Federal Departments Issue Final Report and Recommendations of the GAPB Advisory Committee
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Department of Veterans Affairs Announces Extended Timely Filing Period for Claims Impacted by Change Healthcare Cyberattack
On August 22, 2024, the Department of Veterans Affairs (VA) published a notice in the Federal Register announcing an extension of the timely filing limits for claims impacted by the Change Healthcare cyberattack.
In February, Change Healthcare announced that it was the victim of a massive cyberattack. In response, Change Healthcare proactively took down several of its online platforms, including its online claim submission platform. This platform is used by the VA to receive electronic claims. The VA indicated that this resulted in what it calls “limited or no ability” to receive electronic claims between February 21, 2024 and May 8, 2024 (referred to hereinafter as the “Limited Access Period”).
The current notice is intended to address problems with timely filing that resulted from that Limited Access Period. Specifically, the VA is announcing that claims that would have been considered timely had they been submitted during the Limited Access Period will continue to be treated as timely filed to the extent they are submitted on or before October 31, 2024.
Claims submitted after that date will not be considered timely filed, and will be denied.
Thus, the VA is effectively extending the timely filing period for VA claims through October 31, 2024. The VA expressly noted that this would include claims for transportation furnished to veterans with dates of service between February 21, 2022 and March 23, 2024. Note: the specific program under which ambulance transportation claims are being paid will determine the actual timely filing limits. The VA was simply noting the earliest and latest possible qualifying dates.
Therefore, if you have claims for ambulance services that were recently denied by the VA for lack of timely filing, the AAA encourages you to resubmit those claims to the VA under this extending timely filing period.
GAPBAC Balance Billing Report Released to Congress
Read Full GAPBAC Report to Congress
A Message from GAPBAC Committee Member Shawn Baird
Please see below for a video message from former American Ambulance Association President Shawn Baird, who participated on the Ground Ambulance Patient and Billing Advisory Committee. A formal analysis of the complete report to Congress is forthcoming.
Video Transcript
Hello, I’m Shawn Baird, past president of the American Ambulance Association.
Together with my fellow ambulance profession representatives Ted Van Horne, Regina Crawford, and Rhonda Holden, I was privileged to speak on behalf of AAA members and the EMS profession as a whole during the deliberations of the Ground Ambulance and Patient Billing Advisory Committee, also known as GAPBAC.
Today, I’m excited to share with you the culmination of our efforts—the release of a report to Congress that could transform how ground ambulance services are reimbursed, ensuring better protection for patients against surprise medical bills as well as fair compensation for the essential mobile healthcare we deliver daily.
We know that the patient care and transport we provide every day, 24/7, is vital to the health and welfare of our communities. In many parts of the country, we are the only healthcare available within hours. I am excited that if Congress acts on these recommendations, patients can not only continue to depend on our vital care, but also be relieved of the financial stress of the unknown bill when insurance falls short of appropriate payment. Quite frankly, if adopted by Congress, these recommendations would take patients out of the middle between providers and insurers, and free us to remain focused on what we do best; taking care of patients, 24/7.
Let me rewind a bit and give you the full context for this report.
GAPBAC was formed following the American Ambulance Association’s successful advocacy efforts to carve ground ambulance services out of the No Surprises Act. Through the dedication of AAA volunteer leaders made possible by your dues investment, we were able to successfully educate legislators about the unique nature of EMS. We effectively highlighted our inability to pick and choose patients, our role as the safety net provider in rural and medically underserved urban areas, as well as our sky-high costs of readiness. Instead of rolling ambulance services into a one-size-fits-all healthcare billing scheme that wouldn’t work for EMS, legislators had the vision and foresight to create the GAPBAC committee.
The group’s charter was signed in November 2021, and the roster was announced in December 2022. We are proud that former American Ambulance Association board member Asbel Montes was selected to take the helm as Chair.
Since then, our committee, composed of patient advocates, physicians, EMS experts, government officials, and insurance industry representatives, has worked collaboratively to address a critical issue—out-of-network billing for ground ambulance patients covered by non-ERISA health plans.
