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Organized Labor is Making a Comeback

In my early EMS leadership career, I worked for an organization that was swallowed up by a large national EMS consolidator. The unsettled times that occurred during, and immediately following the acquisition,  led a small group of paramedics to petition for union representation. At the time, I had not yet finished my undergraduate or law degree.  My experience with leading a management team through a union campaign was non-existent.  The organization hired a labor attorney to work with our team to ensure that we stayed compliant in the weeks leading up to the National Labor Relations Board (NLRB) election.

 

It was an incredibly difficult time for both the leadership and the employees.  Anyone who has lived through a union campaign can tell you, it can make you question the type of leader and manager you think you are.  It puts an unbelievable strain upon everyone in the organization.  Ultimately, the employees elected not to be represented by a union. As a team, we learned a great deal during this process. We realized that we were not the employee-centric organization that we believed we were.  There is an old saying in labor relations, “every company gets the union it deserves.”

 

Union representation had been on the decline for several decades as numerous laws and regulations have been enacted to address many of the concerns that drove union membership. As we know, the last few years have presented incredible challenges for EMS organizations and their employees. The Biden Administration brings with it a President who has adopted a pro-union agenda and a Secretary of Labor, who is a former union leader.

 

A recent article published by the National Law Review states that union petitions are up 57%. Nearly every day there is a story of unionization at organizations that were previously not union strongholds.  Additionally, polling seems to suggest that Americans view unions far more favorably than they did just over a decade ago. Traditionally, unions used to focus on larger employers, but have recently added all employers, including those with smaller collective bargaining units.

 

EMS agencies are no exception to this trend in union representation. It should be no surprise to EMS leaders that several unions believe that EMS is ripe for labor organizing. I will not go into all of the reasons that EMS is the focus of labor organizations but suffice it to say, the recent workforce challenges have made their message far more enticing to employees. Recently, an organization that I once was a part of and would not have believed was ripe for organizing, just overwhelmingly voted to be represented by a union.

 

The Best Strategy

If your organization is committed to remaining in a non-union environment, it is critical that you make this an intentional part of your strategic plan. Generally, employees join unions because they are unhappy or dissatisfied with the relationship they have with the management team or company they work for.  This is often articulated by dissatisfaction with pay and benefits, consistency in policy and procedure practices, and the day-to-day interactions with management. More specifically, the relationship or treatment by their immediate supervisor.

 

The best strategy is to be proactive. This is not something that employers can or should ignore. This must be a stated and intentional part of your organizational strategic plan. Due to the workforce shortage, most organizations have been evaluating their pay and benefits programs. However, we are not always so good at communicating these benefits to our employees. Often, we treat pay and benefits like trade secrets, even with our own folks. EMS is notorious for its rumor mill and it is far better to control or influence the narrative regarding the benefits that your employees enjoy by working for your organization. You will be surprised how many on your team have no idea that some of your benefits exist or are available to them.

 

Education and communication are key elements in any union-free workplace strategy. Employers should utilize the AAA Total Compensation Statement that highlights all costs associated with pay and benefits.

The leadership team should evaluate the frequency of supervisor-employee interactions and the tools used to track these engagements. The stronger the relationship between the frontline employees and the leadership team, the less likely your employees are to invite an outside third party to represent them. If this is not one of your organization’s leading Key Performance Indicators (KPIs) or Vital Signs, it will disappear into the whirlwind of activity that consumes your team’s day.

 

Rules of the Road

It is important for your team to know the rules of the road as it relates to a fostering union-free strategy. The playing field is not exactly even.  Unions have the right to solicit employees and make promises of increased wages, benefits, and working conditions, regardless of their ability to deliver.  However, employers are far more limited in what actions they can take regarding union representation.  Employers can find themselves in trouble if they fail to follow some simple rules. Here are a few TIPS to help employers stay compliant.

T –          Employers cannot Threaten to discipline or reduce wages and/or benefits if their employees unionize or engage in union activity;

I –           Employers cannot Interrogate employees about their activities or feelings on union representation;

P –          Employers may not make Promises to employees to improve wages, benefits, or working conditions if they remain union-free;

S –          Employers cannot Spy on employees’ union-related activities.

Employers are free to discuss what joining a union might mean for the employee. For example, an employer can say “if the workforce is represented by a union, the terms and conditions of employment will be subject to collective bargaining.  The collective bargaining process may result in employees getting more, getting less, or the same wages and benefits that they have now.” The key is, to be honest in all communications with your employees.

A Path Forward

EMS leaders should deliver a clear message to their frontline leadership team. Focus on developing strong relationships with their employees. Encourage open and frequent lines of communication, listen to employee concerns, and address them quickly. Ensure that frontline leaders have been provided training and the TIPS for maintaining a union-free work environment. Lastly, be sure to contact the AAA at hello@ambulance.org if you have questions or need assistance.

