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CMMI Releases Preview of ET3 RFA

Written by Brian Werfel on . Posted in ET3, Member Advisories, Member-Only, News, Reimbursement.

On May 22, 2019, the Center for Medicare and Medicaid Innovation (CMMI) released a preview of the Request for Applications (RFAs). This documentation will be used by ambulance providers and suppliers to apply for inclusion as “Participants” in the Emergency Triage, Treat, and Transport (ET3) pilot program.

Webinar: Learn More About the RFA

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Speakers: Brian Werfel, Kathy Lester, Rebecca Williamson, Asbel Montes
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Relevant Background

On February 14, 2019, CMMI announced the creation of a new 5-year pilot program designed to give participating EMS agencies greater flexibility to address the needs of Medicare beneficiaries following a 911 call. The ET3 model would create a new payment model under which participating EMS agencies will be eligible for Medicare reimbursement for: (1) transportation to alternative treatment destinations and (2) treatment at the scene. At the time, CMMI indicated that it anticipated starting the ET3 model in early 2020. To that end, CMMI anticipated soliciting Requests for Participation in the Summer of 2019.

Participation in this pilot program is voluntary. Regardless of whether an ambulance provider or supplier participates in the pilot program, payment for ambulance transportation currently covered under the Medicare Ambulance Fee Schedule will not be affected.

The RFA provides a good deal of additional information regarding the proposed operation of the ET3 Model. These additional details are summarized below.

Eligibility Criteria/Application Process

To be eligible to participate, you must be a Medicare-enrolled ambulance provider or supplier.  In addition, CMMI is limiting eligibility to ambulance providers and suppliers that are located in a state or state in which at least 15,000 Medicare FFS emergency ambulances took place in calendar year 2017.  Note: based on this restriction, ambulance providers and suppliers in the State of Alaska would not be eligible for participation in the ET3 Model.

Medical Necessity Requirement

CMMI previously indicated that the existing medical necessity requirements would apply to ambulance transportation to alternative treatment destinations. In the RFA, CMMI reiterated this requirement. As a result, EMS agencies will only be eligible for reimbursement for transportation to alternative treatment destinations to the extent the beneficiary’s condition is such that safe transport by other means is contraindicated.

CMMI indicated that beneficiaries that do not meet the medical necessity requirements for ambulance transportation may still meet the medical necessity requirements for a Medicare-covered item or service furnished by a qualified health care practitioner, and, therefore, may allow an EMS agency to receive payment for treatment at the scene under the ET3 Model.

Payments under the ET3 Model

The ET3 Model provides for a number of new payment streams.  The two payment streams being made available to participating EMS agencies are: (1) payment for transportation of Medicare beneficiaries to alternative treatment destinations and (2) payment for treatment of the Medicare beneficiary at the scene, where such care was rendered by a qualified health care practitioner either at the scene or via telehealth.

Payment for Transportation to Alternative Treatment Destinations

When the ET3 Model was first announced, CMS indicated that the reimbursement to EMS agencies for providing transportation to alternative treatment destinations would be based on the corresponding BLS “base rate” in the area. However, in the RFA, CMMI indicates that the payment for transportation to an alternative treatment destination will now be made at either the applicable BLS emergency or ALS emergency base rate.  In order to qualify for payment at the applicable ALS emergency rate, the EMS agency must meet Medicare’s definition of “Advanced Life Support” (i.e., the provision of valid ALS intervention and/or the provision of a qualifying ALS assessment).  The payment for this base rate would include the current adjustments for transports provided in urban, rural, or super-rural areas.

The EMS agency would also be eligible for payment for all loaded mileage, at the applicable Medicare mileage rate. This payment would include all current adjustments, including the “bonus” paid for the first 17 rural miles.

Note: CMMI indicated that it would be creating an exception to general Medicare requirement that patients be transported to the nearest appropriate facility. Based on the language in the RFA, it appears clear that CMMI would cover all of the mileage to an alternative treatment destination, even where transportation to the nearest hospital ED would have been shorter.

Based on the language in the RFA, it appears that claims for transportation to alternative treatment destinations will be submitted using the normal ambulance HCPCS codes (i.e., A0427 for an ALS emergency and A0429 for a BLS emergency).

