posted in Government Affairs, Legislative, Reimbursement.

As president of your association, keeping you informed of our advocacy efforts is one of my top priorities. In keeping with this approach, I would like to share with you an update on the American Ambulance Association’s latest efforts on Capitol Hill. The temporary Medicare ambulance increases are currently scheduled to expire on December 31, 2017. And once again, Congress is waiting until the last minute to extend them. Thankfully, a long-term solution is on the horizon.

The House and Senate are in the process of negotiating the details of a Medicare provider extender package including our ambulance provisions. The House and Senate positions both include a five-year extension of the 2% urban, 3% rural, and super rural increases. Where their positions differ reflects the respective preferences of the Senate Finance and House Ways and Means Committees on how best to collect cost data from ambulance services suppliers and providers.

The Senate position is based on a Senate Finance Committee Discussion Draft from October 26 which includes the five-year extension of the increases as well as a data collection system based on the one from the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 967). The provision would direct CMS to collect data from a statistically significant number of ambulance service suppliers and providers. This would occur each year for the first three years, then a minimum of every three years thereafter. The penalty for not reporting data if selected would be a 10% cut in Medicare reimbursement for the following year. The language gives CMS flexibility in designing the system, and would place minimal burden on small ambulance service suppliers. The outcome would be usable data to further substantiate the need for rate increases and reform of the Medicare ambulance fee schedule.

The House position is based on H.R. 3729, which also includes the five-year extension of the increases. However, it adds mandatory annual cost reporting for ambulance service suppliers and providers as well. The AAA worked with the bill sponsors and Committee staff to modify the cost reporting language to reflect the unique nature of our industry. However, since ambulance service suppliers and providers aren’t paid based on cost reports, and cost reporting requirements are very stringent, there are several compatibility issues when attempting to apply this model to our industry. The primary problem is the penalty for not reporting timely data, as well as a new standard requiring the data to be accurate and complete. As a result, after the first two years of reporting, the penalty of an overpayment for not reporting timely, accurate, and complete data could be an entire year of Medicare payments. The AAA therefore prefers the Senate language due to its flexibility for our industry as well as its less severe penalty.

The good news is that the House and Senate are in agreement on a five-year extension of the increases. As part of the increase package, our industry will also have a data collection system to demonstrate that we are reimbursed below cost, and to make data-driven decisions on reforming the Medicare ambulance fee schedule. However, it is critical that we get the data collection provision right so that it provides useful information and is not overly burdensome for our members.

Thanks to our champions on Capitol Hill, member advocates, and our lobbying team, the super rural bonus payment has been in effect since 2003, and the urban and rural increases since 2008. Subsequently, we have successfully advocated for Congress to extend the increases eight times, including the current 33-month extension. However, with Congress pressed to address a number of priorities by the end of this year, a Medicare extenders package may not occur until early January.

Securing a five-year extension will require the action of our entire membership. I urge you to please write your members of Congress today in support of the Medicare ambulance increases!

Contact your members of Congress now>

AETNA/CVS Deal Along with Uber Concepts May Finally Change Ambulance Industry

Written by Mark Postma on . Posted in Community, Government Affairs, News, Press, Private Insurance, Reimbursement.

Mark Postma, AAA President & Asbel Montes, AAA Payment Reform Chair

The recent merger of Aetna/CVS may be the catalyst that finally brings the change that the ambulance industry has been advocating for over the past several years. This new healthcare strategy supports the ambulance industry’s ideas that alternative patient destinations are needed in EMS.

To explain this better, one must understand the current state of ambulance reimbursement via the 911 system or equivalent. At this point in time most commercial payers of healthcare (Insurance) as well as Medicare will not pay for 911 ambulance transportation to any destination other than the “nearest appropriate” hospital based emergency room; arguably, the most expensive and least efficient form of healthcare. The continuation of this policy discounts the advanced capabilities of both EMS and new clinical settings and the savings that can be achieved through innovative change. In addition, at the same time that the cost of healthcare in general is increasing, reimbursement from all payers is decreasing, creating a significant challenge for providers. Medicare consistently pays providers below cost for providing life-saving services and state Medicaid agencies are consistently underfunding the critical services to the un- and under-insured populations that have allowed intermediaries to delay or not pay ambulance services.

Much of the U.S. population believes that vital 911 EMS services or the equivalent are provided free or included in their local property taxes. This is generally not the case. While EMS services must be at the ready on a 24/7/365 basis, they are not paid for being on call, but only when the service is used.

Many communities have governing rules that require 911, or the equivalent, paramedic services to arrive on-scene within 8-12 minutes of receiving the call. This cost of readiness is VERY expensive. Skyrocketing personnel costs, ambulances, equipment, and other high cost drugs only exacerbate an already fragile reimbursement structure. Although recent articles about calling Uber or Lyft sound intriguing, these drivers and cars are not prepared for any type of injury. Nor can they alert the hospital in critical situations to have the heart cath lab ready or a trauma surgeon on standby, shortening the time to definitive care when time matters most. Emergency paramedics are highly trained, are nationally and/or state certified, and provide services on state regulated ambulances equipped to manage all types of emergencies. Ambulances are also often strategically placed to arrive in that 8-12 minute response time requirement. However, there is one piece missing from the ambulance scenario that allows for Uber/Lyft to succeed; your personal credit card is on file with them. NO GUARANTEED PAYMENT, NO TRANSPORT. The cost of providing ambulance services “on call” with life-saving equipment, medications, and personnel at the ready is steep. When you consider the many regulations providers must adhere to outside of patient care, the cost increases even more. This misunderstanding of the cost often results in patients being stunned when they receive a bill for services provided and feel that it is excessive. However, comparing the cost of a life-saving ambulance transport to an Uber/Lyft ride is like comparing the cost of building a house to putting up a tent.

