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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AAA Pushing Ambulance COVID-19 Relief

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

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

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

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

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

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

AAA Sends Letter to CMS on COVID-19 Response

The AAA has sent a letter to CMS on how the agency can most help ground ambulance service providers and suppliers be better prepared to respond to potential cases of COVID-19. The AAA has requested priority access to personal protection equipment for EMS personnel and COVID-19 test kits and results, as well as easing Medicare and Medicaid policies on alternative destinations and treatment in place. The letter was also sent to the National Highway Traffic Safety Administration (NHTSA) and the Assistant Secretary for Preparedness and Response (ASPR). Read the letter HERE.

Read the Letter

COVID-19 Update II for EMS

First Case of 2019 Novel Coronavirus in the United States

The New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County WA ‘Patient 1’. This was the first reported case of COVID 19 in the US. This seminal document, which given the magnitude of the case and its initial findings is released in full here

The work by Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, et al for the Washington State 2019-nCoV Case Investigation Team was turned round in just over 5 weeks and below is an ‘Executive summary’ ( as extracted from the paper) but the full paper and range of results should be read in full.

Patient Presentation

On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.

On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.

Viral Presence

Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24).

Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).

Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus

Day 8: Condition Improves

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.

History Taking

This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.

Conclusion

There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID 19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken

 

Sample COVID-19 Policies for Mobile Healthcare Providers

Thank you to the following organizations for sharing their policies as examples.

Global Medical Response maintains a COVID-19 page to provide information to all members of the GMR community—clinicians and non-clinicians.

Updates from GMR Chief Medical Officer, Dr. Ed Racht

GMR Procedures

General Information for Caregivers

Compliance

HIPAA Reminder

FirstWatch Solutions

The intention of the COVID-19 Process/Policy Template is to provide agencies, medical directors, or others who want to utilize it, an outline/template on which to build an agency-specific policy/protocol to address COVID-19. This includes suggestions for development and/or oversight committees, outside partners and stakeholders, as well as preparation and process for EMS workers who provide best practice care for patients as well as providing for the protection of pre-hospital providers and medical director(s). Its application is totally up to the user.

This document is meant to be a living document that can be revised as circumstances or guidance changes. It can also be a discussion piece for those who choose to develop a different type of policy but may want to use some of the components of the document as a starting point.

Agency Guidance

CDC Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States
NEW March 6, 2020: CMS COVID-19 FAQs for Healthcare Providers (PDF Download)

March 5, 2020: CMS issued a second Healthcare Common Procedure Coding System (HCPCS) code for certain COVID-19 laboratory tests, in addition to three fact sheets about coverage and benefits for medical services related to COVID-19 for CMS programs.  https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests

March 4, 2020: CMS issued a call to action to healthcare providers nationwide and offered important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare. https://www.cms.gov/newsroom/press-releases/cms-announces-actions-address-spread-coronavirus

February 13, 2020: CMS issued a new HCPCS code for providers and laboratories to test patients for COVID-19.  https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test

February 6, 2020: CMS gave CLIA-certified laboratories information about how they can test for SARS-CoV-2. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/notification-surveyors-authorization-emergency-use-cdc-2019-novel-coronavirus-2019-ncov-real-time-rt

February 6, 2020: CMS issued a memo to help the nation’s healthcare facilities take critical steps to prepare for COVID-19.  https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/information-healthcare-facilities-concerning-2019-novel-coronavirus-illness-2019-ncov

Member Advisory: CMMI Releases Initial List of ET3 Participants

The Centers for Medicare and Medicaid Services (CMMI) has released its initial list of applicants selected to participate in the ET3 pilot program. CMMI notes that the list is not final as it still needs to execute participation agreements with the applicants. CMMI will issue a final list once it completes the process.

Applicants from 36 states and the District of Columbia were selected to participate in the program. Approximately 200 applicants were approved with instances in which the same ambulance service organization submitted applications for multiple counties as well as more than one organization submitting an application for the same county. CMMI has sent notifications to each of the applicants letting them know to expect a follow up email with the partnership agreement, program guidance and additional details.