Payment for Treatment at the Scene

When the EMS agency facilitates in-person treatment by a qualified health care practitioner (QHP), the EMS agency will be paid an amount equivalent to the BLS emergency or ALS emergency base rate.  In order to qualify for payment at the applicable ALS emergency rate, the EMS agency must provide medically necessary supplies and services and either a qualifying ALS assessment or the provision of at least one ALS intervention. When the EMS agency facilitates treatment in pace via telehealth, the EMS agency will be paid a modified “telehealth originating site facility fee” equivalent to the applicable BLS emergency or ALS emergency base rate.

Claims submitted for treatment at the scene, whether by the QHP in person or via telehealth, will be submitted using a model-specific code (yet to be announced).

Performance-Based Payment Adjustment for EMS Agencies

EMS agencies that provide transportation to alternative treatment destinations and/or treatment at the scene may be eligible for performance-based payment adjustments of up to 5%, based upon meeting certain performance and reporting metrics. These adjustments will become available no earlier than Year 3 of the ET3 Model, and are not guaranteed.  Performance-based payment adjustments would be based on performance during the previous year (e.g., if the EMS agency meets the performance criteria in Year 3, it would see an increase in Year 4). These performance-based payment adjustments apply only to payments under the ET3 Model, i.e., they do not apply to Medicare payments made under the current Medicare Ambulance Fee Schedule.

Payment for Non-Participant Partners

When an EMS agency transports a patient to an alternative treatment destination, that facility will bill Medicare for the services it renders to the beneficiary using its normal claims submission procedures.

Payment for Qualified Health Care Practitioners

A QHP that partners with an EMS agency to provide treatment at the scene will bill Medicare using the applicable HCPCS code for the services it furnished under existing Medicare FFS rules.  When that service is furnished via telehealth, the QHP must submit a claim to Medicare for telehealth services furnished from the distant site.  QHPs that provide services to Medicare beneficiaries during non-business hours (defined as being from 8:00 p.m. to 8:00 a.m. local time) will be eligible for a 15% increase in the payment rates normally applicable to their in-person or telehealth services.

Notice of Funding Opportunity for 911 Dispatch Centers

Separate from the RFA process, CMMI expects to allocate funding to governmental entities and their designees that operate 911 dispatch centers.  The purpose of this funding is to support the successful implementation of medical triage lines integrated into the local 911 system.  These Notice of Funding Opportunity (NOFOs) will be released following the first round of Participant selection (i.e., likely in the Fall/Winter of 2019).

Application Timelines

The RFA is the first of up to three potential RFAs that will be used to select EMS agencies to participate in the ET3 Model as “Participants.” CMMI is indicating that it hopes to select enough EMS agencies to participate to capture up to 30% of the existing volume of Medicare FFS emergency ground ambulance transports. Additional RFAs will be considered based on available funding and evidence that the ET3 Model is working as intended.

CMMI is not currently accepting applications. Round 1 applications will be accepted via an application portal that will be opened at a later date. Information on the applicable process, including the date the application portal will be opened will be posted on the ET3 Model website: https://innovation.cms.gov/initiatives/et3

Application Submission Process

If you elect to apply for participation in the ET3 Model, you will be required to identify a “region” in which you propose to implement the model. CMMI indicates that this region should be a county or equivalent entity, or multiple counties or equivalent entities.

In selecting Participants, CMMI indicated that it will give preference to applicants who propose a region that includes at least one county (or county-equivalent) where at least 7,500 Medicare FFS emergency ground ambulance transports occurred in 2017. CMMI provided a list of the number of Medicare FFS emergency ground ambulance transports that occurred in each county (organized by state)  That list can be obtained by clicking here.

Applicants will be required to participate in the transportation to alternative treatment destination (ATD) portion of the program. Applicants will have the option – – but not be required – – to propose the creation of a program to provide treatment at the scene in conjunction with QHPs.  Note: CMMI indicated that applicants that elect to implement the treatment at the scene intervention will earn additional points towards their overall application score.

In order to implement the ATD portion, you will be required to partner with alternative destination sites (e.g., Urgent Care Centers), which must be enrolled in Medicare or employ or contract with Medicare-enrolled practitioners, and which must be able to accept and treat Medicare FFS beneficiaries.  If you elect to implement the treatment at the scene portion, you must also partner with QHPs to provide treatment at the scene. These contractual partners are referred to in the RFA as “Non-Participant Partners” (NPPs). To qualify, you must contract with NPPs that can ensure the availability of services for ET3 Model beneficiaries on a 24 hours per day, 7 days a week basis. CMMI will have the right to accept or reject a proposed Non-Participant Partner.