This discussion presented an extraordinary challenge as ambulance services face skyrocketing costs, flat reimbursement from Medicare, and an unprecedented workforce shortage. At the same time, our patients were sometimes confused by the complex health insurance landscape including copays, deductibles, and policy limitations.
But the GAPBAC panel, with the help of experts including AAA’s own Kathy Lester, persevered. Through research, dialogue, and compromise, GAPBAC’s team members developed 14 key recommendations that, if adopted by Congress, would protect patients, financially sustain EMS, enhance transparency, and empower state and local governments to determine fair reimbursement rates for their residents.
While I urge you to read the report to Congress in its entirety, rest assured that the AAA advocacy team will soon share a concise summary with our membership.
As I mentioned, the release of this report has been no small task. The collaboration across various stakeholder groups was unprecedented in EMS history, and every voice brought valuable insights, driving us toward solutions that consider all perspectives on the complex mobile healthcare reimbursement landscape. Together, we’ve laid down a framework that I believe will lead to significant improvements, ensuring that millions more Americans are fully covered during some of the most critical moments of their lives.
As we present our final findings, I hope that the recommendations will be met with thoughtful consideration by Congress and regulators—the well-being of our patients and the integrity of our out-of-hospital healthcare system depend on it. Thank you to American Ambulance Association President Strozyk, the AAA board and committee chairs, and you, the AAA membership, for the overwhelming support through this journey. Together, we will continue to advocate for a sustainable future for EMS!
Shawn Baird
Immediate Past President
American Ambulance Association
Preliminary Calculation of 2025 Ambulance Inflation Update
The AAA is projecting that the 2025 Medicare Ambulance Inflation Factor will likely be 2.6%, plus or minus 0.1%.
Section 1834(l)(3)(B) of the Social Security Act mandates that the Medicare Ambulance Fee Schedule be updated each year to reflect inflation. This update is referred to as the “Ambulance Inflation Factor” or “AIF”.
The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Starting in calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi factor productivity index (MFP). The MFP reduction may result in a negative AIF for any calendar year. The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.
For the 12-month period ending in June 2024, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased by 3.0%.
CMS has yet to release its estimate for the MFP for calendar year 2024. Since its inception, this number has fluctuated between 0.3% and 1.2%. For calendar year 2024, the MFP was 0.4%.
Under normal circumstances, it would be reasonable to expect the 2025 MFP to be within a tenth of a percentage point or two of the 2024 MFP.
Accordingly, the AAA is projecting that the 2025 Ambulance Inflation Factor will likely be 2.6%, plus or minus 0.1%.
The AAA will notify members once CMS issues a transmittal setting forth the official 2025 Ambulance Inflation Factor.
OSHA Announces Public Hearing on the Proposed Emergency Response Rule
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EMS.gov | Responding to Behavioral Health Emergencies
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CMS Publishes Two New Reports on GADCS Website
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| Dear Ground Ambulance Providers and Suppliers,
We wanted you to be aware that we posted 2 reports on our Medicare Ground Ambulance Data Collection System website under Reports: |
What The Guardian Missed About US Ambulance Balance Billing
Media Response
The letter to the editor below was submitted to The Guardian on July 23, following the July 21 publication of the article referenced.
To the Editor of The Guardian,
On July 21, The Guardian published Jessica Glenza’s “Plan to end exorbitant ‘surprise’ ambulance bills heads to Congress.” The inflammatory title and lack of context do no justice to the years of bipartisan collaborative effort leading to the forthcoming report to Congress. As a member of the Advisory Committee on Ground Ambulance and Patient Billing (GAPB) and Immediate Past President of the American Ambulance Association, I believe it is critical to set the record straight.
It is essential to understand that EMS directly bills patients instead of insurers only as a last resort. Sadly, as a frequent entry point to healthcare, EMS often faces the unenviable task of educating people about their limited insurance coverage or high deductibles, both of which are out of our control. As mobile healthcare is entirely decentralized in the United States, it is often unfeasible for small or volunteer-staffed ambulance services to negotiate sustainable in-network rates with dozens of insurance plans. The GAPB Advisory Committee’s recommendations seek to remedy this foundational disconnect between patients, EMS providers, and health plans.