National EMS Memorial Bike Ride Registration is OPEN!

The National EMS Memorial Bike Ride is currently accepting registrations for the East Coast, Southern, Midwest, and Weekend of Honor Events.

To learn more about each one of these events, check out the details below.  Looking to register?  Click on the registration buttons located under each of the route headings.

 

Weekend of Honor – July 22nd Crystal City, VA

This single-day event kicks off the Weekend of Honor in coordination with the National EMS Memorial Service. Registration is only $20.

Click Here to Learn More and Register »

MidWest Route – June 20th – June 25th

Experience the beauty of the Midwest from St. Paul, MN. to Chicago, IL over the course of this six-day event.

Click Here to Learn More and Register »

Southern Route – May 22nd – May 28th

This seven-day route begins in Fayetteville, NC, with a final destination of Williamsburg, VA.

Click Here to Learn More and Register »

East Coast – May 21st – May 27th

The original route of The National EMS Memorial Bike Ride will travel from Boston, MA to Baltimore, MD.

Click Here to Learn More and Register »

Colorado Route – September 11th – September 16th

Are you up for a climb?  Don’t worry, half of the route is all downhill.  With a start in Snowmass, CO to Littleton, CO you can take in the best sights of the Rocky Mountains.

Registration Coming Soon…..

West Coast – September 19th – September 24th

From Reno, NV to San Francisco, CA this route has it all, The views, the weather, and the wine of the Napa Valley, don’t miss this season-ending route.

Registration Coming Soon…..

Covid-19 Mitigation
The National EMS Memorial Bike Ride remains committed to providing a safe cycling and support environment for all participants, spectators, and hosts.  During all 2022 events, the CDC Covid-19 guidelines in effect at the time and location of the individual event will be followed by all participants.  You can view these requirements at the CDC Covid-19 Community Levels website by clicking here.
 

The National EMS Memorial Bike Ride, Inc. honors Emergency Medical Services personnel by organizing and implementing long-distance cycling events that memorialize and celebrate the lives of those who serve every day, those who have become sick or injured while performing their duties, and those who have died in the line of duty.

You can learn more about the 2022 National EMS Memorial Service and obtain the hotel reservation list by clicking here

PRF Late Reporting Extended

HRSA announces potential relief for health care providers that missed the deadline to report on their use of Provider Relief Funds

On April 7, 2022, the Health Resources and Services Administration (HRSA) posted a notice that offers providers that missed the deadline to report on their use of HHS Provider Relief Funds the opportunity to potentially be able to file that report and therefore avoid the potential recoupment of PRF funds.  The “Request to Report Late” is limited to situations where the failure to timely submit the required report was due to one or more extenuating circumstances.

 

If you were notified that you failed to submit your required PRF Report on a timely basis and are being asked to return PRF funds, you should read this member advisory carefully. 

 

Relevant Background

 

On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion (increased to $178 billion by subsequent legislation) to the creation of the CARES Act Provider Relief Fund (PRF) which was used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.

 

Under the terms of the PRF program, health care providers that received more than $10,000 in any reporting period were required to submit a report that provides details on how those funds were expended.  The first report covered PRF payments received between April 10, 2020, and June 30, 2020, and was due on or before September 30, 2021.  HHS subsequently enacted a 60-day grace period, which ran from October 1, 2021, through November 30, 2021.  The second report covered PRF payments received July 1, 2020, and December 31, 2020, and was due on or before March 31, 2022.

 

Providers that failed to submit any required report by these deadlines are subject to the potential recoupment of those funds.

 

What HRSA Considers to be “Extenuating Circumstances”

 

According to the notice, health care providers will be permitted to request the opportunity to complete their report after the deadline to the extent the filing of their report was delayed due to one or more of the following:

 

  • Severe illness or death – a severe medical condition or death of a provider or key staff member responsible for the reporting hindered the organization’s ability to complete the report during the relevant reporting period.
  • Nature Disaster – a natural disaster occurred during or in close proximity to the end of the reporting period that damaged the organization’s records or information technology.
  • Lack of receipt of reporting communications – an incorrect email or mailing address on file with HRSA prevented the organization from receiving instructions prior to the relevant reporting period deadline.
  • Failure to click “Submit” – the organization registered and prepared a report in the PRF Reporting Portal but failed to take the final step to click “Submit” prior to the reporting deadline.
  • Internal Miscommunication or error – internal miscommunication or error regarding the individual who was authorized and expected to submit the report on behalf of the organization and/or the registered point of contact in the PRF Reporting Portal.
  • Incomplete Targeted Distribution payments – the organization’s parent entity completed all General Distribution payments, but a Targeted Distribution(s) was not reported on by the subsidiary.