On the other hand, these highly trained paramedics, with vehicles that are comprehensively (medically) equipped to meet the highest safety standards, have no credit card on file. They do not treat you based on your ability to pay. In fact, approximately less than half of ambulance patients have insurance, and when commercial insurance does pay, they are increasingly paying only a percentage of the total bill, leaving their insured left to pay the balance. In a time of an emergency, insurers should not place an additional burden on their insured through underpayment or claiming out of network status. In addition, although many emergency 911 calls begin as a “frantic call for help,” not all are life threatening and require the highest level of care; however, they do need some type of a health care intervention.

It is this high volume of low acuity patients who do not have primary care physicians and who currently by law must be transported to hospitals that continue to bottleneck emergency rooms. This bottleneck then requires ambulances to be “on the wall” at local hospital emergency rooms. The cost to the 911 EMS system rapidly begins a domino effect where all the patients begin to be diverted/directed to other hospitals causing an overflow to the next hospital. In large EMS systems, this domino effect can bring emergency rooms at all available hospitals to capacity quickly. EMS units are unable to go on additional emergency calls because they are caring for a patient while waiting on hospital staff to become available to take over. They also cannot leave that hospital with the patient to go to another hospital due to federal laws that prohibit this movement.

So why does the AETNA/CVS excite the leaders of EMS organizations? Most people assume that since this acquisition just occurred, Walgreens will probably follow suit with another insurer. Other local pharmacy “CVS types” may partner with local hospitals or medical insurance cooperatives as well. This leads the ambulance industry to believe that the capacity to transport patients to alternative locations could greatly change the landscape of EMS. The idea that local CVS/Walgreens/clinics could receive low acuity patients breaks open the bottleneck and can provide several benefits for the ambulance service and patient. One benefit is that adding these stores/clinics greatly increases the resources for caring for low acuity patients and could potentially double the locations an ambulance can transport to, which will allow for quicker transport times and increase efficiencies. Lastly, and most importantly, diverting the low acuity patients to these additional community resources would reduce overflow in the emergency departments and allow true emergency patients to be transferred over more quickly to receive the higher level of care they require. This scenario is also a win for the patient. They could be transported to the most appropriate location to care for their needs and therefore can be billed more accurately for services they require rather than the emergency department fees which are usually costlier.

To make this happen, obviously the CVS system needs to evolve to receive these patients. More importantly, ambulance reimbursement by federal, state, and private payers must evolve to meet the demands of the market. Due to the complexities of how EMS services are provided because of state and local regulations, mandatory response times, service area parameters, and others, reimbursement for these services must be adequately paid for by Medicare, Medicaid, and private insurers. Today EMS agencies can only “hope” that their patients have a source of payment!

Although one would think that this state of concern for EMS services is being monitored, it currently has only a very small voice in the healthcare continuum. Federal agencies seem to want to look at what EMS will look like in 10 to 25 years rather than where EMS is today and where it can develop over the next few years. EMS reform needs to happen soon to save these systems from bankruptcy and/or the public from higher taxation.

We hope that this merger will be the beginning of alternative EMS/ambulance destinations with allocated reimbursements that meet the costs of providing high quality, efficient, and necessary 911 ambulance services.

Mark Postma, COO, Sunstar Paramedics
American Ambulance Association, President
Works for Sunstar Paramedics, Florida’s largest EMS provider
MPostma@sunstarems.com, 727-224-0295

Asbel Montes, Vice President, Acadian Ambulance Service, Inc.
American Ambulance Association, Chair-Payment Reform Committee
Works for Acadian Ambulance Service, Inc., Louisiana’s largest EMS provider
Asbel.Montes@acadian.com, 337-291-3310

Is the TX Moratorium Ending?

Written by Brian Werfel on . Posted in Regulatory.

Is CMS Ending the Temporary Moratorium on Enrollment of New Non-Emergency Ground Ambulance Providers in Texas?

On September 2, 2017, the Centers for Medicare and Medicaid Services (CMS) posted a notice on its website that it was lifting the temporary moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017.  CMS indicated that the lifting of this temporary moratorium was intended to aid in the disaster response to Hurricane Harvey.

For reasons I will discuss in greater detail below, this explanation has struck a number of commentators as curious.  These commentators have speculated that this may notice may foretell a permanent elimination of the enrollment moratorium for non-emergency ground ambulance providers in Texas.

Background on Temporary Moratorium on New Enrollments in Texas

The Affordable Care Act granted CMS several new tools to combat fraud, waste, and abuse in the Medicare, Medicaid, and Children’s Health Insurance Programs.  This included Section 6401(a), which granted the CMS Secretary the authority to impose temporary moratoria on the enrollment of new Medicare, Medicaid, or CHIP providers to the extent the Secretary determined that doing was necessary to prevent fraud and abuse.

The implementation of the first enrollment moratorium under this new authority was made on July 30, 2013, when CMS announced enrollment moratoria on new home health agencies in Chicago, Illinois, and Miami, Florida, as well as on new ground ambulance suppliers in the Houston, Texas metropolitan area.  On January 30, 2014, CMS expanded the enrollment moratorium on new ground ambulance suppliers to the Philadelphia, Pennsylvania metropolitan area.  CMS subsequently extended these enrollment moratoria every 6 months thereafter, up to July 29, 2016.  On that date, CMS announced that it was making several significant changes to the enrollment moratoria:

  1. It was lifting the moratoria on the enrollment of new emergency ground ambulance suppliers in both areas;
  2. At the same time, it was expanding the moratorium on the enrollment of new non-emergency ground ambulance suppliers to the entire states of New Jersey, Pennsylvania, and Texas.

CMS further announced the creation of an “Enrollment Moratoria Access Waiver Demonstration” program that would permit non-emergency ambulance providers in those states to apply for a waiver (i.e., to permit them to enroll in the Medicare, Medicaid, or CHIP Programs) to the extent they could demonstrate an access to care issue.