The article notes that some EMS providers are owned by private equity, but overlooks that the vast majority of ambulance services in the United States are small, often conducting only a few dozen patient transports per day. These community-based services—some of which are the sole healthcare provider for miles—face skyrocketing costs for wages, fuel, and medical supplies that threaten their ability to keep their doors open. The collaborative work of the GAPB Advisory Committee sought to address these challenges by proposing recommendations that, if adopted by Congress, would help alleviate these financial pressures while also enhancing patient protection from surprise insurance denials.
The article implies that Patricia Kelmar was the only representative of the public interest on the panel. In fact, another Committee participant was explicitly appointed to represent patient advocacy groups, and as healthcare providers, EMS professionals and physicians consistently advocate for our patients’ well-being. The committee’s composition, as established by Congress within the No Surprises Act, was intentionally diverse and included stakeholders ranging from physicians to elected officials to insurance providers to ensure balance.
Additionally, it is important to clarify that the Health Affairs research cited in the article does not provide data on actual balance bills received by patients. Rather, it roughly estimates only potential balance bills as calculated based on a flawed estimation process. Even if we were to accept Health Affairs estimates as fact, the average balance bill calculated according to their methods would be just a few hundred dollars. This is far from the sole and extreme outlier bill cited in the piece. This distinction is critical as it underscores the need for data-driven policy decisions based on real-world evidence rather than projections and one-off examples.
Finally, the piece misses entirely the largest challenge with the Committee’s recommendations and their potential adoption by Congress. Based on longstanding legal precedent, ERISA plans, which cover about half of Americans through their employers, would not be bound by any legislation drafted based on our report. In Washington state and elsewhere, innovative “opt-in” clauses enable ERISA plans to voluntarily comply with state regulation. We encourage this and hope to see it replicated throughout the nation.
People become first responders because they have a passion for caring for others, and our communities trust them to do just that—24/7. Our Committee’s report to Congress includes 14 key recommendations designed to improve transparency, ensure fair reimbursement rates, and ultimately protect patients by strengthening state and local control. If these recommendations are adopted, they will help remove patients from the middle of billing disputes, allowing EMS providers to focus on our primary mission: delivering life-saving and life-sustaining healthcare around the clock.
For a detailed understanding of our recommendations and the Committee’s work, I encourage reading the full GAPB Advisory Committee report when it becomes available later this summer.
Shawn Baird
Immediate Past President, American Ambulance Association
Member, Advisory Committee on Ground Ambulance and Patient Billing
Portland, Oregon
Treatment In Place Bill Introduced in House
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2024 Ambulance Ride-Along Toolkit
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OSHA NPRM Emergency Response Standard 2nd Comment Period Extension
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OSHA Emergency Response Rule Comment Period Extended Again
From the OSHA Website on June 4, 2024
NEW Update: The deadline for comment submission has been extended a second time to July 22, 2024.
The Emergency Response proposed rule is here!
OSHA is happy to announce that the Emergency Response proposed rule has been published in the Federal Register and is now available for viewing.
OSHA welcomes and encourages the submission of public comments in response to this proposed rule. To allow additional time for those individuals interested in creating and submitting a comment, OSHA will be further extending the window for comment submission. The comment period now ends on July 22, 2024.
Comments can be submitted to the Emergency Response Docket at https://www.regulations.gov/docket/OSHA-2007-0073.
OSHA will also be hosting a public hearing, the date of which has yet to be determined. To ensure access to the hearing for all interested members of the public, remote access will be provided.
Additional information on OSHA’s rulemaking process and how stakeholders can participate is available at https://www.osha.gov/laws-regs/rulemakingprocess.