Applicants will also be required to describe their strategy for engaging other payers in their proposed service area, or explain how they can successfully implement the model for Medicare FFS beneficiaries only.

Accountability and Performance Metrics/Ongoing Educational Commitments

Participants in the ET3 will be required to report certain metrics to CMMI and its contractors. You will also be required to participate in what CMMI is calling a “Learning System.”  This is a structured approach to sharing, integrating, and actively applying quality improvement concepts, tactics, and lessons designed to improve the likelihood of success of the model. At a minimum, this will include consistent participation in monthly ET3 Model learning activities, and participation in at least one in-person event, with the location to be determined by CMMI at a later date.

The above is a brief summary of the new information available regarding the ET3 Model. It is not intended to be a complete discussion of all of the requirements for participation. AAA Members are strongly encouraged to read the RFA for themselves to determine whether they want to participate in the ET3 Model.

New SNF PPS Edits Highlight the Importance of Facility Agreements

Written by Brian Werfel on . Posted in Medicare, Member-Only, Reimbursement, Talking Medicare.

On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that are intended to better identify ground ambulance transports that are furnished in connection with an outpatient hospital service that is properly bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime.

These edits work by comparing the ambulance claim to the associated outpatient hospital claim.  Hospital claims were already subject to CWF edits designed to identify outpatient hospital services that should be bundled to the SNF.  These hospital edits operate by referencing a list of Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes that correspond to outpatient hospital services that are expressly excluded from SNF Consolidated Billing.  Hospital claims for outpatient services that are submitted with one of these excluded codes bypass the existing CWF edits, and are then sent to the appropriate Medicare Administrative Contractor for further editing and payment.  Hospital claims submitted without one of these codes are denied for SNF Consolidated Billing.

The new ambulance edits will extend these process one step further.  The ambulance claim will be associated with the outpatient hospital claim on the same date.  To the extent that hospital claim is bundled under SNF Consolidated Billing, the associated ambulance claim will also be bundled.  To the extent the hospital claim is unbundled, the associated ambulance claim will be unbundled.

In order for these new edits to work properly, there must be an outpatient hospital in Medicare’s claim history. If the ambulance claim beats the hospital claim into the system, the ambulance claim will be rejected. If and when an outpatient hospital claim with the same date of service enters Medicare’s system, the initial rejection of the ambulance claim will be overturned, and the ambulance claim will be reprocessed using the same edits.

It is important to note that the new edits were designed to reject the ambulance claim as a bundled service unless the hospital claim indicates that it should not be bundled.  In other words, these edits are designed to be “over inclusive.”  This over-inclusiveness creates the potential for ambulance denials in situations that, on their face, would not appear to be bundled.

A few examples will help illustrate this point. Imagine a situation where the patient elects, for whatever reason, to pay out-of-pocket for their hospital care (in a situation where that care would not be bundled to the SNF), and, as a result, the hospital does not submit a bill to Medicare for its services.  Based on how the new edits are designed, your ambulance claim for the transport to that excluded service will be rejected based on the lack of a hospital claim. Or maybe the patient has both Medicare and the V.A., and has elected to have the V.A. be the primary payer for their required hospital care.  Again, there would likely be no outpatient hospital claim submitted to Medicare on that date of service, resulting in the rejection of your ambulance claim.

I can see your point, but those examples are pretty far-fetched.  How big an issue is this really?

I agree those examples are pretty far-fetched.  However, there are other situations that create the same problem.  For example, what about an emergent response to transport an SNF patient to the hospital for necessary emergency services?  Imagine if you are called to respond late at night (e.g., 11:30 p.m.) tonight.  Now imagine that, by the time you get to the patient, load them into the vehicle, and transport them to the ED, it has crossed over midnight into the next day.

What date of service is going to be on the hospital’s claim?  Almost certainly, the hospital will use tomorrow’s date.  As a result, when your claim hits Medicare’s system, there will not be an associated hospital claim, which will result in your claim being rejected as the responsibility of the SNF.  In this situation, Medicare’s edit has worked as intended, but the result is the denial of a claim that should be separately payable by Medicare Part B.

Okay, I can see how this might be annoying,
but I can appeal the claim and likely win on appeal, right? 

Yes and no.  The problem is that you are not likely to win on either of the first two levels of appeal, as they are likely going to rely upon the information in the CWF.  I can see you possibly winning your appeal at the ALJ level…5 to 7 years from now.