The ET3 program is a five-year voluntary pilot program designed to test the potential benefit to the Medicare program and patients of ambulance service providers and suppliers furnishing treatment in place as well as transport to alternative destinations. For more information about the ET3 program, please go the ET3 website.

CMS Announces New Healthy Adult Opportunity Initiative

On January 30, 2020, the Centers for Medicare and Medicaid Services (CMS) announced the roll-out of its “Healthy Adult Opportunity” (HAO) initiative.  Under the initiative, participating states will have a portion of their current federal Medicaid funding converted to block grants.  In return, the states will gain greater flexibility in providing for the health care needs of certain portions of their existing Medicaid populations.

In a letter directed to State Medicaid Directors, CMS outlined the details of how the HAO initiative would operate.  The initiative will be operated under CMS’ 1115 waiver authority.  In order to participate, a state must submit an application setting forth the specific demonstration projects it intends to implement.  CMS reiterated that participation in the HAO initiative is voluntary.  CMS further indicated that it will review state applications on a case-by-case basis and make an independent decision on whether the proposed policies merit approval.  States with existing Section 1115 waivers that cover eligible populations will be permitted to transition existing demonstrations into the HAO initiative.

CMS indicated that HAO demonstrations will generally be approved for an initial 5-year period, and successful demonstrations may be renewed for a period of up to 10 years.

A summary of some of the major provisions of this initiative is provided below.

Federal Funding

The Medicaid Program is a joint federal and state program that provides free or low-cost health coverage to nearly 65 million Americans.  The Program is administered by each state, with the federal government reimbursing states for a percentage of their qualifying Medicaid expenditures.  The amount of federal matching funds is based on a statutory formula that compares a state’s per capita income to the national average.  States with lower per capita incomes receive a higher Federal Medical Assistance Percentage (FMAP).  FMAPs range from 50% to a maximum of 83%.  In addition, the federal government provides higher matching rate (called an Enhanced FMAP) for certain services or populations.  For example, the federal government currently pays 90% of the costs of providing health care to those covered by the Medicaid expansion included in the Affordable Care Act.

Under the HAO initiative, participating states would forego the FMAP for certain Medicaid populations.  Instead, these states would receive a fixed amount of federal funding (i.e., a block-grant), which will be calculated based on either a total expenses or per-enrollee basis.  To the extent the state spends more than its budgeted amount, it would not be eligible for additional federal matching funds.  To the extent the state ends up spending less than its budgeted amount, the state would participate in the cost-savings.

Eligible Medicaid Populations

The HAO initiative is focused on the non-mandatory adult Medicaid populations, i.e., individuals that are under the age of 65, and who are not eligible for Medicaid on the basis of disability, or their need for long term care, and who are not otherwise eligible under a State Medicaid Plan.  In other words, this initiative is largely targeted at those individuals that become eligible for Medicaid as a result of the Affordable Care Act.

Benefit Package Design

Under the HAO initiative, states will have the ability to design benefit packages that closely resemble the benefit packages provided by private insurers.  At a minimum, this would include benefit packages that cover all of the Essential Health Benefits (EHBs) required for commercial insurances sold on the State ACA Exchanges.  States may also design federally qualified health center coverages that facilitate the use of value-based payment design among safety-net providers.

Beneficiaries that are shifted into HAO demonstration projects will retain certain beneficiary protections, including all federal disability and civil rights laws, fair hearing rights, and limits on their mandatory cost-sharing amounts.

Coverage of Prescription Drugs

One major change would be to state’s coverage of prescription drugs.  The initiative would give states the flexibility to offer formularies under an HAO demonstration project similar to those provided in commercial health insurance markets.  This would remove the current mandate that states provide a so-called “open formulary.”  States that elect to establish their own formulary would be required to comply with the EHB requirements regarding prescription drug benefits.  States would also be required to cover substantially all drugs used to treat: (1) mental health disorders (i.e., antipsychotics and antidepressants), (2) HIV (i.e., antiretroviral drugs), and (3) opioid use disorders (i.e., all forms, formulations, and delivery mechanisms) where there are rebate agreements in place with the manufacturers.