 

Process for Applying for Permission to Submit a “Late Report”

 

To the extent one or more of the extenuating circumstances described above applies, the provider will be given the opportunity to submit a Request to Report Late Due to Extenuating Circumstances.  The timeframe to submit these requests will run from April 11, 2022, to April 22, 2022. 

 

HRSA is indicating that any provider that plans to submit such a request but has yet to register in the PRF Reporting Portal, should register prior to submitting their request.

 

To submit a request to file late, the provider will need to submit a form indicating the extenuating circumstance(s) that prevented the required report from being submitted in a timely fashion.  That form will require the provider to provide a “clear and concise explanation” of the applicable extenuating circumstance.  However, providers will not be required to submit any supporting documentation.  The provider will be required to attest to the truthfulness and accuracy of their extenuating circumstance.

 

After submitting their request, the provider will be notified by HRSA whether their request is approved or denied.  If the request is approved, the provider will have 10 days from the date of the notification to submit the required report through the PRF Reporting Portal.

 

If the request is denied, HRSA will proceed with the recoupment of the PRF funds subject to the missed report.

 

National EMS Memorial Bike Ride Registration is OPEN!

The National EMS Memorial Bike Ride is currently accepting registrations for the East Coast, Southern, Midwest, and Weekend of Honor Events.

To learn more about each one of these events, check out the details below.  Looking to register?  Click on the registration buttons located under each of the route headings.

 

Weekend of Honor – July 22nd Crystal City, VA

This single-day event kicks off the Weekend of Honor in coordination with the National EMS Memorial Service. Registration is only $20.

Click Here to Learn More and Register »

MidWest Route – June 20th – June 25th

Experience the beauty of the Midwest from St. Paul, MN. to Chicago, IL over the course of this six-day event.

Click Here to Learn More and Register »

Southern Route – May 22nd – May 28th

This seven-day route begins in Fayetteville, NC, with a final destination of Williamsburg, VA.

Click Here to Learn More and Register »

East Coast – May 21st – May 27th

The original route of The National EMS Memorial Bike Ride will travel from Boston, MA to Baltimore, MD.

Click Here to Learn More and Register »

Colorado Route – September 11th – September 16th

Are you up for a climb?  Don’t worry, half of the route is all downhill.  With a start in Snowmass, CO to Littleton, CO you can take in the best sights of the Rocky Mountains.

Registration Coming Soon…..

West Coast – September 19th – September 24th

From Reno, NV to San Francisco, CA this route has it all, The views, the weather, and the wine of the Napa Valley, don’t miss this season-ending route.

Registration Coming Soon…..

Covid-19 Mitigation
The National EMS Memorial Bike Ride remains committed to providing a safe cycling and support environment for all participants, spectators, and hosts.  During all 2022 events, the CDC Covid-19 guidelines in effect at the time and location of the individual event will be followed by all participants.  You can view these requirements at the CDC Covid-19 Community Levels website by clicking here.
 

The National EMS Memorial Bike Ride, Inc. honors Emergency Medical Services personnel by organizing and implementing long-distance cycling events that memorialize and celebrate the lives of those who serve every day, those who have become sick or injured while performing their duties, and those who have died in the line of duty.

You can learn more about the 2022 National EMS Memorial Service and obtain the hotel reservation list by clicking here

DOL Electronic Injury & Illness Reporting

Proposed Changes to the OSHA Electronic Injury & Illness Reporting Requirements

The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) is proposing amendments to its occupational injury and illness recordkeeping regulation, 29 CFR 1904.41. The current regulation requires certain employers to electronically submit their summary injury and illness data (Form 300A) to OSHA annually. OSHA uses these reports to identify and respond to emerging hazards and makes aspects of the information publicly available.

In addition to reporting their Annual Summary of Work-Related Injuries and Illnesses, the proposed rule would require certain establishments in certain high-hazard industries to electronically submit additional information from their Log of Work-Related Injuries and Illnesses, as well as their Injury and Illness Incident Report (Form 300, 300A, & 301). The latest proposed rule will require certain employers to submit more detailed information and is a return to the original electronic data submission rule that was proposed in 2016 and rolled back in 2017, prior to the rule taking effect. EMS organizations will be included in those industries that are considered high-hazard and thus, required to submit this information.

As we reported last month, OSHA reported that there was a 249% increase in illnesses and injuries reported by healthcare employers in 2020. This is no surprise given that this was at the heart of the pandemic. OSHA believes this rule will improve the agency’s ability to use the information in its enforcement and compliance assistance efforts to identify workplaces where workers are at high risk.