In other words, the appeals process is unlikely to provide an acceptable resolution.  Instead, I think the majority of ambulance providers are going to look to the SNFs to make good in these situations.  Of course, the SNFs are likely going to disclaim liability, arguing (correctly) that ambulance transportation to an ED is an excluded service.

This is where the agreement with the SNF comes into play.  One key purpose of contracts is to allocate known risks between the parties.  In this instance, the “risk” that needs to be addressed is the possibility that Medicare might incorrectly reject your claim thinking it is bundled to the SNF.  I would argue that this risk should be absorbed by the SNF.  The transport to the ED should have suspended the patient’s SNF stay, which would have allowed you to receive a separate payment from Medicare.  However, the fact that your claim was rejected is proof positive that the CWF does not reflect the suspension of the patient’s SNF stay.  Indirectly, it also serves as proof that the SNF received a per diem payment for the patient on that date.  To me, the fact that they accepted the per diem payment means they accepted the risk of a bundled ambulance service on that date.  I would also argue that it was their failure to properly suspend the patient’s SNF stay that set in motion your denial.  Either way, I would be looking to the SNF for payment.

Based on my experience, the typical agreement with an SNF does not address this situation.  Frequently, these agreements do not even address the specifics of SNF Consolidated Billing.  Instead, I tend to see general language indicating that the ambulance provider will bill the SNF when payment responsibility lies with the SNF under an applicable federal or state health care program.  I doubt that language is going to convince an SNF to take financial responsibility for the situation discussed above.

The good news is that your existing agreements can easily be revised to address this situation.  The language I would recommend is something along the lines of:

“The parties acknowledge and agree that a denial from Medicare for SNF consolidated billing shall constitute conclusive evidence that a transportation service is the financial responsibility of the facility.” 

In sum, the new SNF Consolidated Billing edits are going to increase the frequency with which we are forced to look to the SNFs for payment.  In most instances, it will be a situation where the SNF is legally responsible under SNF Consolidated Billing.  However, there will also be situations where the over-inclusive nature of the edits results in the claim being incorrectly denied as the SNF’s responsibility.  The question becomes how you want to handle these incorrect denials.  Do you want to appeal and hope CMS reverses its decision?  Or do you want to hold the SNF responsible?  If you want to hold the SNF responsible, you will likely need to revise your agreements with the SNFs.

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

Summary of March 28, 2019 Ambulance ODF

Written by Brian Werfel on . Posted in Finance, Medicare, Member-Only, News, Reimbursement.

The Centers for Medicare and Medicaid Services (CMS) held its latest Open Door Forum on Wednesday, March 28, 2019.  As with past Open Door Forums, CMS started the call with the following announcements:

  1. Ambulance Cost Data Collection – CMS reminded the industry that the Bipartisan Budget Act of 2018, enacted on February 9, 2018, requires CMS to create a new cost data collection system by December 31, 2019.
  2. Emergency Triage, Treat, and Transport Model – A representative from the Innovation Center within CMS provided an overview of the “Emergency Triage, Treat, and Transport Model” or “ET3.” This is a 5-year pilot program intended to provide ambulance providers with greater flexibility to handle low-acuity 911 calls, by providing Medicare payment for: (a) ambulance transportation to alternative treatment destinations and (b) treatment at the scene. The CMS representative indicated that CMS is in possession of data that suggests that 16% of emergency ambulance transports to a hospital emergency department could have been resolved by transporting the patient to an alternative treatment site, e.g., an urgent care center. CMS estimates that had all of these patients elected to receive care in the lower-acuity setting, it would have saved the Medicare Program approximately $560 million each year. With respect to the operation of the model itself, CMS essentially repeated the information that had been previously provided on its webinars. You can view the AAA Member Advisory on the ET3 Model by clicking here.
  3. Ambulance Inflation Factor – CMS reiterated that the 2019 Ambulance Inflation Factor is 2.3%.