Temporary Lifting or Permanent Elimination?

The Medicare enrollment process is a lengthy one.  Following the submission of an enrollment form (CMS-855b), it typically takes the Medicare contractor up to 60 days to review the form and approve it.  Moreover, the Medicare contractor will frequently request additional information, which can add up to several months to the process.  Once approved by the Medicare contractor, the application is passed along to the Site Review Contractor for a visit to the enrollee’s physical practice locations.  All told, it is not unusual for the process to take 4-6 months from start to finish.  The time limits for enrollment in Medicaid and CHIP are similar.

It seems unlikely that a ground ambulance supplier that temporarily responded to the areas affected by Hurricane Harvey would go through the enrollment process, especially considering they would likely be seeking reimbursement for their efforts either directly through the Federal Emergency Management Agency (FEMA) and its contractor, or through the existing 1135a waiver program.  For this reason, it seems logical to assume that an ambulance supplier would only go through the enrollment process only if it intends to permanently establish operations in the affected area.

Editor’s Note: it is possible that CMS intended to address storm damage to an enrolled provider’s existing practice locations, i.e., the lifting of the moratorium would make it easier for these providers to add additional practice locations while they repaired their existing facilities.  However, there is nothing in CMS’ website notice that suggests that this was intended to be limited to existing enrolled providers.  This is simply speculation on my part.

CMS indicated that it would be publishing a notice in the Federal Register formally announcing the lifting of the enrollment moratorium.  A month ago, it was assumed by most commentators (myself included) that the notice would make clear that the lifting of the moratorium was temporary, and that it would set a date for its re-establishment.  However, it has now been more than a month since CMS announced the lifting of the moratorium, and that notice has yet to appear in the Federal Register.  The longer we go without an announcement from CMS, the more this starts to look like a permanent lifting of the moratorium.

What This Means Today to Non-Emergency Ambulance Suppliers in Texas

The lifting of this moratorium applies to new enrollments in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  Therefore, as of today, and pending a subsequent re-establishment of the enrollment moratorium by CMS, Part B ground ambulance suppliers in Texas that are not otherwise enrolled as non-emergency ground ambulance suppliers will now be permitted to enroll in the Medicare, Medicaid, and CHIP Programs.  The lifting of the moratorium will also permit companies that are already enrolled as non-emergency ambulance suppliers to add additional practice locations throughout the state.  CMS has indicated that both new enrollments and changes in enrollment to add additional practice locations will be subject to “high” screening under 42 C.F.R. §424.518(c)(3)(iii).

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

Time to handle 911 call demands with Paramedics

Written by Scott McConnell on . Posted in Community, Legislative, Medicaid, Medicare, News, Training.

When discussing this new and growing field of pre-hospital care, there seems to be two unique paths that services are following. The first is the hospital-owned or contracted service, where community providers seek ways to decrease readmission rates for CHF, COPD, Pneumonia, Sepsis, MI and other chronic illnesses.

When a patient discharged with one of these targeted conditions is readmitted within a 30 day window, “hospitals face penalties of up to 3 percent of Medicare payments in 2018” (Gluck, 2017, para. 10). That is a lot of money. Consider, “Lee Health, Southwest Florida’s largest hospital operator, which is expected to lose $3.4 million in payments” (Gluck, 2017, para. 2). This model represents the if, or, and type of service, meaning if we can do it for less and there are providers willing to do this type of medicine, then we can save the expensive penalties from CMC.

The other model of community paramedicine is 911 abuse reduction. For years EMS has conditioned the public to call 911 for any emergency. But today, what we consider an emergency is far from the public’s perception of an emergency. “EMS has experienced a 37% increase in 911 calls since 2008.” (White, 2016, para. 6) Yet have we increased staffing proportionally to meet the demand? Afraid not since “only 50% of EMS services in 2008 were fully staffed, and more than 63% had a volunteer component as part of their staffing level” (“Critical Staffing Shortages,” 2015, para. 2).

The article references increasing wages to help compensate for the decrease in trained providers by attracting more professionals to the field. With the CMC limiting payments and the major insurance companies following suit, doubtful this will be an option in the near future.

To reduce calls and increase levels of service, we can try to reeducate the public to what is a true emergency, but that is a long and slow process. For example, Philadelphia has started the trend and placed several billboards up around neighborhoods that contribute an ordinarily high amount of non-emergent 911 calls. Will this work? Time will tell but I would believe not enough to affect the volume of calls.

What about enlisting Community Paramedics in these situations? I believe this is a viable solution with nurses triaging the low acuity calls in the 911 center. Dispatching Community Paramedics armed with not only the usual equipment, but also the knowledge base to connect these patients with primary care physicians, social workers, and the programs that are available to them. This will help people receive the long-term care they deserve.

Scott F. McConnell is Vice President of EMS Education for OnCourse Learning and one of the Founders of Distance CME. Since its inception in 2010, more than 10,000 learners worldwide have relied on Distance CME to recertify their credentials. Scott is a true believer in sharing not only his perspectives and experiences but also those of other providers in educational settings.

References
* Critical Staffing Shortages (2015)
* Gluck, F. (2017, February 7th, 2017). Lee Health will lose $3.4 million in Medicare payments because of readmission rates. USA Today
* White, D. (2016, February 16th, 2016). Community paramedic? program intended to reduce 911 calls. Manatee Technical College

House Introduces H.R. 3236 – Write to Your Reps!

Written by Aidan Camas on . Posted in Advocacy Priorities, Government Affairs, Legislative, Member Advisories, News, Reimbursement.