AAA Submits Paramedic Expedited Visa Comments in Line with PARA-EMT Act
On May 13, the AAA submitted a Comment Letter to the Department of Labor (DOL) in response to their Request for Information (RFI) on modernizing the process and updating the occupations that fall under the Schedule A program. Schedule A is a program administered by DOL which allows for expedited visa processing for occupations with a predetermined workforce shortage. The AAA advocated in our letter for the DOL to add paramedics and EMTs to Schedule A which currently includes nurses, physical therapists and individuals with exceptional abilities in the sciences and arts.
The comment letter by the AAA is in line with a provision of the PARA-EMT Act (H.R. 6433) by Congresswoman Gluesenkamp Perez (D-WA) and Congressman Brad Finstad that would direct DOL to conduct a study on the EMS workforce shortage and report to Congress on consideration by the Department to add paramedics and EMTs to the list of occupations under Schedule A.
EEOC Updated Enforcement Guidance on Harassment in the Workplace
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DHS Updates the Resource Typing EMS Resources Under NIMS
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4/11 CMS Ambulance Open Door Forum
The next CMS Ambulance Open Door Forum scheduled for:
Date: Thursday, April 11, 2024
Start Time: 2:00pm-3:00pm PM Eastern Time (ET);
Please dial-in at least 15 minutes before call start time.
Conference Leaders: Jill Darling, Maria Durham
**This Agenda is Subject to Change**
I. Opening Remarks
Chair- Maria Durham, Director, Division of Data Analysis and Market Based Pricing
Moderator – Jill Darling (Office of Communications)
II. Announcements & Updates
1. Medicare Ground Ambulance Data Collection System (GADCS)
III. Open Q&A
**DATE IS SUBJECT TO CHANGE**
Next Ambulance Open Door Forum: TBA
ODF email: AMBULANCEODF@cms.hhs.gov
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This Open Door Forum is open to everyone, but if you are a member of the Press,
you may listen in but please refrain from asking questions during the Q & A portion of
the call. If you have inquiries, please contact CMS at Press@cms.hhs.gov. Thank
you.
NEW and UPDATED Open Door Forum Participation Instructions:
This call will be a Zoom webinar with registration and login instructions below.
Register in advance for this webinar:
https://cms.zoomgov.com/webinar/register/WN_vfsU5LSKR3atiW9T_AhrDg
Meeting ID: 160 823 4591
Passcode: 200020
After registering, you will receive a confirmation email containing information about
joining the webinar. You may also add the webinar to your calendar using the dropdown arrow on the “Webinar Registration Approved” webpage after registering.’
Although the ODFs are now a Zoom webinar, we will only use the audio function, no need for cameras to be on.
For ODF schedule updates and E-Mailing List registration, visit our website at http://www.cms.gov/OpenDoorForums/.
Were you unable to attend the recent Ambulance ODF call? We encourage you to visit our CMS Podcasts and Transcript webpage where you can listen and view the most recent Ambulance ODF call. The webinar recording and transcript will be posted to: https://www.cms.gov/Outreach-andEducation/Outreach/OpenDoorForums/PodcastAndTranscripts.html.
CMS provides free auxiliary aids and services including information in accessible formats. Click here for more information. This will point partners to our CMS.gov version of the “Accessibility & Nondiscrimination notice” page. Thank you.
EMS.gov | HHS Announces New Performance Goals to Enhance Cybersecurity
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OHSA Notice of Proposed Rule Making (NPRM) Emergency Response Standard
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Recent Announcements and New Resources on EMS.gov
From EMS.gov on January 24, 2024
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CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Auth Process
Final rule modernizes the health care system and reduces patient and provider burden by streamlining the prior authorization process
As part of the Biden-Harris Administration’s ongoing commitment to increasing health data exchange and strengthening access to care, the Centers for Medicare & Medicaid Services (CMS) finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) today. The rule sets requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and issuers of Qualified Health Plans (QHPs) offered on the Federally-Facilitated Exchanges (FFEs), (collectively “impacted payers”), to improve the electronic exchange of health information and prior authorization processes for medical items and services. Together, these policies will improve prior authorization processes and reduce burden on patients, providers, and payers, resulting in approximately $15 billion of estimated savings over ten years.
