Government Affairs Archives - Page 18 of 18 - American Ambulance Association

Member Advisory: OIG Issues Report on Questionable Billing Practices for Ambulance Suppliers

Written by Brian Werfel on September 30, 2015. Posted in Government Affairs, Member Advisories, Member-Only, Regulatory.

HHS OIG Analysis Part 1 of 2 – Read Part Two of the Analysis

On September 29, 2015, the Department of Health and Human Services Office of the Inspector General (OIG) issued a report titled “Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports” (OEI-09-12-00351). The report, conducted by the Office of Evaluation and Inspections (OEI), looked at claims data for 7.3 million ambulance transports furnished during the first half of 2012. The OIG reviewed this claims data to determine whether claims were billed appropriately to the Medicare program.

Summary of the OIG’s Findings

The OIG determined that Medicare paid $24.2 million in the first half of 2012 for ambulance transports that did not meet certain program requirements for payment. The OIG identified an additional $30.2 million paid for transports for which the beneficiary did not receive Medicare services at either the pick-up or drop-location, or anywhere else. Finally, the OIG determined that 1 in 5 ambulance suppliers met certain criteria that indicated they may have engaged in questionable billing practices. According to the OIG, more than half of all questionable transports were provided to beneficiaries residing in 4 metropolitan areas.

Detailed OIG Findings

Medicare paid $24.2 million for ambulance transports that did not meet certain Medicare requirements justifying payment. This included transports to a non-covered destination, as well as transports to a covered destination but where the level of service was inappropriate.

The OIG determined that Medicare paid $17.4 million for ambulance transports to non-covered destinations. This amount also include return trips following treatment at the non-covered destination. These transports represented 0.6% of all Medicare payments during the first half of 2012.

The OIG indicated that transports to a physician’s office were the most common type of non-covered destination. Payments for transports to and from a physician’s office accounted for $8.7 million in improper payments. Medicare also paid $5.8 million for transports of beneficiaries to and from community mental health centers or psychiatric facilities (other than duly-licensed psychiatric hospitals). Other transports to non-covered destinations included independent laboratories, diagnostic or therapeutic sites (i.e., “D” modifiers), non-SNF nursing facilities, long-term care and hospice facilities.

The OIG determined that Medicare paid $7 million for transports with inappropriate combinations of the level of service billed and the type of destination. This included $4.3 million in payments for specialty care transports (SCT) where either the origin or destination was something other than a hospital, SNF, or intercept site. The majority of these inappropriate SCT transports involved transports between the patient’s SNF or residence and a free-standing dialysis facility. The OIG also determined that Medicare paid $2.7 million for emergency transports where the destination was not a hospital.

Medicare paid $30.2 million for ambulance transports for which the beneficiary did not receive Medicare services at any origin or destination.

The OIG identified $30.2 million in payments for ambulance transports where the beneficiary did not appear to receive any Medicare services at either the origin or destination within 1 day of the date of transport. To account for the possibility that the ambulance supplier may have submitted a claim with the wrong origin or destination, the OIG only flagged a claim as questionable if its records determined that the beneficiary did not receive Medicare services at any other facility type within 1 day of the transport. The OIG stated its belief that, since there was no record of the beneficiary receiving Medicare services at or close to the date of transport, the OIG believed that it was likely that Medicare inappropriately paid for the ambulance transports. The OIG did note the possibility that these transports occurred during an inpatient hospital or SNF stay, and therefore may have been the responsibility of the inpatient facility. These transports represented 1.1% of all Medicare payments during the first half of 2012.