Take Action for Extending Medicare Ambulance Relief

Ask your Representatives to Support H.R. 3236 – The Ambulance Medicare Budget and Operations Act of 2017

The current 33-month extension of the Medicare add-on payments is set to expire at the end of December 2017. Losing these add-on payments would be a devastating blow to ambulance services across the country. It is crucial that the payments be extended as we push for a long-term solution. H.R. 3236 introduced by Reps. Nunes, Upton, and Welch would extend the current temporary Medicare add-ons for five years. More details about the Bill can be found below. Let your Representative know that you support H.R. 3236 — Here are three quick and easy ways to get involved!

Writing to your members of Congress only takes 2 clicks, follow these simple steps:

1. Enter contact information below (required by Congressional offices) and click “Submit”
2. On the next page you’ll see the letter to your Representative (Message 1) and the letter(s) to your Senators  (Message 2) – click “Submit Messages”
Feel free to personalize your letter(s) before submitting them.

Active on Social Media? Tweet at your Representative asking for their support of H.R. 3236!

  • Authorize Your Account
  • Enter Contact Information
  • Tweet! (Tweet will be auto-generated with your Senators tagged)
Know your Senators’ Twitter accounts already? Tweet:
“#ambulance svs in your district need you, @[your Representative]! Please co-sponsor HR 3236  to help us continue to provide quality #EMS!”

Post on Facebook why H.R. 3236  is important! Be sure to tag your Representative and encourage others to share your post! Ask others to write letters of support as well! http://bit.ly/AAAbill

More About Our Bill H.R. 3236, the Ambulance Medicare Budget and Operations Act of 2017:
Legislation to extend the Medicare ambulance add-on payments for five years has been introduced by Representatives Nunes, Upton, and Welch (H.R. 3236).
Specifically, the bill:

  • Provides Medicare Ambulance Relief, by extending for five years the current temporary 2 percent urban, 3 percent rural, and super rural bonus payments.
  • Requires the Medicare Payment Advisory Commission (MedPAC) to submit a report to Congress detailing the burden of cost reports on the ambulance industry and accuracy of the data received through ambulance cost reports and making recommendations on whether the system should be modified no later than July 1, 2019.
  • Requires CMS to work with stakeholders in the development of an ambulance cost report.

Ambulance Ride-Along Toolkit

Written by Aidan Camas on . Posted in Government Affairs, Member Advisories, News, Press.

AAA ambulance emt member legislation

2018 Ride-Along Toolkit Now Available!

Educating your members of Congress about ambulance industry issues makes them much more likely to support your efforts.  An easy and effective way to educate them is to invite them to participate in a local Ambulance Ride-Along!

Congress is scheduled to adjourn on July 28 for their August congressional recess with members of Congress returning home to their districts and states.  This is the perfect opportunity for you to educate your members of Congress about those issues, in particular Medicare ambulance relief and reform, which are important to your operation. The most effective way to deliver these key messages is to host your member of Congress or their staff on a tour of your operation and an ambulance ride-along. If you cannot host a tour and ride-along, we strongly encourage you to arrange local meetings with your members of Congress during August. The AAA has made the process of arranging a ride-long or scheduling a meeting easy for you with our 2018 Congressional Ride-Along Toolkit.

Are you willing to host a Member of Congress at your service but unsure of how to set it up? Email Aidan Camas at acamas@ambulance.org and Aidan can help you set up a meeting.

Everything you need to arrange the ride-along or schedule a meeting is included in the Toolkit. Act now and invite your elected officials to join you on an Ambulance Ride-Along!

Download Ride-Along Toolkit

President’s Perspective: July 2017

Written by Mark Postma on . Posted in Annual Conference & Tradeshow, Legislative.

Dear Fellow AAA Member,

I am proud to share with you that just yesterday legislation was introduced in the House on a long-term extension of Medicare ambulance add-ons. The House bill follows introduction of the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 967) in the Senate, giving us a bill in both houses of Congress.

The Ambulance Medicare Budget and Operations Act (H.R. 3236) would extend for five years the 2% urban, 3% rural, and super rural bonus increases. The bill would also direct CMS to collect cost data from ambulance service suppliers. The AAA has been working with Congressman Nunes (R-CA) and Upton (R-MI) as well as the House Ways and Means and Energy and Commerce Committees on the bill language. You will soon receive a Call to Action to reach out to your Representatives to cosponsor the new House bill.

  1. 967 would make the add-on payments permanent and direct CMS to collect cost data from ambulance service suppliers using a survey methodology. Since its introduction, four additional Senators have signed on to co-sponsor S. 967, Senators Sanders (VT), Cochran (MS), Tester (MT) and Gillibrand (NY), bringing the total number of cosponsors to nine. While this is good progress, we need our member’s continued assistance in getting more co-sponsors on both of our bills.

While both bills meet the needs of our industry, the language in the two bills is different. That being said, it is not uncommon for the Senate bill and the House bill to have minor differences in their respective language that have to be worked out before getting final approval. When this happens, a special conference committee made up of members from both houses will work together to come to consensus about the different provisions in the bill. It is unlikely that our bills will be passed as stand-alone legislation. Instead, our provisions will likely be included in a larger bill similar to how the extenders were passed last time as a part of the CHIP (Children’s Health Insurance Program) Reauthorization Act. It is crucial that we have as many co-sponsors on both of our bills so that we can again be included on a larger piece of legislation.

The Medicare ambulance add-on payments will expire on December 31, 2017. To ensure continued access these critically-necessary extenders, we need the collective advocacy of ambulance services across the country. We ask that you please add your voice to the AAA’s by writing your Senators in support of Bill S.967. Additionally, you will soon receive a Call to Action to reach out to your Representatives to cosponsor the new House bill.

As always, the AAA Board, Government Affairs Committee, advocacy consultants, and staff are working diligently to build support on Capitol Hill to ensure that this vital revenue remains in place. If you missed our June 29 government affairs update webinar, I invite you to watch it on-demand now.