The proposed rule would:

  • Require establishments with one hundred (100) or more employees in certain high-hazard industries to electronically submit information from their OSHA Forms 300, 301, and 300A to OSHA once a year. Currently, only the Form 300A summary data is submitted electronically.
  • Update the classification system used to determine the list of industries covered by the electronic submission requirement.
  • Remove the current requirement for establishments with 250 or more employees not in a designated industry to electronically submit information from their Form 300A to OSHA annually.
  • Require establishments to include their company name when making electronic submissions to OSHA.

Under the proposed rule, establishments with 20-99 employees in certain high-hazard industries would continue to be required to electronically submit information from their OSHA Form 300A annual summary to OSHA annually.

Those interested can submit comments must do so by May 30, 2022. If you have questions about your organization’s reporting requirements under the OSHA Regulations, be sure to contact the AAA at hello@ambulance.org for assistance.

2021 Ambulance Ride-Along Toolkit

AAA ambulance emt member legislation

2021 Ride-Along Toolkit Now Available!

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

Congress has adjourned for summer recess and members have returned home to their districts and states. This is the perfect opportunity for you to educate your members of Congress about our issues, in particular our Medicare Ambulance Bill, Balance Billing, and access to the Provider Relief Fund, which are all essential to your service.

The most effective way to deliver these key messages is to host your member of Congress or their staff on a tour of your operation and an ambulance ride-along. While COVID-19 has made a traditional ride-along difficult, you can still host them for a virtual site visit to show your operation and how you are handling the public health emergency. The AAA has made the process of arranging a ride-long or scheduling a meeting easy for you with our 2021 Congressional Ride-Along Toolkit.

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

Bipartisan, Bicameral Members of Congress Reach Agreement on “Surprise” Billing Legislation

It appears that members of Congress on the House Ways & Means, Energy & Commerce, and Education & Labor Committees along with the Senate Health, Education, Labor, & Pensions Committee have reached a compromise agreement that will allow “surprise” billing legislation to be considered for passage before the end of the year.  While the details of the legislation have yet to be unveiled, the American Ambulance Association has learned that it is likely to include provisions related to ground ambulance service and air ambulance service providers and suppliers.

Earlier legislation moved forward by the House Education & Labor Committee included a requirement for the Administration to create a Federal Advisory Committee to review ways to increase transparency around fees and charges for ground ambulance services and to better inform consumers about their treatment options.  We believe that this language will be included in the compromise, but that there may be an opportunity to suggest modifications to make it more balanced and fairer in terms of the charge of the Committee and the types of individuals and organizations who will be selected to participate on it.  The AAA is recommending that the Advisory Committee have at least a year to study and report on issues related to balance billing by ground ambulance service providers and suppliers, including the role of local and state governments in EMS systems amongst other considerations.  It is also important that the Committee members include representatives from all types, sizes, and geographical areas of ground ambulance service providers and suppliers, as well as state EMS officials, and paramedics and EMTs.

It is likely that if the congressional leadership agree to move this legislation forward, it would be attached to the end of the year packages that may also include COVID-19 relief, Medicare extenders, and the annual spending bills.

CDC Advisory Committee Recommends EMS for Phase 1 Vaccine Distribution

As reported in various media outlets, on December 1 the Center for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) voted 13-1 to recommend that health care providers, expressly including EMS personnel, be prioritized to receive the COVID-19 vaccines during Phase 1a of the vaccine distribution plan. The complicating factor is that State and local governments have the final say in whether these recommendations are incorporated into their own distribution plans. Thus, we encourage all AAA members to engage actively with their State and local governments to urge the adoption of the CDC recommendation. The AAA has developed a toolkit for members to use in reaching out to their state and local government officials.

View and Download Toolkit Here

The AAA has been engaging with ACIP and other federal policy makers to urge them to prioritize EMS in the vaccine distribution plan. On November 19, the AAA submitted a comment letter to the ACIP advocating that the advisory committee specifically include EMS personnel in their recommendation of groups in the first phase of receiving the vaccination. Even though States and local governments will create their own list, having EMS listed in Phase 1a CDC recommendations is a critically important step toward influencing the State and local process.

During its second emergency meeting in less than a month, ACIP met to develop recommendations on the prioritization of vaccines, given that it will be impossible to provide access to everyone in the United States immediately after the vaccines are approved. In both virtual meetings, Committee members noted the importance of EMS personnel having access to the vaccine in the very top tier for prioritization. Other health care personnel on this list are defined as hospitals, long-term care facilities, outpatient clinics, home health care, pharmacies, and public health. The Phase 1a tier also includes residents of nursing homes, assisted living facilities, and other residential care settings, given that approximately 40 percent of all COVID-19 deaths have occurred in these settings. The final recommendation approved states:

When a COVID-19 vaccine is authorized by FDA and recommended by ACIP, vaccination in the initial phase of the COVID-19 vaccination program (Phase 1a) should be offered to both 1) health care personnel§ and 2) residents of long-term care facilities.