The OIG determined that 1 in 5 ambulance suppliers had questionable billing

As part of the methodology used for this report, the OIG developed a set of 7 measure that it believed could be evidence of questionable billing practices. These seven measures were:

No Medicare service provided at either the origin or destination – The OIG believes that a high percentage of an ambulance supplier’s for which the beneficiary did not receive Medicare services at either the origin or destination could be indicative of either: (a) billing for transports to non-covered destinations or (b) billing for transports that were not provided.
Excessive mileage for urban transports – The OIG believes that high average mileage for transports within an urban area could be indicative of either: (a) billing for more miles than the ambulance supplier actually drove or (b) billing for mileage beyond the nearest appropriate facility.
High number of transports per beneficiary – The OIG believes that a high average of per-beneficiary transports could be indicative of billing for transports that were not medically necessary.
Compromised Beneficiary Number – The OIG believes that a high percentage of an ambulance supplier’s transports provided to beneficiary with compromised beneficiary ID numbers could be indicative of billing for transports that were not medically necessary, or which were not provided.
Inappropriate or unlikely transport level – The OIG believes that a high percentage of an ambulance supplier’s transports with inappropriate or unlikely transport levels (given the destination) could be indicative of “upcoding”.
Beneficiary sharing – The OIG believes that when multiple ambulance suppliers all provide dialysis transports to the same beneficiary that it could be evidence of the misuse of a beneficiary’s ID number, or it could be evidence that the beneficiary is shopping his or her ID number for kickbacks.
Transports to or from partial hospitalization programs – The OIG believes that transports to and from a partial hospitalization program (PHP) is unlikely to be medically necessary because beneficiary’s that meet Medicare’s coverage requirements for PHP services generally do not qualify for ambulance transportation.

The OIG indicated that 21% of ambulance suppliers met one of the seven measures it developed for identifying questionable billing practices. 17% of ambulance suppliers met only 1 of the 7 measures, while 4% met 2-4 of these measures. No ambulance suppliers met more than 4 of these measures.

The OIG identified 2,038 out of the 15,614 ambulance suppliers reviewed (13%) that had questionable billing based on the percentage of their transports where the beneficiary did not receive Medicare services at either the origin or destination. The OIG flagged an ambulance supplier’s billing as questionable if 3% or more of its transports involved situations where no Medicare service was billed at the destination. 46 ambulance suppliers had 95% or more of their transports involve situations where the beneficiary did not receive Medicare services at either the origin or destination. By contrast, the median for all ambulance suppliers was zero transports where the beneficiary did not receive services at either the origin or destination.

The OIG identified 642 out of the 15,614 ambulance suppliers reviewed (4%) that had questionable billing based on the average mileage they billed for beneficiaries residing in urban areas. The OIG indicated that the typical ambulance supplier average 10 miles for an urban transport. By contrast, the average mileage for the 642 suppliers identified by the OIG was 34 miles. The OIG identified 48 suppliers with an average urban mileage of more than 100 miles.

The OIG identified 533 out of the 15,614 ambulance suppliers reviewed (3%) that had questionable billing based on the average number of transports per beneficiary. Beneficiaries transported by the typical ambulance supplier that provided dialysis transports received an average of 4 ambulance transports during the first 6 months of 2012. Beneficiaries transported by the 533 suppliers identified by the OIG received an average of 21 transports during the first half of 2012.

The OIG identified 358 out of the 15,614 ambulance suppliers reviewed (2%) that had questionable billing based on the percentage of their transports that were associated with compromised beneficiary ID numbers. In studying this measure, the OIG excluded ambulance suppliers that did not bill for any transports involving the use of compromised beneficiary ID numbers. Among those suppliers that billed any transports that involved the use of a compromised ID number, only 1% of the typical supplier’s involved the compromised ID numbers. The 358 suppliers identified by the OIG used a compromised ID number for at least 7% of their claims. 31 suppliers used a compromised ID number for more than 95% of their submitted claims.

The OIG identified 268 out of the 15,614 ambulance suppliers reviewed (2%) that had questionable billing based on the percentage of claims submitted with unlikely or inappropriate transport levels and destinations. For the typical supplier that billed any claims with an inappropriate combination of transport level and destination, these claims accounted for less than 1% of all claims submitted in the first half of 2012. For the 268 suppliers identified by the OIG, these claims accounted for more than 3% of all claims submitted in the first half of 2012. The OIG identified 19 suppliers that used an inappropriate or unlikely combination on at least 25% of the claims they submitted during the first half of 2012.