In theory, this would permit states to cover only a single drug for many pharmaceutical classes.

Cost-Sharing Amounts

States would have the flexibility to impose additional cost-sharing obligations on beneficiaries covered under a demonstration program, subject to two broad limitations:

  1. Aggregate out-of-pocket costs for beneficiaries covered under an HAO demonstration must not exceed 5% of the beneficiary’s household income, measured on a monthly or quarterly basis; and
  2. Premiums and cost-sharing charges for tribal beneficiaries, those beneficiaries living with HIV, those beneficiaries needing treatment for substance use disorders, and the cost-sharing charges for prescription drugs used to treat mental health conditions must not exceed amounts permitted under the implementing regulations. States would also not be permitted to suspend enrollment for these individuals if they fail to pay their premiums or cost-sharing amounts.

Wrap-Around Services (Including NEMT)

States would be given the flexibility to discontinue the coverage of Alternative Benefit Plan wrap-around services, including non-emergency medical transportation (NEMT) and early and periodic screening, diagnostic and treatment services (EPSDT) for individuals aged 19-20.

Ambulance Cost Collection Rule Summary

The proposed rule sets the foundation for the data collection system for ground ambulances.  It proposes a stratified random sample method, that is very similar to the one the AAA proposed via the work we commissioned through The Moran Company. We are working through the stratification categories, which are slightly different than those we identified.

CMS also proposes the cost and revenue data elements it plans to use.  There are some details in the proposed rule text and others will be in the proposed tool that will be posted the CMS website today.

CMS also proposes the collection period and penalties for failing to report.

While the data collection provision was the key component for ground ambulance services, CMS also proposed changes to the PCS requirement sought by the AAA. CMS is proposing to reference the PCS also as non-physician certification agreements. The agency is further proposing to clarify that the focus is on the certification of the medical necessity provisions and the form of the certification statement is not prescribed.  As part of the non-physician statement, CMS is proposing expanding the staff of you may sign the statement when an attending physician is unable to sign.

Download Full PDF Summary by Kathy Lester, Esq.

CMS Releases Proposed Cost Collection Rule

Today, CMS has released the proposed rule that would establish the ambulance fee schedule cost collection system as required by statute. The AAA is currently reviewing the rule and will provide a more detailed summary in the coming days.

On Tueusday, July 30 at 12:00pm Eastern, the AAA will be hosting a free webinar during which AAA counsel will provide an overview of the proposals in the rule. Do not miss out on this chance for the most up to date information.

Read the Proposed Rule

Sign Up for the Webinar

Questions?: Contact Us:

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

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

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

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

Thank you for your continued membership and support.

HHS OCR Requests Feedback on HIPAA Privacy Rule

On January 28, 2019, the Office of Health and Human Services the Office for Civil Rights (HHS OCR) issues a Request for Information (RFI) seeking input from covered entities regarding several aspects of the Health Insurance Portability and Accountability Act (HIPAA).  Specifically, the HHS OCR is seeking input regarding several elements of the Privacy Rule, including the following:

  • Encouraging information-sharing for treatment and care coordination
  • Facilitating parental involvement in care
  • Addressing the opioid crisis and serious mental illness
  • Accounting for disclosures of PHI for treatment, payment, and health care operations as required by the HITECH Act
  • Changing the current requirement for certain providers to make a good faith effort to obtain an acknowledgment of receipt of the Notice of Privacy Practices

I am aware that several AAA member services who have struggled with many of the HIPAA restrictions regarding the sharing of PHI with other healthcare entities.  In particular, with regard to individuals who suffer opioid overdoses and efforts to ensure the individual has access to drug treatment programs.  Additionally, HHS OCR is seeking input from covered healthcare providers regarding the “good faith” efforts to obtain acknowledgement of the receipt of Privacy Practices.  This has been a considerable challenge for EMS given the nature of our healthcare delivery model.  The relaxing of this regulatory requirement would substantially reduce the burden on EMS agencies.