Annual Conference

The Education Committee recently finalized programming for the 2017 AAA Annual Conference & Trade Show. This year, we welcome three exciting keynotes—Steven M.R. Covey, Mel Robbins, and Dr. Zubin “ZDoggMD” Damania—as well as dozens of industry leaders and experts. I hope that you will join me and hundreds of our colleagues in ambulance leadership in Las Vegas in November! Online registration is open now.

Educational Events

AAA will host its inaugural SimLab workshop in Tulsa, Oklahoma on September 28. We are excited to share with members this immersive learning experience. AAA SimLab content will also be featured at the Mississippians for EMS Conference October 2–4 in Biloxi, Mississippi.

Save the date for AAA’s newest educational partnership, the Midwest EMS Expo May 2–3, 2018 in La Crosse, Wisconsin. Co-hosted with the Minnesota Ambulance Association and the Professional Ambulance Association of Wisconsin, the Midwest EMS Expo will bring together the best in national and regional education.

AAA is also proud to offer learning on-the-go, in the form of engaging webinars on human resources, reimbursement, compliance, and other topics. Don’t miss upcoming sessions on drug use, the OIG Safe Harbor on Cost Sharing, and the management of airborne medical emergencies.

Website

I am happy to share with you that AAA has a new URL, www.ambulance.org. This updated domain should assist us in clearly communicating our identity to the world, as well as in attracting new members not previously familiar with our organization.

Capital Campaign

To date, we have raised more than $255,000 of our $1mm Capital Campaign goal through the generous contributions of our fellow members. Our deepest thanks to all who have given. If you have not done so already, please consider donating today. Funds contributed to this campaign are managed separately from operating accounts, and can only be accessed after a full Board vote.

Stars of Life

It was a privilege to see many of you at Stars of Life in Washington in June. This year’s Stars program recognized 108 EMS providers from across the nation who have served their communities with distinction. The Stars, accompanied by their executive-level Hosts, met with their Senators and US Representatives to shine a light on the importance of ambulance services to our healthcare infrastructure. Nominations for the 2018 class of Stars will open in January. We hope to meet your Stars in D.C. next year.

As always, please don’t hesitate to contact the AAA at 703-610-9018 or info@ambulance.org if we can be of assistance to your service.

Thank you for your service to your communities, and have a great summer.

Mark Postma
President
American Ambulance Association
“Representing EMS in America”
www.ambulance.org

Talking Medicare: CMS Transmittal 236

Written by Brian Werfel on . Posted in Government Affairs, Member Advisories, Regulatory, Talking Medicare.

On June 16, 2017, the Centers for Medicare & Medicaid Services (CMS) released Transmittal 236. This Transmittal makes some minor changes to Chapter 10 of the Medicare Benefit Policy Manual. Specifically, CMS is clarifying its definitions related to the “ALS assessment” and “locality.” The change to the locality definition has prompted some discussion within the industry as to the impact on Medicare’s reimbursement for mileage beyond the nearest appropriate facility. In this month’s blog, I will explain the recent change, and hopefully convince you that this isn’t something that should cause you undue concern.

Medicare’s Definition of “Locality”

The definition of “locality” appears in Section 10.3.5 of Chapter 10 of the Medicare Benefit Policy Manual. That definition reads as follows:

The term “locality” with respect to ambulance service means the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services.

CMS then includes the following example to explain how that definition should be applied to real world situations:

EXAMPLE: Mr. A becomes ill at home and requires ambulance service to the hospital. The small community in which he lives has a 35-bed hospital. Two large metropolitan hospitals are located some distance from Mr. A’s community and both regularly provide hospital services to the community’s residents. The community is within the “locality” of both metropolitan hospitals and direct ambulance service to either of these (as well as to the local community hospital) is covered.

Conceptually, the locality definition is intended to address situations where there are several local options that residents of a community could choose for the receipt of necessary medical care. CMS recognizes that a strict adherence to its general policy of only covering mileage to the nearest appropriate facility would undermine a patient’s right to choose from these various institutional health care providers. The locality definition ensures that, when the two or more facilities are reasonably close to one another, the patient can safely choose the further facility without fear that they may end up being responsible for some incremental portion of the mileage.

The Proposed Clarification

Effective September 18, 2017, Transmittal 236 adds the following sentence to the end of the current definition of locality:

The MACs have the discretion to define locality in their service areas.

Analysis of the Proposed Clarification

The first question that should be asked is whether this clarification is actually a change in CMS policy? I would argue that it not, as Medicare Administrative Contractors have always had the discretion to define what constitutes the “locality” for an ambulance transport. For that reason, I view the purpose of this Transmittal as simply clarifying “who” (i.e., CMS vs. the MACs) has the primary responsibility for making these determinations.

Nor do I believe that this clarification is being made in response to potential abuse of the locality issue, either by providers billing for excess mileage under an expansive reading of “locality” or by the MACs in processing claims. Rather, I think this clarification is being made in response to repeated questions from the provider community, both on Open Door Forums and at state association meetings with their MACs. In other words, I think CMS is simply making clear that concerns regarding locality should be raised with the MACs, rather than CMS itself.

The Transmittal does leave open the possibility that MACs could impose their own definitions of locality. However, as I noted above, they already have this authority. I am not aware of any MAC ever electing to define the issue. Typically, the MAC will simply restate the CMS Manual definition of locality in its LCD.

So why have MACs been reluctant, up to this point, to define localities? I think it has to do with the administrative burden that would be involved. First and foremost, the MAC would need to have a sense of the larger demographic trends that dictate patient referral patterns in any given area. While that information is available, in theory, it is not available in any way that is readily useable by the MAC. Moreover, as the test focuses on what is “normal” or “expected” for patients, this would be a moving target, as patient preferences change over time, new facilities open, other facilities close or change the services they offer, etc. Thus, to the extent a MAC defined a locality, it would be constantly forced to revisit that definition every so often.  Finally, the MAC would have to make allowances for transports that are outside the locality, but where the patient is seeking specialized care that may not be available within the locality.