Finally, the OIG noted that the ambulance suppliers that tested “positive” for any of the questionable billing practices it identified were disproportionately likely to provide BLS non-emergency transports (including dialysis). The OIG noted that BLS non-emergency transports accounted for only 36% of transports billed by providers that did not meet any of its questionable billing measures, while BLS non-emergency transports accounted for 65% of all claims submitted by those suppliers it identified as having at least one questionable billing practice.

More than half of questionable ambulance transports were provided to beneficiaries residing in 4 metropolitan areas

The OIG determined that questionable billing was concentrated in the metropolitan areas of Houston, Los Angeles, New York, and Philadelphia. These 4 areas accounted for 18% of all ambulance transports during the first half of 2012, but 52% of all questionable transports. Collectively, these areas accounted for $104 million of the $207 million in Medicare payments for “questionable” ambulance transports during the first half of 2012.

The OIG also determined that, on average, ambulance suppliers that provided transports to beneficiaries in these 4 metropolitan areas transported more Medicare beneficiaries and received more in Medicare payments than suppliers in other metropolitan areas. For example, the average ambulance supplier in Los Angeles received a total of $105,696 in Medicare payments, compared with an average of $16,137 in Medicare payments per supplier in other metropolitan areas. The numbers in NY ($85,606), Philadelphia ($56,667), and Houston ($34,951) were also far in excess of the national average.

OIG’s Recommendations

In this report, the OIG makes a number of recommendations to CMS to reduce the number of inappropriate payments and questionable billing practices. These recommendations include:

Expanding the temporary moratoria on new enrollments to additional metropolitan area. The OIG is recommending that CMS consider whether the existing moratoria (in place in Houston and Philadelphia) should be expanded to NY and Los Angeles.CMS concurred with this recommendation, and stated that it will continue to monitor these geographic areas, and will impose additional temporary moratoria if warranted.
Require ambulance suppliers to include the National Provider Identifier (NPI) of the certifying physician on non-emergency claims that require a certification. The OIG is recommending that when a physician certification is required (e.g., for dialysis transports), that the physician’s NPI be listed on the claim. The OIG notes that the NPI of the ordering physician is already required for laboratory and DME claims. The OIG also recommended that the physician’s NPI be listed on PCS forms.CMS concurred with the recommendation, and indicated that it will explore the best way to implement this recommendation.
Implement new claims processing edits, or improve existing edits, to prevent inappropriate payments for ambulance transports. The OIG is recommending that CMS update its edits to prevent payment: (a) for transports to non-covered destinations and (b) for transports with inappropriate combinations of the destination and the level of service billed (e.g., emergency transports to a patient’s residence).CMS partially concurred with the recommendation, but indicated that it wanted to review the data on the claims identified by the OIG in the report before taking any actions.
Increase CMS’ monitoring of ambulance billing. The OIG is recommending that CMS continue to monitor the billing of ambulance claims using the measures of questionable billing that the OIG developed.CMS appeared to concur with the recommendation, indicating that it would continue its current monitoring. However, the OIG indicated that its recommendation was not to continue monitoring at the current levels, but rather to increase the monitoring of ambulance claims.
Determine the appropriateness of the claims billed by the ambulance suppliers identified in this report and take appropriate action. The OIG indicated that it would be providing CMS with a separate memorandum that lists the claims it identified that did not meet Medicare billing requirements. The OIG was suggesting that CMS or its contractors should take a closer look at these providers, for example by reviewing medical records or performing unannounced site visits to determine whether additional actions are appropriate.CMS partially concurred with the recommendation, but indicated that it wanted to review the data on the claims identified by the OIG in the report before taking any actions.

Update: House & Senate Approve Veterans Health Care Choice Act

Written by Todd Tuten on July 30, 2015. Posted in Government Affairs, Legislative, Reimbursement.

Yesterday, the House of Representatives voted overwhelmingly to approve H.R. 3236, the Surface Transportation and Veterans Health Care Choice Improvement Act. Update 2:16 p.m. on July 30: The Senate approved the legislation today, and it is now headed to the President’s desk for signature.