“When a doctor says a patient needs a procedure, it is essential that it happens in a timely manner,” said HHS Secretary Xavier Becerra. “Too many Americans are left in limbo, waiting for approval from their insurance company. Today the Biden-Harris Administration is announcing strong action that will shorten these wait times by streamlining and better digitizing the approval process.”
“CMS is committed to breaking down barriers in the health care system to make it easier for doctors and nurses to provide the care that people need to stay healthy,” said CMS Administrator Chiquita Brooks-LaSure. “Increasing efficiency and enabling health care data to flow freely and securely between patients, providers, and payers and streamlining prior authorization processes supports better health outcomes and a better health care experience for all.”
While prior authorization can help ensure medical care is necessary and appropriate, it can sometimes be an obstacle to necessary patient care when providers must navigate complex and widely varying payer requirements or face long waits for prior authorization decisions. This final rule establishes requirements for certain payers to streamline the prior authorization process and complements the Medicare Advantage requirements finalized in the Contract Year (CY) 2024 MA and Part D final rule, which add continuity of care requirements and reduce disruptions for beneficiaries. Beginning primarily in 2026, impacted payers (not including QHP issuers on the FFEs) will be required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services. For some payers, this new timeframe for standard requests cuts current decision timeframes in half. The rule also requires all impacted payers to include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or an appeal when needed. Finally, impacted payers will be required to publicly report prior authorization metrics, similar to the metrics Medicare FFS already makes available.
The rule also requires impacted payers to implement a Health Level 7 (HL7®) Fast Healthcare Interoperability Resources (FHIR®) Prior Authorization application programming interface (API), which can be used to facilitate a more efficient electronic prior authorization process between providers and payers by automating the end-to-end prior authorization process. Medicare FFS has already implemented an electronic prior authorization API, demonstrating the efficiencies other payers could realize by implementing such an API. Together, these new requirements for the prior authorization process will reduce administrative burden on the healthcare workforce, empower clinicians to spend more time providing direct care to their patients, and prevent avoidable delays in care for patients.
In response to feedback received on multiple rules and extensive stakeholder outreach HHS will be announcing the use of enforcement discretion for the Health Insurance Portability and Accountability Act of 1996 (HIPAA) X12 278 prior authorization transaction standard to further promote efficiency in the prior authorization process. Covered entities that implement an all-FHIR-based Prior Authorization API pursuant to the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) who do not use the X12 278 standard as part of their API implementation will not be enforced against under HIPAA Administrative Simplification, thus allowing limited flexibility for covered entities to use a FHIR-only or FHIR and X12 combination API to meet the requirements of the CMS Interoperability and Prior Authorization final rule. Covered entities may also choose to make available an X12-only prior authorization transaction. HHS will continue to evaluate the HIPAA prior authorization transaction standards for future rulemaking.
CMS is also finalizing API requirements to increase health data exchange and foster a more efficient health care system for all. CMS values public input and considered the comments submitted by the public, including patients, providers, and payers, in finalizing the rule. Informed by these public comments, CMS is delaying the dates for compliance with the API policies from generally January 1, 2026, to January 1, 2027. In addition to the Prior Authorization API, beginning January 2027, impacted payers will be required to expand their current Patient Access API to include information about prior authorizations and to implement a Provider Access API that providers can use to retrieve their patients’ claims, encounter, clinical, and prior authorization data. Also informed by public comments on previous payer-to-payer data exchange policies, we are requiring impacted payers to exchange, with a patient’s permission, most of those same data using a Payer-to-Payer FHIR API when a patient moves between payers or has multiple concurrent payers.
Finally, the rule also adds a new Electronic Prior Authorization measure for eligible clinicians under the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category and eligible hospitals and critical access hospitals (CAHs) in the Medicare Promoting Interoperability Program to report their use of payers’ Prior Authorization APIs to submit an electronic prior authorization request. Together, these policies will help to create a more efficient prior authorization process and support better access to health information and timely, high-quality care.
The final rule is available to review here: https://www.cms.gov/files/document/cms-0057-f.pdf.
The fact sheet for this final rule is available here: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.
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