Following the announcements, CMS moved into a Question & Answer period. The majority of the questions related to the ET3 pilot program. As is typical, many questions were not answered on the call; instead, CMS asked the individual to submit their question in writing. However, the following questions were answered on the call:

  1. Payment Rates under ET3 – CMS was asked whether the BLS base rate payment would be the BLS emergency base rate. It was not clear that the CMS representative fully understood the question, although she indicated that it would.
  2. Eligibility for Government Agencies – CMS was asked whether governmental agencies that operate 911 centers would submit applications to participate as part of the RFA process in the Summer of 2019. CMS responded that governmental agencies that operate 911 centers would not submit RFAs, but would rather wait for the Notice of Funding Opportunity (NOFO), which will be issued after the ambulance providers and suppliers are selected for participation (expected to be the late Fall/Winter of 2019). CMS further confirmed that if the governmental agency also operated its own ambulance service that it would be eligible to apply for both aspects of the ET3 Model.
  3. Limit on Ambulance Providers – CMS was asked whether it would cap the number of ambulance providers and suppliers selected to participate in the program. CMS responded that, at the present time, it has no intent to cap the number of participating ambulance providers and suppliers at any specific number.
  4. Return Transports from Alternative Treatment Destinations – CMS was asked whether the model would provide for ambulance payment for the return transport after a patient was transported to an alternative treatment site. CMS indicated that the model does not provide for payment for the return transport.
  5. Definition of “Telehealth” – CMS confirmed that the model will use the same definition of “telehealth” used in other areas of the Medicare Program. CMS further confirmed that telehealth encounters require both audio and video connections.
  6. Approval of Alternative Treatment Sites – CMS confirmed that state and local regulatory agencies would have final approval over acceptable alternative treatment sites.
  7. Qualified Health Care Practitioner – CMS confirmed that a “qualified health care practitioner” would be an individually enrolled Medicare practitioner, which includes physicians and nurse practitioners. In some instances, it can also include physician’s assistants. CMS confirmed that the definition would not include registered nurses or advance scope paramedics.
  8. NOFO Funding – CMS indicated that, at the present time, it is not prepared to release additional details on the nature or size of the funding opportunities available to governmental agencies and their designees that operate or have authority over 911 centers.
  9. Medicare Advantage and Other Payers – CMS confirmed that the ET3 Model applies only to Medicare beneficiaries enrolled in FFS Medicare. It does not apply to Medicare Advantage enrollees, Medicaid recipients, etc.

Questions? Email Brian at bwerfel@aol.com

HHS OIG Issues Advisory Opinion on Community Paramedicine

Written by Brian Werfel on . Posted in Member Advisories, Member-Only, News, Operations, Patient Care, Talking Medicare.

HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions

On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions.

The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions.

Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include the requirement that the patient have CHF and either: (1) be currently admitted as an inpatient at Requestor’s hospital or (2) be a patient of Requestor’s outpatient cardiology department, and who had been admitted as an inpatient at Requestor’s hospital within the previously 30 days. The clinical nurses would identify those patients at higher risk of hospital admission based on a widely used risk assessment tool. The clinical nurses would also determine whether the patient had arranged to receive follow-up care with Requestor’s outpatient CHF center. Patients that do not intend to seek follow-up care with the CHF center, or who have indicated that they intend to seek follow-up care with another health care provider, would not be informed of the current program. Eligible patients would be informed of the current program, and offered the opportunity to participate. The eligibility criteria for the expanded program for COPD patients would operate in a similar manner.

Eligible patients that elect to participate in the current program or the expanded program would receive in-home follow up care for a thirty (30) day period following enrollment. This follow up care would consist of two visits every week from a community paramedic employed by the Requestor. As part of this in-home care, the community paramedic would provide some or all of the following services:

  • A review of the patient’s medications;
  • An assessment of the patient’s need for follow-up appointments;
  • The monitoring of the patient’s compliance with their discharge plan of care and/or disease management;
  • A home safety inspection; and/or
  • A physical assessment, which could include checking the patient’s pulse and blood pressure, listening to the patient’s lungs and heart, checking the patient’s cardiac function using an electrocardiogram, checking wounds, drawing blood and running blood tests, and/or administering medications.

The community paramedic would use a clinical protocol to deliver interventions and to assess whether a referral for follow-up care is necessary. To the extent the patient requires care that falls outside the community paramedic’s scope of practice, the community paramedic would direct the patient to follow up with his or her physician. For urgent, but non-life threatening conditions, the community paramedic would initiate contact with the patient’s physician.

The Requestor certified that the community paramedics would be employed by the Requestor on either full-time or part-time basis, and that all costs associated with the community paramedic would be borne by the Requestor or its affiliates.  The Requestor further certified that no one involved in the operation of the program would be compensated based on the number of patient’s that enroll in the programs. While one of the states in which the Requestor operates does reimburse for community paramedicine services, Requestor certified that it does not bill Medicaid for services provided under the program.