Among its provisions, the bill would allow the Department of Veterans Affairs (VA) to use $3.3 billion from the Veterans Choice Fund to pay for care provided to veterans by non-VA providers between May 1 and October 1, 2015 under the VA’s community care programs.

H.R. 3236 also would require the VA to develop a plan to consolidate all non-VA programs into a single “Veterans Choice Program” and to submit a report on the plan to Congress by November 1, 2015. Among its provisions, the plan must include the structuring of the billing and reimbursement process; a description of the reimbursement rate to be paid; and an explanation of the processes to be used to ensure that the Secretary will fully comply with the federal Prompt Payment Act.

Further, H.R. 3236 would make a number of changes to the current Veterans Choice Program, including: eliminating the requirement that a veteran be enrolled in the VA health care system by Aug. 1, 2014 in order to participate; allowing the VA to expand the number of non-VA providers that may offer medical services; waiving the program’s wait-time eligibility threshold if clinically necessary for the veteran; and allowing veterans residing within 40 driving miles of a VA medical facility to use non-VA services if the VA facility does not have a full-time physician on staff.

M. Todd Tuten is a Senior Policy Advisor at Akin Gump Strauss Hauer & Feld, LLP.

CMS Issues Proposed Rule for Calendar Year 2016

Written by Brian Werfel on July 10, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Member-Only, Regulatory, Reimbursement.

On July 8, 2015, the Centers for Medicare and Medicaid Services (CMS) published a display copy of a proposed rule titled “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016”. The proposed rule makes a number of changes to the Medicare Physician Fee Schedule. It also makes certain changes to the Medicare Ambulance Fee Schedule. These proposed changes are summarized below.

AAA’s 2015 Ambulance Ride-Along Toolkit

Written by on July 8, 2015. Posted in Government Affairs, Legislative, Medicare, Reimbursement.

It is that time of year. With the summer heat, fireworks, baseball and barbecues comes your greatest opportunity to meet with and influence your federal legislators, the August Recess. This year, Congress is scheduled to begin recess early in August and return to normal business after the Labor Day Holiday. The recess means that many members of Congress will be in their districts and states. This will be a great opportunity for you to educate your members of Congress about current issues affecting our industry. In particular, it will give you the chance to talk about permanent Medicare ambulance relief.

The easiest and most effective way to discuss key issues with your members of Congress is to invite them and their staffs to participate in a tour of your operation and on an ambulance ride-along. This gives you the opportunity to show all of the valuable services that you provide to the community and how Congress can continue to help. The AAA has made the process of scheduling and arranging a ride-along easy for you with the release of our 2015 Congressional Ride-Along Toolkit.

In April of this year, Congress extended the temporary 2% urban, 3% rural and super rural bonus payment through December, 2017. While this was a great victory for the AAA and ambulance services nationwide, a permanent solution is still needed. With temporary extensions of Medicare ambulance relief, ambulance services are incapable of adequately preparing for their financial future and providing quality care to their patients. The AAA has worked hard to have legislation introduced in the both the U.S. House of Representatives and the Senate that would make the temporary relief become permanent. We are still seeking cosponsors for the bill (H.R. 745, S. 377) and hope that you will assist in our search.

We invite you to use the Ambulance Ride-Along toolkit as you prepare to meet with your members of Congress over the coming months.

Ask Your Members of Congress to Cosponsor Permanent Medicare Relief Legislation

Written by Michael Hall on June 3, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Reimbursement.

Yesterday morning, Congressmen Walden, Welch, Nunes and Neal sent a Dear Colleague to their fellow members of the House of Representatives asking them to cosponsor the Medicare Ambulance Access, Fraud Prevention and Reform Act of 2015 (S. 377, H.R. 745). This bill will make the current temporary ambulance add-on payments permanent for all ambulance services.

Even with our recent victory of a temporary 33-month extension of crucial Medicare ambulance relief, our Champions on Capitol Hill realize the importance of receiving permanent Medicare relief. They, like every ambulance service across the country, understand that a permanent solution is necessary to provide quality health care to individuals and our communities both today and tomorrow.

Ask Your Members of Congress to Cosponsor Permanent Medicare Relief Legislation

Written by Michael Hall on June 3, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Reimbursement.