In sum, defining the locality for even a single community would be a significant administrative burden on the MAC. When you consider that there are hundreds, if not thousands of distinct communities within each state, you can understand the MACs reluctance to offer specific guidance on this approach.

Instead, I believe that the MACs will continue to address the mileage issue in the same way they have done up to this point. Most MACs have imposed an upper limit on the mileage they will pay without question. This upper mileage limit may be for its entire MAC Jurisdiction, it could be statewide, or it could have two or more mileage limits for a particular state.  For example, some MACs use a smaller mileage edit for transports that originate in and around a major metropolitan center, and a larger mileage edit for transports in the more rural areas of a state.

This approach offers a number of administrative benefits to the MAC.  First, it limits the number of claims that run afoul of the edit, and therefore that potentially may need to be reviewed by the MAC on appeal.  It also offers clarity to the provider community.

So, if your MAC has previously indicated that it has a mileage edit, I think you can safely assume that this will continue to be the guiding principle used by the MAC after the effective date. If the MAC doesn’t have a published mileage edit, I don’t think that is likely to change come September.

I would suggest that ambulance providers continue to monitor their remittances. If you are seeing mileage over a certain amount consistently denied by the MAC, that is their mileage edit. Please note that the MAC is not indicating this mileage is never covered, just that it has determined that it will not necessarily pay this higher number of miles without seeing the underlying documentation. In other words, the MAC is putting the burden on you to prove that the entire mileage was covered. If you are not seeing mileage being denied, I wouldn’t expect that to change either. I hope this helps to put everyone’s mind at ease.

Have a wonderful Fourth of July.

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

Now On-Demand: Member Government Affairs Webinar

Written by Matt Swift on . Posted in Executive, Government Affairs, Legislative, Regulatory.

The American Ambulance Association (AAA) hosted the Government Affairs and Member Forum on June 29 to provide an update on legislation on the expiring temporary Medicare ambulance add-on payments, the immediate and long-term goals of AAA on Medicare reform, and how members can get involved with ambulance service-related issues. Mark Postma, president of AAA, and a panel of experts covered varied topics, including where Senate Bill S.967 stands and what changes might occur within the industry, and then fielded questions from members to offer a better understanding of regulatory issues and what’s happening in Washington.

“We put a forum together at this critical time because we currently have a Senate bill to make the add-on permanent, and we’ve been working on a House bill for a long-term extension of the add-ons to be dropped soon,” said Postma. “We have been working diligently to get the appropriate bills introduced, to keep the Medicare extenders and other items that we’ll discuss in this forum.”

Capitol Hill Landscape

The Senate “Medicare Ambulance Access, Fraud Prevention and Reform Act” (S.967) has bipartisan support and is currently being championed Sen. Debbie Stabenow (D-MI), Pat Roberts (R-KS), Chuck Schumer (D-NY), Susan Collins (R-ME) and Patrick Leahy (D-VT). The bill would make permanent the temporary Medicare add-ons, treat ambulance service suppliers more like providers, cut down on dialysis transport fraud and abuse, and implement our preferred cost-data collection system that is beneficial, not burdensome, to ambulance services.

The AAA is currently working on the language for a bill to introduce the House of Representatives. While the bill has yet to be introduced, the AAA is collaborating with our House supporters and Committee staff to put together a bill that, at the very least, extends the Medicare add-ons for five years.  The bill will also include cost-data reporting on which the AAA is negotiating the final details.

“This year really is critical for us,” said Tristan North, senior vice president of government affairs for AAA. “We need to make sure  the Medicare add-on payments don’t expire on December 31.”

Going Forward

The panel discussed immediate, intermediate, and long-term goals to improve the ambulance fee schedule in the foreseeable future. The pending legislation covers many of the immediate goals, but AAA consultant Kathy Lester offered information that could impact the industry in the future.

Lester talked about better defining nonemergency services, the “Uber-ization” of medical transport, and what community paramedicine means to ambulance service providers.

The panel agreed that members and the community need to show their support for legislation, causes, and issues that will shape the future of ambulance services. It was suggested that members advocate to their representatives and leaders—offering to take them on ambulance “ride-alongs,” writing letters, or showing up at government functions—and explain to them how important these pieces of legislation and resources are to the EMS profession.

“We’re working hard and hoping for change in the future,” AAA’s Chair of Government Affairs, Jamie Pafford-Gresham, said. “We need you professionals and the relationships you have with your elected officials… your voices matter to Congress and they matter to us.”

Watch On Demand

Download the PowerPoint

 

EMS Education – A Look Forward

Written by Scott McConnell on . Posted in News, Professional Standards, Regulatory.

I have always believed EMS parallels the career trajectory of nursing. This is especially true when you look at the infancy of nursing—1750 to 1893—in what was a subservient apprenticeship with no didactic education. “Most nurses working in the States received on-the-job training in hospital diploma schools. Nursing students initially were unpaid, giving hospitals a source of free labor. This created what many nurse historians and policy analysts see as a system that continues to undervalue nursing’s contribution to acute care.” (History Lesson: Nursing Education has evolved over the decades, 2012, para. 5).

We reached a turning point in 1893 when the Columbian Exposition met, and although Ms. Florence Nightingale was unavailable to attend, she did have a paper presented at the exposition. In essence, the paper proved that a well-educated nursing workforce with standards of practice was needed to improve the health care of the United States.

This is exactly where EMS is now. Young enough to have moved through our growing pains of the late ’60s and early ’70s, but lucky enough to be in an age of extensive medical growth where all levels of providers are looking to enhance the care being provided.

So where do we go from here? We can choose to keep the status quo or we can move forward, hopefully, at a much greater speed than our nursing brothers and sisters. We should consider moving away from being governed by the Department of Transportation and the National Highway Traffic Safety Administration. A much more appropriate body is the Department of Health, which gives us the ability to stop thinking of our discipline as transport to the hospital, and more like bringing a hospital-like service to the to the sick and injured.