Health care personnel are defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials.

Long-term care facility residents are defined as adults who reside in facilities that provide a variety of services, including medical and personal care, to persons who are unable to live independently.

The CDC plans to publish this recommendation in the Morbidity Mortality Weekly Report as well.

The only controversial issue related to whether long-term care facility residents should receive the vaccine given the limited information available about its effectiveness and safety in these populations.

Because President Trump has indicated that State and local governments do not have to follow the CDC recommendations, it is critically important that AAA members work closely with their State and local governments to ensure that the CDC recommendations with regard to EMS are adopted by them as well. The AAA has posted a tool kit on our website to help our members provide the necessary information to their State and local governments as they are making these decision.

ACIP will continue to evaluate the distribution prioritization for Phase 1b, which will likely be non-health care essential workers, and Phase 1c, which will include adults with high-risk medical conditions and adults 65 years or older.

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

President signs law providing funds to combat Corona Virus

President Donald Trump today signed H.R. H.R. 6074 into law, approving $8.3 billion in supplemental appropriations to fund programs in response to the COVID-19 illness. The bill would bolster vaccine development, research, equipment stockpiles, and state and local health budgets as government officials and health workers fight to contain the outbreak, which has claimed 11 lives in the U.S. and sickened more than 160 people across more than a dozen states.

The AAA advocated to negotiators of the bill that first responders needed to be included in the funding package and that all communities be eligible for the funding. Due in part to our outreach, the emergency funding provides a transfer of no less than $10 million to the National Institute of Environmental Health Sciences for worker-based training aimed at preventing exposure of the virus to emergency first responders, and others at risk of exposure (i.e., hospital employees).

The supplemental also appropriates $1 billion for state and local preparedness, which will allow state and local governments to carry out preparedness and response activities, with each State receiving a minimum of $4 million. Of the $1 billion, $300 million is allocated for global disease detection and emergency response, and FY 2019 Public Health Emergency Preparedness grantees.

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.

House Committees Consider Balance Billing Proposals

This past Tuesday and Wednesday, respectively, the House Ways & Means and Education & Labor Committees marked up their proposals on balance or “surprise” billing. As we reported on Monday of this week, the Ways & Means Committee proposal, the Consumer Protections Against Surprise Medical Bills Act (H.R. 5826), did not include a provision on ground ambulance services. The House Education & Labor proposal, The Ban Surprise Billing Act (H.R. 5800), however, included a provision to create a federal advisory committee to recommend restrictions on the ability of ground ambulance service providers and suppliers to balance bill.

The Ways & Means Committee reported out H.R 5826 favorably by voice vote. While the Education & Labor Committee also reported out H.R. 5800 favorably, the vote was 30 to 13 as a block of its Committee members preferred the approach of the Ways & Means proposal on how to address balance billing for other providers. It is now up to House leadership to determine next steps on how the chamber will approach a final package on balance billing.

While H.R. 5800 as reported out by the Education & Labor Committee still includes the provision on ground ambulance services, Chairman Scott (D-VA) and Ranking Member Foxx (R-NC) prior to mark up had removed the most problematic language in the bill. As introduced, H.R. 5800 would have given the Department of Health and Human Services the authority to issue regulations to restrict balance billing based on the findings of the advisory committee. This would have eliminated federal lawmakers from being able to evaluate the recommendations prior to the changes being implemented. The language was removed in the chairman’s mark of the bill, and thus the Congress would now have an opportunity to debate and craft legislation on the recommendations.

The AAA along with the International Association of Fire Chiefs (IAFC), International Association of Firefighters (IAFF) and National Association of EMTs (NAEMT) had advocated against the ground ambulance provision. We thank Chairman Scott, Ranking Member Foxx and members of the Committee for listening to our concerns and removing the regulation authority language.

Only one of the four pieces of legislation on balance billing reported out by congressional committees includes a provision on ground ambulance services. We will continue to advocate to preserve the ability of local governments to determine the rates and standards for their EMS systems and against the inclusion of a ground ambulance provision in a final package on balance billing.

We will keep you apprised of new developments on the issue.

2018 National and State-Specific Medicare Data

The American Ambulance Association is pleased to announce the publication of its 2018 Medicare Payment Data Report. This report is based on the “Early Edition” of the 2018 Part B National Summary Data File (previously known as the Bess Report). The report consists of an overview of total Medicare spending nationwide, and then a separate breakdown of Medicare spending in each of the 50 states, the District of Columbia, and the various other U.S. Territories.