The AAA recommends that our members review the HHS OCR Request for Information and submit comments by the February 12, 2019 deadline.  If members have any questions or need assistance in submitting their comments, the AAA is here to help.

Reports of Ambulance Pilot Programs

Earlier this week, health care trade press reported that the Centers for Medicare and Medicaid Innovation (CMMI) will be rolling out in the coming weeks several innovation pilot programs including a couple related to ambulance services. Over the last several months, the AAA has been meeting with CMMI and CMS officials about a pilot or change in policy to allow for coverage of transports by ambulance to destinations other than emergency departments. These efforts have coincided with efforts by others in the industry on alternative destination as well as reimbursement on some form of treat and refer of a patient.

The AAA is pleased that CMMI and CMS have listened to the recommendations of the AAA and other groups in moving forward on testing different policy changes. However, it is critical that the AAA and our members see the specifics of any pilot programs before we determine whether to support the initiative. CMMI cannot provide details of the program until available publicly and all the specifics of such programs are critical to whether they will be a success and if it will be a positive change for the industry and our ability to provide quality patient care.

We will provide you details of the pilot programs and the position of the AAA as soon as the details are made public. 

Rural Health Day Advocacy Update

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

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

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

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

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

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

Read the Full Letter

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

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

Questions?: Contact Us

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

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

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

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

Thank you for your continued membership and support.

HIPAA Breach Results in Highest Settlement in OCR History

The U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) announced earlier this month that is has entered into the largest settlement agreement in the history of the Department with Anthem, Inc., the largest Blue Cross and Blue Shield health benefit companies in the country.  Anthem, Inc. agreed to pay $16 million to HHS and take substantial corrective action to settle numerous potential violations of both HIPAA Privacy and Security Rules after it exposed protected health information (PHI) for nearly 79 million people.

In March 2015 Anthem filed a breach report with OCR after they discovered that their Information Technology (IT) systems were infiltrated by cyber-attackers who had gained access to their systems after an Anthem employee opened a phishing email.  This email released an undetected continuous persistent threat attack that permitted the cyber-attackers to access their systems from December 2014 through the end of January 2015.  This attack opened access that ultimately resulted in the PHI of nearly 79 million people to be stolen.

OCR’s investigation revealed that Anthem failed to conduct an enterprise-wide risk analysis.  Additionally, OCR determined that Anthem “failed to have sufficient policies and procedures to regularly review IT system activity, identify and respond to suspected or known security incidents, and failed to implement adequate minimum access controls to prevent impermissible access to electronic PHI.”

As part of the settlement, Anthem must comply with a Corrective Action Plan (CAP) for a period or two years.  As part of that CAP, Anthem must conduct an “accurate and thorough risk analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of all ePHI held by Anthem.” This risk assessment must be submitted to OCR for review and approval.  The CAP includes the review, revision, and distribution of all written policies and procedures addressing Information System Activity Review and Access Control for systems containing ePHI.  The CAP requires regular and ongoing reporting to OCR for actions taken under the Plan and for any reportable events.

The day following the Anthem, Inc. settlement press release, OCR and the Office of the National Coordinator for Health Information Technology (ONC) announced that they have strengthened the Security Risk Assessment (SRA) Tool to improve functionality.  The SRA is designed for use by small to medium sized health care providers to help them identify risks and vulnerabilities to ePHI within their practices.  All HIPAA covered entities and business associations are required to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI in their organizations.

Ambulance services should conduct a comprehensive Risk Analysis of their systems.  This Risk Analysis should include all provisions and requirements under HIPAA.  While this settlement highlights the significant risks associated with ePHI and IT systems, there remains significant risks to PHI in non-electronic forms as well.  This settlement is a great illustration of how apathy or reduced focus can result in potentially devastating results.

Contact the American Ambulance Association (AAA) with questions or assistance regarding any HIPAA related or other ambulance service compliance issue.