Ambulance Open Door Forum, April 22, H.R. 2

Written by David Werfel on April 28, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Regulatory, Reimbursement.

CMS held its latest Ambulance Open Door Forum on April 22. It started with the following two announcements:

– H.R. 2 was signed into law extending the temporary ambulance adjustments through December 31, 2017. The adjustments are 2% (urban pick-ups), 3% (rural) and 22.6% (super rural).

– For free standing facilities, use the “P” modifier if the facility is not part of the hospital and use “H” if it is hospital-based.
Following these announcements, there was a Question and Answer period. Most of the questions were not answered on the call and the caller was asked to submit their questions to CMS, or was told to ask their Medicare Administrative Contractor or was told to appeal the denied claim referenced in their question. A few were answered, as follows:

Senate Delays Vote on SGR Repeal Package

Written by Michael Hall on March 27, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Reimbursement.

Early this morning after completing action on a FY 2016 Senate Budget Resolution, Senate Majority Leader Mitch McConnell (R-KY) announced that the Senate would not act on legislation (H.R. 2) to permanently repeal the sustainable growth rate (SGR) formula for physicians until after the Easter recess. H.R. 2 includes the 33-month extension of the temporary Medicare ambulance increases. Senate Majority Leader McConnell had sought consideration today of H.R. 2 under unanimous consent which requires the support of all 100 Senators. There were objections to the expedited vote and thus the Senate is now expected to consider the bill when it returns on April 14.

The temporary Medicare ambulance increases expire on March 31. However, contractors have a standard requirement to hold all Medicare claims for 14 days before making payment. The Centers of Medicare and Medicaid Services (CMS) has issued a notice to contractors formally directing them to utilize this hold. So if the Senate does complete action on H.R. 2 on April 14 there will be no need for reprocessing any claims for the retroactive increases. Should action on H.R. 2 be delayed further, Congress could do a short-term extension or simply allow the provisions to expire for a short period of time. Senate Majority Leader Mitch McConnell and Senate Minority Leader Harry Reid (D-NV) have both stated they would like quick consideration of H.R. 2 when the Senate returns.

We will continue to keep you posted of new developments.

House Votes in Favor of Permanent Doc Fix, Bill Moves to the Senate

Written by Michael Hall on March 26, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Regulatory, Reimbursement.

Earlier today, the U.S. House of Representatives voted in favor of H.R. 2, doing away with Medicare’s sustainable growth-rate formula and passing a permanent doc fix. The 392-37 vote was overwhelmingly bipartisan. As we reported on March 24, thanks to our champions on Capitol Hill, a 33-month extension of the temporary Medicare ambulance increases was included in the bill. If enacted, the bill would extend the deadline for expiration of Medicare ambulance relief from March 31 until December 31, 2017.

The Senate still needs to pass the bill and is working on a short time-line before they adjourn for recess. Senate Republicans and Democrats have expressed concerns about different aspects of the bill so it is unclear whether the chamber will consider H.R. 2 before it recesses. It is also uncertain if Congress would pass a short-term extension to give the Senate more time or if CMS would be required to formalize its 14-day claim hold policy should H.R. 2 not be enacted before March 31.

In addition to Medicare ambulance relief, the package also includes language from the Protecting Integrity of Medicare Act (H.R. 1021) expanding the current prior authorization pilot programs on repetitive BLS non-emergency ambulance transports in South Carolina, Pennsylvania and New Jersey. Starting in January 2016, the bill would expand the programs to Delaware, DC, Maryland, North Carolina, West Virginia and Virginia. The program would then expand nationwide starting in January 2017.

The AAA will continue to push for the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 377, H.R. 745). S. 377 and H.R. 745 would make the current temporary ambulance increases permanent and place our industry in a strong position moving forward for data-driven reforms to the ambulance fee schedule. S. 377 and H.R. 745 would also address fraud and abuse with repetitive BLS non-emergency dialysis transports. While a similar program to the current pilot programs. The prior authorization within S. 377 and H.R. 745 would apply only to dialysis transports and would institute additional safeguards to ensure timely prior authorization for medically necessary transports.