For each jurisdiction, the report contains two charts: the first reflects data for all ambulance services, with the second limited to dialysis transports. Each chart is further broken down by HCPCS code. The charts provide information on the total number of allows services and the total Medicare payments for CYs 2017 and 2018. Percentage changes will allow members to view payment trends over the past year.

2018 National & State-Specific Medicare Data

Questions? Contact Brian Werfel at bwerfel@aol.com.

 

CMS Releases List of Ambulance Organizations Selected for Data Collection

CMS Releases List of Ambulance Organizations Selected for Data Collection

The Centers for Medicare & Medicaid Services (CMS) has released the list of ambulance service providers and suppliers selected to provide data in the first year of data collection. CMS has published the data by National Provider Identifier (NPI) number and the AAA has also sorted the data by state in alphabetical order.

On Friday, CMS had made public the final rule on the Establishment of an Ambulance Data Collection System. The AAA will be issuing a Member Advisory tomorrow on the details of the final rule and changes from the proposed rule.

To access the list by NPI number click here and to access the list by state click here.

Provider List by NPI

Provider List by State

CMS Announces 2020 Ambulance Inflation Factor

On October 4, 2019, CMS issued Transmittal 4407 (Change Request 11497), which announced the Medicare Ambulance Inflation Factor (AIF) for calendar year 2020.

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 2018, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased 1.6%. CMS further indicated that the CY 2020 MFP will be 0.7%. Accordingly, CMS indicated that the Ambulance Inflation Factor for calendar year 2019 will be 0.9%.

CMS Announces Comment Period for National Expansion of Prior Authorization Process

On October 29, 2019, the Centers for Medicare and Medicaid Services (CMS) posted a notice in the Federal Register announcing an opportunity for the public to provide comments on the proposed national expansion of the prior authorization process for repetitive, scheduled non-emergent ground ambulance transportation.  CMS refers to this process as its “RSNAT Prior Authorization Model.”  The CMS Notice can be viewed in its entirety at: https://www.govinfo.gov/content/pkg/FR-2019-10-29/pdf/2019-23584.pdf.

Under the Paperwork Reduction Act of 1995, federal agencies are required to publish a notice in the Federal Register concerning each proposed collection of information, and to allow 60 days for the public to comment on the proposed action.  Interested parties are encouraged to provide comments regarding the agency’s burden estimates and other aspects of the proposed collection of information, including the necessity and utility of the proposed information for the proper performance of the agency’s functions, and ways in which the collection of such information can be enhanced.

In this instance, CMS is indicating that it is pursuing approval to potentially expand the existing RSNAT Prior Authorization Model nationwide.  Currently, the RSNAT Prior Authorization Model is in place in 8 states (DE, MD, NJ, NC, PA, SC, VA, and WV) and the District of Columbia.  National expansion is contingent upon CMS’ determination that certain expansion criteria have been met.  CMS is indicating that if the decision is made to expand the program, such expansion may occur in multiple phases.  CMS intends to use the information collected pursuant to this notice to determine the proper payment for repetitive scheduled non-emergent ambulance transportation.

In plain English, CMS is soliciting comments from stakeholders as to the efficacy of the current process, including whether the existing paperwork requirements are sufficient to ensure that approved patients meet the medical necessity requirements for an ambulance.  CMS is also seeking suggestions for how to best expand the program nationally, e.g., whether it makes sense to expand the program in phases, etc.

The AAA Medicare Regulatory Committee has been monitoring the current model for several years.  As a result, the AAA is in a good position to provide constructive feedback to CMS regarding the potential national expansion of the RSNAT Prior Authorization Model.  These suggestions will be included in the AAA’s comment letter.  The AAA also encourages members to offer their own comments.  The AAA anticipates providing members with a sample comment letter in early December that members can use to submit their own comments.

To be considered, comments must be submitted no later than 5 p.m. on December 30, 2019.  Comments may be submitted electronically by going to: http://www.regulations.gov.  Commenters would then need to click the link for “Comment or Submission,” and follow the instructions from there.  Comments may also be submitted by regular mail to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier: CMS-10708, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

HHS OIG Issues Proposed AKS Safe Harbor Rule

On Thursday, October 17, 2019, the HHS Office of the Inspector General (OIG) issued a proposed rule titled “Medicare and State Health Care Programs: Fraud and Abuse; Revisions to Safe Harbors Under the Anti-Kickback Statute, and Civil Monetary Penalties Regarding Beneficiary Inducements.”  The proposed rule would amend the existing safe harbors to the Federal Anti-Kickback Statute (AKS) and the civil monetary penalty rules (CMPs).  These changes are part of HHS’ Regulatory Sprint to Coordinated Care.  The stated purpose of these changes is to reduce the regulatory barriers and accelerate the transformation of the healthcare system away from the traditional fee-for-service payment model, and towards a value-based system that rewards healthcare providers for better outcomes.  The proposed rule can be viewed in its entirety at: https://www.govinfo.gov/content/pkg/FR-2019-10-17/pdf/2019-22027.pdf.