Statement on Ambulance Cost Data Collection

October 22, 2018

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

For Immediate Release

Statement on Cost Data Collection for Ambulance Services

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

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

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

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

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

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

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About the American Ambulance Association (AAA)

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

MedPAC Examines Beneficiary Use of Emergency Departments

During its October meeting, the Medicare Payment Advisory Commission (MedPAC), reviewed Medicare’s current policies related to non-urgent and emergency care, as these topics relate to the use of hospital emergency departments (EDs) and urgent care centers (UCCs). The Commission is examining this topic because the use of ED services in recent years has grown faster than that of physician offices.  At the same time, the share of ED visits that are coded as high acuity has increased.

The Commission is exploring Medicare beneficiaries’ use of EDs and UCCs for non-urgent services. In addition, the Commission is analyzing ED coding to determine if the increase in coding high-acuity visits reflects real change in the patients treated in EDs. This slide deck shows the potential savings Medicare could realize if beneficiaries shift certain care to the UCC setting.

During the meeting, the staff sought feedback from Commissioners for developing next steps. This topic will likely continue to be addressed in future meetings.

From the perspective of ambulance payment reform, the observations made by the Commissioners and staff would also seem to support incorporating scope-appropriate ambulance services in the context of community paramedicine or treatment at the scene with referral. While additional work needs to be done by the ambulance community before these services can be incorporated into the Medicare reimbursement program, discussions like the one at MedPAC last week, show the importance of getting the details right so that ambulance services can be part of new payment models likely to be considered.

The American Ambulance Association is leading the effort with the Medicare program to develop appropriate models that account for the cost of providing services through sustainable reimbursement rates, rather than the use of temporary grants. We are also focused on ensuring services align with the scope of practice laws. Led by the Payment Reform and the Medicare Regulatory Committees, our efforts include regular meetings and discussions with leaders at the Centers for Medicare & Medicaid Services, as well as key Members of Congress. Follow us on Facebook and Twitter to learn more about our ongoing efforts.

Government Affairs Update

Government Affairs Update: What We’re Working On

The AAA continues to press policy initiatives with Congress and the Administration that are important to our members. While not as high-profile as our successful efforts earlier this year on the five-year extension of the Medicare ambulance add-ons, the AAA is working hard on ambulance legislation and regulations that impact the EMS industry and ambulance services across the country. Here is a snapshot of those current efforts. Over the next month, we will be providing weekly in-depth updates highlighting these issues.

Ambulance Cost Data Collection System

The AAA was successful in getting our preferred language of an ambulance cost data collection system using a survey and random sample methodology included with the extension of the add-ons in the Bipartisan Budget Act of 2018. However, that was just the first key step in the process. We now need to ensure that CMS gets the details right as the agency develops the structural specifics and data elements for the system. It is critical that the system is designed in a way that ambulance service suppliers and providers will submit the most accurate data possible.

The data will ultimately provide the information necessary for Congress, the Centers for Medicare and Medicaid Services (CMS) as well as the AAA and other stakeholders to reform the Medicare ambulance fee schedule. Reform will include potential reimbursement for services such as community paramedicine, treat and refer, and other items that don’t involve transporting the patient.  However, in order to determine the reimbursement levels, we first need the data on what it could cost for these additional services. The AAA therefore has been working closely with officials at CMS on the development of the data collection system.

Medicare Community Bill

The five-year extension of the add-ons and authorization of data cost collection system were the first steps needed in the long-term goal of reforming the Medicare ambulance fee schedule. The AAA is now developing the next piece of legislation as step two of the process. The “Community Bill” would make the Medicare ambulance add-ons permanent, treat ambulance service suppliers like providers in three specific instances, direct the Centers for Medicare and Medicaid Services (CMMI) to do additional pilot programs on innovative services being done by ambulance agencies, reduce regulatory burdens, and implement a more accurate definition of what Goldsmith Modification zip codes should remain as rural. The AAA is currently developing the draft bill and reaching out to congressional offices regarding the introduction of the bill which will likely occur early next Congress.