I want to thank all AAA members, staff and consultants who continue to work tirelessly on extending essential Medicare ambulance relief. We will keep you posted of new developments.

House SGR Repeal Package Contains Ambulance Relief Extension

Written by Michael Hall on March 24, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Regulatory, Reimbursement.

Earlier today, House Republican and Democratic leadership released the complete package (H.R. 2) for a permanent fix to the physician fee schedule. I am happy to report that the AAA through our champions on Capitol Hill was successful in getting a 33-month extension of the temporary Medicare ambulance increases included in the bill. If enacted, the bill would extend the deadline for expiration of Medicare ambulance relief from March 31 until December 31, 2017.

The House is scheduled to consider H.R. 2 on either Thursday or Friday prior to adjourning for the two-week Easter recess. The bill is currently expected to pass the House with bipartisan support. Senate Republicans and Democrats have expressed concerns about different aspects of the bill so it is unclear whether the chamber will consider H.R. 2 before it recesses. It is also unclear if Congress would pass a short-term extension to give the Senate more time or if CMS would be required to formalize its 14-day claim hold policy should H.R. 2 not be enacted before March 31.

The package also includes language from the Protecting Integrity of Medicare Act (H.R. 1021) expanding the current prior authorization pilot programs on repetitive BLS non-emergency ambulance transports in South Carolina, Pennsylvania and New Jersey. Starting in January 2016, the bill would expand the programs to Delaware, DC, Maryland, North Carolina, West Virginia and Virginia. The program would then expand nationwide starting in January 2017.

The AAA continues to push for the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 377, H.R. 745). S. 377 and H.R. 745 would make the current temporary Medicare ambulance increases permanent and place our industry in a strong position moving forward for data-driven reforms to the ambulance fee schedule. S. 377 and H.R. 745 would also address fraud and abuse with repetitive BLS non-emergency dialysis transports. While a similar program to the current pilot programs, the prior authorization within S. 377 and H.R. 745 would apply only to dialysis transports and would institute additional safeguards to ensure timely prior authorization for medically necessary transports.

We will keep you posted of new developments.

Advocate for Permanent Medicare Ambulance Relief

Written by Michael Hall on February 6, 2015. Posted in Government Affairs, Legislative, Medicare, Regulatory, Reimbursement.

The U.S. House of Representatives is currently developing a package on a permanent fix to the physician fee schedule. House Speaker John Boehner recently announced the effort for a permanent fix instead of another extension and the framework of a package is coming together quickly. It is therefore critical that you contact your members of Congress today in support of permanent ambulance relief.

Permanent Medicare Ambulance Relief Bills Introduced in Congress

Written by Michael Hall on February 6, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Reimbursement.

I am extremely happy to report our Senate and House champions on Medicare ambulance relief introduced on Wednesday the Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015 (S. 377, H.R. 745). Senators Charles Schumer (D-NY), Pat Roberts (R-KS), Patrick Leahy (D-VT) and Susan Collins (R-ME) introduced the Senate bill (S. 377) and Congressmen Greg Walden (R-OR), Peter Welch (D-VT), Devin Nunes (R-CA) and Richard Neal (D-MA) introduced the House bill (H.R. 745).

Prior Authorization Issues – South Carolina

Written by David Werfel on January 12, 2015. Posted in Government Affairs, Medicare, Regulatory, Reimbursement.

Based on implementation issues involving the Prior Authorization program for repetitive patients inSouth Carolina, Brian and I had a conference call with representatives of CMS and Palmetto on Friday January 9, 2015. Three main issues were discussed, as follows:

1. Legal Representative Payee – There was confusion concerning repetitive patients that had a Legal Representative Payee. These are patients who can not conduct their own affairs and have a form on file at the Social Security Administration for someone else to be their legal representative. When ambulance companies submitted for Prior Authorization for these patients, they were told thePrior Authorization did not apply for the patient. Palmetto posted their policy for these patients on their web site.