The proposed rule makes nearly a dozen major changes to the safe harbors under the AKS and the rules related to CMPs.  Among these are revisions to the recently created safe harbor for local transportation.  The proposed change to the safe harbor for free or discounted local transportation is discussed in greater detail below.

The OIG is soliciting comments on a wide range of topics raised in the proposed rule. The AAA is not taking any formal position with respect to the proposed changes or the requests for additional information set forth in this proposed rule.  However, we encourage any member that wishes to comment to do so. 

To be considered, comments must be submitted no later than 5 p.m. on December 31, 2019.  Comments may be submitted electronically by going to: http://www.regulations.gov. Commenters would then need to click the link for “Submit a comment” and follow the instructions from there.  Comments may also be submitted by courier or by regular, express, or overnight mail to the following address: Office of Inspector General, Department of Health and Human Services, Attention: OIG-0936-AA10-P, Room 5521, Cohen Building, 330 Independence Avenue SW, Washington, DC 20201.

Revisions to Safe Harbor for Free or Local Transportation

In 2014, the OIG created a new safe harbor for free or discounted local transportation provided to Federal health care program beneficiaries. This safe harbor applied to non-ambulance transportation (e.g., wheelchair van, bus and shuttle services, taxis, etc.) provided under the following conditions:

  1. The free or discounted transportation was provided by an “Eligible Entity.” For these purposes, an “Eligible Entity” is any individual or entity, other than individuals or entities (or family members or others acting on their behalf) that primarily supply health care items;
  2. The free or discounted transportation was provided pursuant to an existing policy of the Eligible Entity, and which is applied in a uniform and consistent manner;
  3. The transportation services are not air, luxury, or ambulance transportation;
  4. The Eligible Entity does not publicly market or advertise the free or discounted local transportation services, and no cross-marketing of other health care services occurs during the course of transportation, or at any time by the drivers providing such transportation. In addition, the drivers and anyone arranging the transportation cannot be paid on a per-beneficiary-transported basis;
  5. The transportation services are limited only to “established patients” of the Eligible Entity; and
  6. The transportation is limited to 25 miles in urban areas, or 50 miles in rural areas.

 The safe harbor also permitted the use of “shuttle services” (i.e., a vehicle that runs on a set route, on a set schedule) if the following conditions are met:

  1. The shuttle service is not air, luxury, or ambulance-level transportation;
  2. The shuttle service is not marketed or advertised, and no cross-marketing occurs during the transportation, or at any time by the driver providing such transportation. In addition, the driver and anyone else arranging the transportation cannot be paid on a per-beneficiary-transported basis;
  3. The shuttle services has no stop that is more than 25 miles from any stop on the route where health care items or services are provided, except that this mileage restriction is expanded to 50 miles in rural areas.

In either situation, the safe harbor also requires the Eligible Entity to bear all costs of furnishing such transportation, i.e., they cannot shift that cost onto any Federal health care program, any other payer, or the individual.

In the current proposed rule, the OIG indicated that it received numerous comments from stakeholders that suggested that the 50-mile limit for residents of rural areas was insufficient, as many rural residents might need to routinely travel more than 50 miles to obtain certain medical services.  As a result, the OIG is proposing to expand this limit to 75 miles.

The OIG is also soliciting comments on whether the proposed 75-mile is sufficient, or whether an even larger expansion is warranted.  To the extent you intend to submit comments arguing for a greater mileage limit, the OIG is asking that you submit data or other evidence to support a more appropriate mileage limitation for the safe harbor.  The OIG is also specifically requesting information on how an Eligible Entity would provide transportation over distances in excess of 50 miles (e.g., shuttle services, bus or taxi fare, ride-sharing programs, mileage reimbursement programs, etc.).

Expansion of Safe Harbor for Transportation of Patients Being Discharged After an Inpatient Stay

The OIG is also proposing to eliminate any mileage restriction on transportation of patients back to their residence after being discharged from a facility where that patient had been admitted as an inpatient, regardless of whether the patient resides in an urban or rural area.  The OIG is also proposing to eliminate the mileage restrictions on discharges to another residence of the patient’s choice (such as a friend or relative who will care for the patient post-discharge).