Restructuring of Dialysis Offset

The AAA is supporting the efforts of our members who would be significantly adversely affected by the upcoming reduction in dialysis transport reimbursement to restructure the cut. Congress included in the Bipartisan Budget Act of 2018 an offset to go along with the extension of the add-ons that will cut reimbursement for BLS nonemergency transports to and from dialysis centers by an additional 13%. This will be on top of the existing 10% reduction.  The NEATSA Act (H.R.6269) by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports. The cut is currently scheduled to be implemented on October 1 and impacted AAA members and the AAA are working to get a Senate companion bill introduced shortly.

Rural EMS Grant Program

As an amendment to the Farm Bill (S. 3042) that passed the Senate, Senator Dick Durbin (D-IL) included language similar to the SIREN Act (S. 2830, H.R. 5429) to reauthorize the Rural EMS Grant program. However, in an effort to ensure the funding would go to the most needy, small, and rural EMS providers, the language of the amendment and SIREN Act would change the eligibility to just governmental and non-profit EMS agencies. Therefore, small rural for-profit ambulance service providers would no longer be eligible to apply for grants.

The AAA is pressing Senator Durbin as well as other members supportive of the reauthorization to revise the language to ensure small rural for-profit providers would still be able to apply for grants. In the next few weeks, the AAA will be asking AAA members to reach out to their members of Congress in support of the final Farm Bill including the reauthorization language and that it continues to also apply to for-profit providers as well.

Easing Regulatory Burdens

Over the last year, the AAA has responded to several requests for information from CMS as well as Congress on how to ease regulatory burdens for Medicare providers and suppliers. In addition to these broader opportunities, representatives of the AAA and our members have been meeting with CMS officials to reduce burdens for our industry. As a specific example, we are pushing for the elimination of the PCS for interfacility transports and to expand the categories of facility personnel eligible to sign the form.

Protecting Non-Emergency Ambulance Services

The AAA continues to educate members of Congress and congressional staff about the importance of non-emergency ambulance services. We are providing congressional offices with a clearer picture as to the vital role of these transports as part of the overall health care system. We are also looking to ensure that changes in federal payor policies strengthen the role and distinction of non-emergency ambulance transports from non-medical transportation services to health care facilities.

Zip Code Changes

The current use of Rural-Urban Commuting Areas (RUCA) as the basis of the Goldsmith Modification for determining rural areas in larger urban counties needs to be reformed. There are numerous examples of zip codes that are designated as urban under the Medicare ambulance fee schedule that are clearly rural. The AAA Rural Task Force is leading the way on both short-term and long-term efforts to more accurately capture rural zip codes in large urban counties. The AAA will include the ultimate reform provision crafted by the Task Force within the Community Bill as well as look at other legislative opportunities to make the changes.

Questions?: Contact Us

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

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (703) 610-0216

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (703) 610-5821

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (703) 610-9039

Thank you for your continued membership and support.

Notice of Proposed Change to OSHA Injury Reporting

Notice of Proposed Change to OSHA Electronic Injury Reporting Regulations

The Occupational Safety and Health Administration (OSHA) announced on July 27, 2018 that it has published a Notice of Proposed Rulemaking (NPRM) that would change the Electronic Injury Reporting Regulations (29 CFR Part 1904) for employers with 250 or more employees. OSHA is proposing this change due to a heightened concern that employee Personally Identifiable Information may be at risk of disclosure through the Freedom of Information Act (FOIA).

Currently, all EMS employers must submit their annual injury and illness data to OSHA through the Injury Tracking Application (ITA). Historically, employers were required to track all workplace injuries and illnesses and maintain records of those incidents in the workplace on the OSHA Form 300, 301, and 300A. Each year, employers are required to post a Summary of Workplace Injuries and Illnesses on the Form 300A from February 1st through April 30th.

In May 2016, OSHA amended the regulations requiring all employers to submit their Form 300A Summary electronically through the Injury Tracking Application (ITA). Employers with 250 or more employees were required to electronically report all injury and illness data from Forms 300, 301, and 300A each year. Initially OSHA believed that the reporting of electronic injury data would encourage employers to focus on workplace safety because the summary of injury data would be published for public use.