Unfortunately, you will not know right away which patients have a legal representative payee. Most likely you will not know until you receive a rejection of the Prior Authorization request. Therefore, until you have been told a repetitive patient has a legal representative payee, file with Palmetto for the priorauthorization.

Once you are told the patient has a legal representative payee, then submit claims, just as you would for non-repetitive patients, i.e. do not continue to try to obtain prior approval or a Unique Transaction Number (UTN).

We have asked Palmetto if there is a database that you can access before going through the priorauthorization process. So far, there is not, but they are checking on this issue.

FYI, this was a policy instituted by CMS for the Prior Authorization process based on other programs (not ambulance) they have in place.

2. Incorrect Edit for Non-Repetitive Patients – On Wednesday, January 7th, we advised Palmetto that claims for non-repetitive patients were either being denied or that they needed further development as there is a systems edit that is pulling patients who had multiple transports over a period of time, but are not supposed to be in this Prior Authorization program. For example, a patient who has had four hospital discharges following illnesses for a fracture, a CVA, pneumonia and surgery, is not “repetitive”, for Prior Authorization purposes. On the conference call on Friday, Palmetto and CMS agreed with our assessment of the situation. They indicated that not only has the cause of the problem been identified, but they believe that it will be fixed in approximately one week. They are testing it now. They are looking at January 19 as the date for the “fix” to be implemented.

They have located 485 claims in this status that are currently “suspended”. When the “fix” is implemented, they will release these claims for processing, i.e. those providers should not resubmit the claims as Palmetto will do it automatically. Claims for these non-repetitive patients that have already been rejected should be resubmitted.

NOTE: Novitas is having the same problem. They sent out a notice to providers in their jurisdiction advising them they are aware of the problem. We assume that the same “fix” will be tried by Novitas.

3. Common Errors – We asked Palmetto if they could come up with a list of the common errors being made by ambulance companies. Following the conference call, they provided us with the list below. Providers in South Carolina (as well as in New Jersey and Pennsylvania, even though NJ and PA submit to Novitas) should review the list to ensure you are not making these mistakes:

– The PCS submitted does not have a valid signature date.

– The date of the signature is post- dated, perhaps to match a future date the patient will be starting.

– The signature on the PCS is not identifiable. The name of the physician must be identifiable. This does not mean the signature itself must be legible, it means that Palmetto has to be able to read the name of the physician that signed the PCS.

– The PCS has been amended (e.g. to print or type the name of the physician) without any notation by the amending individual. Any amendments/additional information should be clearly signed or initialed and dated by the person making the change or note.

– Submission of contradictory documentation. For instance, the PCS may support the transport, but the supporting documentation from the certifying physician does not.

– If the Prior Authorization is approved, the UTN is not entered into the appropriate field or submitted at all.

– For claims that are non-emergent, non-repetitive, providers are listing something (e.g. “N/A” or “not a PA” or “non-repetitive”) in the UTN field. For these non-repetitive patients, do not put anything the UTN field. The edit for the prior authorization is hard coded. Therefore, if their computer finds anything in this field, for patients who do not have prior authorization, the claim will reject.

Palmetto indicated that they will have a conference call with ambulance providers to discuss “hot issues”, including those above. At this time, they are looking to have that conference call on January 19th, although that is subject to change. For those affected, check the Palmetto web site and otherwise look for the notice for this conference call.

Finally, implementing a program of this nature is always going to have some start-up problems. Now that the two issues noted in #1 and #2 above have been identified and are about to be resolved, the remaining problems, such as those noted in #3 above, are mostly left up to the providers to understand what is needed, where the information is to be listed, etc. Once that is understood, the process will work smoothly as it did for many years in Ohio, when Palmetto and its predecessor used a prior authorization process for ambulance transports of non-emergency dialysis patients.

Of course, there will always be those situations where you believe medical necessity is met, but Palmetto does not agree. In those situations you will have to decide if more information is needed, whether you agree with Palmetto and the patient can be transported via wheelchair van, whether you need to advise the patient/facility accordingly, whether to accept the denial or whether to appeal.

Summary of the OIG’s Findings

Detailed OIG Findings

OIG’s Recommendations

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