The question posed to the OIG was whether any aspect of the program violated either the federal anti-kickback statute or the prohibition against the offering of unlawful inducements to beneficiaries.

In analyzing the program, the OIG first determined that the services being offered under the program offer significant benefit to enrolled patients. The OIG specifically cited the fact that one state’s Medicaid program reimbursed for similar services as evidence of this value proposition. For this reason, the OIG concluded that the services constitute “remuneration” to patients. The OIG further concluded that this remuneration could potentially influence a patient’s decision on whether to select Requestor or its affiliates for the provision of federally reimbursable items and services.  Therefore, the OIG concluded that the program implicated both the anti-kickback statute and the beneficiary inducement prohibition.

The OIG then analyzed whether the program would qualify for an exception under the so-called “Promoting Access to Care Exception.” This exception applies to remuneration that improves a beneficiary’s ability to access items and services covered by federal health care programs and which otherwise pose a low risk of harm. The OIG determined that while some aspects of the program would likely fall within this exception, other aspects would not. Specifically, the OIG cited the home safety assessment as not materially improving a beneficiary’s access to care.

Having concluded that there was no specific exception that would permit the arrangement, the OIG then analyzed the arrangement under its discretionary authority, ultimately concluding that the program posed little risk of fraud or abuse. In reaching this conclusion, the OIG cited several factors:

  1. The OIG felt that the potential benefits of the program outweighed the potential risks of an improper inducement to beneficiaries. The OIG cited the fact that beneficiaries must have already selected Requestor or its associated clinic as their provider of services before learning about the program. As the OIG indicated “the risk that the remuneration will induce patients to choose Requestor or the Clinic for CHF- or COPD-related services is negligible because patients already have made this selection.” The OIG also noted that the community paramedic will inform beneficiaries of their right to choose a different provider prior to referring the beneficiary to the Requestor or its clinic for services outside the scope of the program.
  2. The OIG noted that, to the extent the program works as intended, it would be unlikely to lead to increased costs to federal health care programs. As noted above, Requestor had certified that it would not bill federal health care programs for the services of the community paramedic.
  3. The program was designed in a way as to minimize the potential for interference with clinical decision-making.
  4. The Requestor certified that it would not advertise or market the program to the public, thereby minimizing the chances of beneficiaries learning about the program prior to selecting Requestor for their CHF- or COPD-related care.
  5. The OIG noted that the program appeared to be reasonably tailored to accomplish the goal of reducing future hospital admissions. For example, the OIG cited the fact that the Requestor limited inclusion in the program to patients deemed to be at a higher-than-normal risk of hospital admission or readmission, and that it made these determinations using a widely used risk assessment tool.  The OIG noted that these patients would likely benefit from the continuity of care offered under the program. In addition, the OIG noted that the community paramedics would be in a position to keep the patients’ physicians appraised of their health by documenting all of their activities.

Potential Impact on Mobile Integrated Health and/or Community Paramedicine Programs

OIG advisory opinions are issued directly to the requestor of the opinion. The OIG makes a point of noting that these opinions cannot be relied upon by any other entity or individual. Legal technicalities aside, the OIG’s opinion is extremely helpful to the industry, as it lays out the factors the OIG would consider in analyzing similar arrangements. Thus, the opinion is extremely valuable to ambulance providers and suppliers that current operate, or are considering the operation of, similar mobile integrated health and/or community paramedicine programs. 

Update on New SNF Edits

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

CMS Set to Implement New Common Working File Edits to Identify Ambulance Services Provided in Connection with Outpatient Hospital Services that should be bundled to the SNF under Consolidated Billing.

In a Member Advisory issued last week, the AAA provided an update on a series of new Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019. 

In our discussion of the implementation specifics, we attempted to answer the question of what would happen when an ambulance claim is submitted prior to the receipt of the associated hospital outpatient claim, and where the associated hospital claim eventually hit Medicare’s system. Specifically, we indicated as follows:

“The Transmittal contains further instructions that the CWF be updated to identify previously rejected ambulance claims upon receipt of an associated hospital claim for the same date of service that contains an Exempted Code.  Once identified, the Shared System Maintainer (SSM) is supposed to adjust the previously rejected or denied ambulance claim.  At this point, the nature of that “adjustment” is unclear, i.e., it is unknown whether the SSM will automatically reprocess the ambulance claim for payment.  The AAA is seeking additional clarification from CMS on this important point.”