OSHA is now concerned about disclosure of information on the Form 300 and 301, which contains a great deal of sensitive information, including the employee’s date of birth, injury type, and limited treatment information. There have been several instances in which organizations have sought this sensitive information by invoking the Freedom of Information Act (FOIA). In addition, OSHA stated that collecting this data costs the Department of Labor roughly nine (9) million dollars and places a substantial administrative burden on employers.

The Summary of Proposed Rulemaking is seeking comment on only the change to Part 1904.41 which requires employers with 250 or more employees to submit the data represented on Form 300 and 301. The proposed change would eliminate the requirement for employers with 250 or more employees to submit the information on those form, but they would still be required to report the Form 300A summary data. However, all employers are required to maintain records, and be able to produce the data on Form 300 and 301 for OSHA if requested. This also does not change an employer’s required Form 300A posting requirements from February 1st through April 30th.

OSHA also proposed a change to the regulations seeking to require employers to include the Employer Identification Number (EIN) when they electronically submit their Form 300A data on the ITA annually. This proposed change would allow the Department of Labor to reduce duplicative reporting of information because it would allow them to match data with information submitted through other Department agencies, such as the Bureau of Labor Statistics.

This proposed change would be a win for employers as it significantly reduces a great deal of administrative burden. Employers are encouraged to submit comments to these proposed changes by September 28, 2018. If members have any questions on what their current reporting obligations are under OSHA or how these proposed changes will affect their organizations, please contact Scott Moore at the AAA.

Submit your comments here. 

CMS Non-Emergency Ambulance Transport Open Door Forum 7/26

CMS Issues Data Elements and Templates for Non-Emergency Ambulance Transports (NEAT): Open Door Forum for
Thursday, July 26, 2018 Just Announced

As part of its Patients Over Paperwork Project, the Centers for Medicare & Medicaid Services (CMS) Provider Compliance Group (PCG) has been hosting quarterly listening sessions and reviewing the Request for Information submissions. The American Ambulance Association has been actively engaged in these efforts, highlighting the recommendations we submitted to CMS and the House Ways & Means Committee last year. These recommendations included suggestions as to how CMS could streamline regulatory requirements to eliminate duplicative requirements and reduce regulatory burdens.  In addition to these efforts, CMS has been working to standardize documentation data elements and establish templates that providers and suppliers can use to help make the current documentation processes less burdensome as well.

On July 24, CMS released draft documentation-related clinical data elements and clinical templates that could be used for the Physician Certification Statement, Progress Notes, and Prior Authorization requests. View the Documents. These documents are not intended to change current law.

CMS also announced yesterday that it will discuss the templates on a Special Open Door Forum which is scheduled for July 26 at 2-3 pm ET.  The call-in information is:

  • Participant Dial-In Number: 1-(888)-989-4575
  • Conference ID: 3068545

We have shared our concern about the short notice about the call and CMS has indicated it will continue to take comments on the documents after the call as well. The AAA is in the process of reviewing these documents closely and will develop a written comment letter to provide to CMS after the call on Thursday. We welcome input from all our members as part of this process.

While these new documents may be helpful for many services, the AAA also remains committed to move its recommendations which would result in some changes in the PCS and other ambulance provider and supplier requirements.

 

 

Robert Wilkie Confirmed as VA Secretary

The Senate voted today to confirm Robert Wilkie as Department of Veterans Affairs secretary. Wilkie, previously an undersecretary at the Pentagon, was approved by the Senate 86-9. Of note, Wilkie becomes the fourth VA Secretary in the past five years.



New VA Secretary, Robert Wilkie

Senate confirms Robert Wilkie to be the next VA Secretary
What To Know About Trump’s VA Secretary Nominee Robert Wilkie

Wilkie takes over after Secretary David Shulkin was fired earlier this year. Wilkie is the second nominee put forward to replace Shulkin after White House physician, Ronny Jackson, withdrew his nomination in April.