“EMS is a critical component of the nation’s healthcare system. Indeed, regardless of where they live, work or travel, people across the US rely on a sufficient, stable and well-trained workforce of EMS providers for help in everyday emergencies, large-scale incidents and natural disasters alike.” (“Education,” 2015, para. 1)

To get there, our education needs to reflect growth, and evidence-based medicine should be the law of the land. If this is proven to be effective, then let’s adopt it. If not, let’s stop teaching the worthless skills of yesterday, just as we have seen with the near extinction of the Long Spine Board. Let’s increase the minimum requirements for every level of provider. Let’s give Paramedics an associate’s degree, a diagnosis’s language, and a licensure, not a certification. Let’s all take the reins of our chosen career paths and have better continuing education that is challenging and accessible, and not an alphabet soup of certifications.

Yes, these are my musings about the future of EMS education. I know places that are very progressive in this country exist. I know there are protocol driven areas too. So let’s stop the segregation and become a health care group with a real mission, an everyday purpose. A place where we act as a group, not as individuals. A place where we treat our patients with the skill, compassion, and talent I know exists. Are you ready to join me?

Scott F. McConnell is Vice President of EMS Education for OnCourse Learning and one of the Founders of Distance CME. Since its inception in 2010, more than 10,000 learners worldwide have relied on Distance CME to recertify their credentials. Scott is a true believer in sharing not only his perspectives and experiences but also those of other providers in educational settings

References

Education. (2015). Retrieved from https://www.ems.gov/education.html

History Lesson: Nursing Education has evolved over the decades. (2012, November 12th, 2012). History Lesson: Nursing Education has evolved over the decades Blog post. Retrieved from https://www.nurse.com/blog/2012/11/12/history-lesson-nursing-education-has-evolved-over-the-decades-

 

Medicare “Locality” Rule & ALS Assessment

Written by David Werfel on . Posted in Government Affairs, Member-Only.

“Locality” Rule – MAC Discretion – Since the inception of the CMS Internet Only Manual (in 2003), the Benefit Policy Manual 100-02, Chapter 10, section 10.3.5 has always defined “Locality” as:

The term “Locality” with respect to ambulance service means the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services.

An example is then listed to indicate that the ambulance transportation to either of two large metropolitan hospitals that regularly provide services to the small community where the emergency arose would be covered destinations.

On June 16, 2017, CMS issued Transmittal 236 to add the following at the end of the paragraph before the example:

The MAC’s have the discretion to define locality in their service areas.

Effectively, there is no change as Carriers and Intermediaries (now MACs) have always had discretion to determine the “locality” around each facility. Often, they did this with mileage edits, e.g. in an urban area, they may have set a parameter of 15 miles, but in a rural area, they have allowed a much larger area. Nevertheless, it is a good time to ask your MAC for their definitions of the localities in their service area or the mileage edits that they use.

A copy of the Transmittal can be obtained at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R236BP.pdf

ALS Assessment

The same Transmittal made two changes to the CMS definition of “ALS Assessment”, as listed in the Benefit Policy Manual, 100-02, Chapter 10, section 30.1.1, as follows:

1. Assuming the ALS assessment is performed and meets the definition, this section now states that the services provided by the supplier or provider “shall” be covered at the ALS emergency level. Previously, the definition indicated the services “may” be covered at the ALS emergency level. This change was needed as some MACs thought they did not have to pay ALS emergency when the ALS assessment is performed in accordance with the definition.

2. The other change was to add to the end of the paragraph “and all other coverage requirements are met”. In other words, aside from providing the ALS assessment in accordance with the definition, there must also be ambulance transportation, the origin/destination requirements are met, the provider/supplier must meet all vehicle and crew requirements, transportation was medically necessary, the ALS assessment was medically necessary, etc.

The effective date for the changes noted above is September 18, 2017.

Write to Your Senators! Support S.967

Written by Aidan Camas on . Posted in Advocacy Priorities, Government Affairs, Legislative, Member Advisories, News, Reimbursement.

Take Action for Permanent Medicare Ambulance Relief

Ask your Senators to Support S.967 – 2017 Medicare Ambulance Access, Fraud Prevention, and Reform Act

The current 33-month extension of the Medicare add-on payments is set to expire at the end of December 2017. Losing these add-on payments would be a devastating blow to ambulance services across the country. It is crucial that the payments be made permanent as we push for a long-term solution. More details about the Bill can be found below. Let your Senators know that you support S. 967 — Here are three quick and easy ways to get involved!

Writing to your members of Congress only takes 2 clicks, follow these simple steps:

1. Enter contact information below (required by Congressional offices) and click “Submit”
2. On the next page you’ll see the letter(s) to your Senators – click “Submit Messages”

Active on Social Media? Tweet at your Senators asking for their support of S. 967!

  • Authorize Your Account
  • Enter Contact Information
  • Tweet! (Tweet will be auto-generated with your Senators tagged)
Know your Senators’ Twitter accounts already? Tweet:
“#ambulance svs in your state need you, @[your Senators]! Please co-sponsor S. 967 to help us continue to provide quality #EMS!”