The OIG further indicated that it is considering protecting transportation to other locations of the patient’s choice, including another health care facility.  The OIG is soliciting comments on the potential fraud and abuse risks associated with permitting free or discounted transportation to other health care facilities, and whether transportation should be protected (and, if so, under what circumstances) when the patient has not previously been admitted to an inpatient facility (e.g., where the patient had been seen as an outpatient in a hospital emergency department).  Finally, the OIG is soliciting comments on whether the transportation of patients being discharged beyond the applicable safe harbor mileage limitations should be limited to patients with demonstrated financial or transportation needs, and, if so, what standards should apply to such demonstration of need.

Possible Expansion to Include Transportation to Non-Medical Services

In the 2014 final rule creating the new safe harbor for local transportation, the OIG declined to extend the safe harbor protections to transportation for purposes other than obtaining medically necessary services or items (although they permitted a qualifying shuttle service to make stops at locations that do not relate to a particular patient’s medical needs).  The OIG has since received numerous comments suggesting that the safe harbor should protect transportation for non-medical purposes that may nevertheless improve or maintain health, e.g., transportation to food banks, social services, exercise facilities, support groups, etc.  The OIG indicated that it considering a further expansion of the safe harbor to include such non-medical needs, and is therefore seeking comments on how the safe harbor could be expanded to such needs without creating an unacceptable risk of fraud and abuse. 

 Clarification of Policy Regarding the Use of Ride-Sharing Services

 Finally, the OIG is clarifying its interpretation of the applicability of the existing safe harbor to the use of ride-sharing services.  In the preamble to the 2014 final rule, the OIG discussed the possibility that patient transportation might be provided via taxi.  In the proposed rule, the OIG indicates that, while it did not explicitly reference ride-sharing services, it views these services are being similar to taxi services for the purposes of the safe harbor.  Specifically, the OIG noted that nothing in the language of the safe harbor expressly precludes their use (or the use of self-driving cars or other similar technology that may become available at some point in the future).  The OIG is inviting anyone that disagrees with this approach to explain the possible basis for exclusion of ride-sharing services.

The OIG did reiterate that the prohibition of the marketing of such free or discounted transportation would still apply.  The OIG indicated that it would be permissible for ride-sharing services to advertise that they provide transportation to medical appointments, and to recommend that patients contact their medical providers to determine if they qualified for free or discounted transportation.  By contrast, the OIG indicated that it would not be appropriate for the ride-sharing service to advertise that it provided free or discounted transportation to particular health care providers.

Other Changes in the Proposed Rule

 In addition to the revisions to the existing safe harbor for free or discounted transportation, the OIG is proposing:

  1. The creation of three new safe harbors for participants in value-based arrangements that promote better coordinated and managed patient care. These include: (i) a safe harbor for Care Coordination Arrangements to Improve Quality, Health Outcomes, and Efficiency, (ii) Value-Based Arrangements with Substantial Downside Financial Risk, and (iii) Value-Based Arrangements with Full Financial Risk.
  2. The creation of a new safe harbor for certain tools and support furnished to patients to improve quality, health outcomes, and efficiency.
  3. The creation of a new safe harbor for remuneration provided in connection with CMS-sponsored models. The purpose of this new safe harbor is to eliminate the need for the OIG and CMS to issue model-specific waivers.
  4. The creation of a new safe harbor for donations of cybersecurity technology and services.
  5. Proposed modifications to the existing safe harbor for electronic health records items and services.
  6. Proposed modifications to the existing safe harbor for personal services and management contractors, in order to add flexibility with respect to outcomes-based payments and part-time arrangements.
  7. Proposed modifications to the existing safe harbor for warranties, to better address bundled warranties covering multiple health care items or services.
  8. The codification of the existing statutory exception for ACO Beneficiary Incentive Programs under the Medicare Shared Savings Program.
  9. A proposed amendment to the definition of “remuneration” under the CMP rules for certain telehealth technologies furnished to in-home dialysis patients.

CMS Announces Extension of Prior Authorization Program

On September 16, 2019, CMS published a notice in the Federal Register that it would be extending the prior authorization demonstration project for another year. The extension is limited to those states where prior authorization was in effect for calendar year 2019. The affected states are Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia and West Virginia, as well as the District of Columbia. The extension will run through December 1, 2020. 

In its notice, CMS indicated that the prior authorization demonstration project is being extended “while we continue to work towards nationwide expansion.”  This strongly suggests that CMS believes the program has met the statutory requirements for nationwide expansion under the Medicare Access and CHIP Reauthorization Act of 2015.  However, CMS indicated that it would use the additional year to continue to test whether prior authorization helps reduce expenditures, while maintaining or improving the quality of care offered to Medicare beneficiaries.

CMS has also updated its CMS Ambulance Prior Authorization webpage to reflect the expansion of prior authorization in the existing states through December 1, 2020.

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