Post on Facebook why S. 967 is important! Be sure to tag your Senators and encourage others to share your post! Ask others to write letters of support as well! http://bit.ly/AAAbill

More About Our Bill S. 967, the 2017 Medicare Ambulance Access, Fraud Prevention, and Reform Act:
Permanent ambulance relief legislation has been introduced by Senators Stabenow, Roberts, Schumer, Collins, and Leahy (S. 967). This legislation will allow ambulance service providers to maintain high quality ambulance services and budget for the future.
Specifically, the bill:

  • Provides Medicare Ambulance Relief, by permanently incorporating the current temporary 2 percent urban, 3 percent rural, and super rural bonus payments into the Medicare ambulance fee schedule rates.
  • Requires the Centers for Medicare and Medicaid Services (CMS) to submit a report to Congress detailing the features of a reformed payment system for ambulance services under the Medicare program no later than July 1, 2019.
  • Modifies the process for the transport of dialysis patients by requiring the Department of Health and Human Services to establish a process for the prior authorization of coverage for such patients.
  • Treat ambulance services designated as “suppliers” as “providers” for certain purposes under Medicare.
  • Specifies CMS to work with stakeholders in the development of a data collection system for ambulance entities that defines the various types of ambulance entities as well as the relevant cost and data elements required for submission.

CMS Letter Regarding Merit-Based Incentive Payment System

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, News, Regulatory.

Over the past week, multiple members have contacted the American Ambulance Association to report that they have received a letter from the Centers for Medicare and Medicaid Services (CMS) related to their participation in the Merit-Based Incentive Payment System (MIPS). The letter appears to have been sent to any entity with a taxpayer identification number (TIN) that is enrolled in the Medicare Part B Program. The stated purpose of the letter is to inform the provider whether it is exempt from participation in the MIPS program.

This member advisory is being issued to advise ambulance suppliers that:

(1) they are not eligible to participate in the MIPS program
(2) no positive or negative adjustments will be made to the ambulance suppliers Medicare payments
(3) no further action is required on their part

Therefore, AAA members that received this letter can safely disregard it. 

 

Support AAA’s Medicare Relief Legislation, S. 967

Written by Mark Postma on . Posted in Government Affairs, Legislative, Medicare, Member Advisories.

Dear Fellow Members,

As you know, the Medicare ambulance add-on payments are set to expire on December 31, 2017. I’m proud to share with you that today, due to AAA advocacy efforts, permanent ambulance relief legislation was introduced by Senators Stabenow, Roberts, Schumer, Collins, and Leahy.

This bill, S.967, “Medicare Ambulance Access, Fraud Prevention, and Reform Act” would make permanent the vital urban and rural Medicare add-ons and super-rural bonus payments. Although some changes are likely during the committee markup process, we are cautiously optimistic that it will also carry through proposals to reclassify ambulance organizations as providers of health care (not suppliers of transportation), as well as a cost data collection system that does not place undue burden on ambulance services.

On behalf of the AAA, I’d like to extend my deepest thanks to Senators Stabenow, Roberts, Schumer, Collins, and Leahy for sponsoring the legislation, as well as the AAA Board, Government Affairs Committee, advocacy consultants, and staff who worked so diligently to build support on Capitol Hill.

Over the coming months, AAA will continue to connect with policymakers to build support for sustainable ambulance Medicare reimbursement. However, we need your help to ensure that this critical revenue remains in place. We ask that you please contact your Senators to voice your support for S. 967. AAA makes it easy to connect with your legislators through our online advocacy tool—please use it today to quickly send messages expressing the importance of the legislation to your ambulance service and the communities you serve.

If possible, we ask that you also work with fellow ambulance providers in your area to schedule in-person meetings with your legislators’ offices. If you arrange a meeting in your home state, please contact AAA staff at info@ambulance.org for talking points to support your conversation.

Now, more than ever, we need the active participation of each member organization to ensure our collective future! Thank you in advance for your assistance with advocacy outreach, as well as for your continued membership to the American Ambulance Association.

Mark Postma
President, American Ambulance Association
“Representing EMS in America”

ACA Repeal and Replace Update

Written by John Jonas on . Posted in Executive, Government Affairs, Legislative, Member-Only, News.

Congress returns to Washington next week, and House Republican Leadership maintains an ambitious agenda to pass the American Health Care Act (AHCA) despite an unclear path navigating its moderate and conservative factions. President Trump, who refuses to let health care reform disappear from the agenda, is especially eager for a victory, and today predicted AHCA would pass within the next few weeks.

During the in-district work period these past two weeks, the White House, House Leadership and Republican committee staff have kept conversations going with the two disagreeing factions within their caucus – the moderate Tuesday Group and the conservative Freedom Caucus. At this stage, there appears to be no agreement within the Republican Caucus, and there are varying reports on how close are discussions. The wild card is whether President Trump and his team can help force a deal. As soon as a deal materializes, the House will move the bill to the floor.

In addition to health care, the discretionary aspects of the Federal government are under a temporary continuing resolution which expires at the end of next week. An effort is underway to pass a measure that will fund the government through the remainder of the 2017 Fiscal Year, which ends September 30. This effort is not without controversy, and includes an attempt by the Trump Administration to appropriate funds to build its border wall. However, Republicans will need at least eight Senate Democrats to vote with them to pass an omnibus spending bill, so compromise will be required. There may be a series of short-term funding patches as Congress considers spending priorities.

One of the more interesting issues Congress and the Trump Administration face is what to do with Affordable Care Act (ACA) subsidies that were meant to help reduce cost sharing (deductibles, co-payments) for especially poor, non-Medicaid eligible individuals buying insurance on the exchange. House Republicans had successfully sued the Obama Administration in district court arguing that Congress must appropriate the money before the ACA’s Cost Sharing Reduction (CSR) subsidies could be paid. With an injunction from the district court in place, Congress must decide whether to appropriate the money in the upcoming spending bill. Some Democrats have stated they will not vote to pass any budget without funds for the CSR program included. If Republicans can pass a budget without funding the CSR subsidies, they aren’t out of the woods yet on the CSR program. Specifically, the President still has to decide whether to appeal the district court decision on May 22. If President Trump chooses to accept the district court decision and there is no appropriation, the President could unilaterally shut down the CSR subsidy program. The President has threatened to use this court decision to bring Democrats to the negotiating table, in the event that the program is not appropriated and AHCA is not passed.

The AAA will continue to keep members up to date on these issues.

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