On March 15, 2019, CMS responded to our request for clarification. Specifically, CMS indicated that it has instructed the SSM and/or its Medicare Administrative Contractor (MAC) to automatically reprocess claims that were rejected for lack of an associated hospital outpatient claim.

Upon reprocessing, the claims will pass the edits to the extent the associated hospital claim contains a HCPCS or CPT code that indicates that the hospital outpatient service was excluded from SNF Consolidated Billing. Such claims would then be forwarded to the MAC for further editing, and either paid or denied. By contrast, when the associated hospital outpatient claim contains HCPCS or CPT codes that suggest the hospital services should be bundled to the SNF, the claim will be reprocessed and denied by the MAC with a remittance advice code indicating that the SNF is financially responsible.

AAA Webinar on New SNF Consolidated Billing Edits

March 27, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Esq.
$99 for Members | $198 for Non-Members

Join AAA Medicare Consultant Brian Werfel, Esq., to go over the new SNF Consolidated Billing edits that go into effect April 1, 2019. These edits are being implemented by CMS in response to 2017 investigation by the HHS Office of the Inspector General that determined that CMS lacked the appropriate claims processing edits to properly identify ambulance transports provided in connection with hospital outpatient services that are not expressly excluded from SNF PPS. The implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on what to do with these claims moving forward. Sign up today to make sure your service is ready!

Register for the Webinar

CMS SNF Edits Go Into Effect – April 1, 2019

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

CMS Set to Implement New Common Working File Edits to Identify Ambulance Services Provided in Connection with Outpatient Hospital Services that should be bundled to the SNF under Consolidated Billing

On November 2, 2018, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 2176 (Change Request 10955), which would establish a new series of Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019. 

Why these edits are necessary?

In 2017, the HHS Office of the Inspector General conducted an investigation of ground ambulance claims that were furnished to Medicare beneficiaries during the first 100 days of a skilled nursing home (SNF) stay. Under the SNF Consolidated Billing regime, SNFs are paid a per diem, case-mix-adjusted amount that is intended to cover all costs incurred on behalf of their residents.  Federal regulations further provide that, with limited exceptions, the SNF’s per diem payment includes medically necessary ambulance transportation provided during the beneficiary’s Part A stay. The OIG’s report was issued in February 2019.

The OIG conducted a review of all SNF beneficiary days from July 1, 2014 through June 30, 2016 to determine whether the beneficiary day contained a ground ambulance claim line. The OIG excluded beneficiary days where the only ambulance claim line related to: (1) certain emergency or intensive outpatient hospital services or (2) dialysis services, as such ambulance transportation would be excluded from SNF Consolidated Billing. The OIG determined that there were 58,006 qualifying beneficiary days during this period, corresponding to $25.3 million in Medicare payments to ambulance suppliers.

The OIG then selected a random sample of 100 beneficiary days for review. The OIG determined that 78 of these 100 beneficiary days contained an overpayment for the associated ambulance claims, as the services the beneficiary received did not suspend or end their SNF resident status, nor was the transport for dialysis. The OIG determined that ambulance providers were overpaid a total of $41,456 for these ambulance transports. The OIG further determined that beneficiaries (or their secondary insurances) incurred an additional $10,723 in incorrect coinsurance and deductibles.

Based on the results of its review, the OIG estimates that Medicare made a total of $19.9 million in Part B overpayments to ambulance suppliers for transports that should have been bundled to the SNFs under SNF Consolidated Billing regime. The OIG estimated that beneficiaries (and their secondary insurances) incurred an additional $5.2 million in coinsurance and deductibles related to these incorrect payments.

The OIG concluded that the existing edits were inadequate to identify ambulance claims for services associated with hospital outpatient services that did not suspend or end the beneficiary’s SNF resident status, and which were not related to dialysis. The OIG recommended that CMS implement additional edits to identify such ambulance claims.

Overview of new claims processing edits

In response to the OIG’s report, CMS issued Transmittal 2176, which implements a new series of claims processing edits to identify ambulance claims associated with outpatient hospital services that should be bundled to the SNF. As noted above, these edits will go into effect on April 1, 2019.

These new claims processing edits are somewhat complicated. In order to properly understand how these claims edits will work, it is helpful to understand that CMS already has claims processing edits in place to identify hospital outpatient claims that should be bundled to the SNF. These CWF edits operate by referencing a list of Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes that correspond to outpatient hospital services that are expressly excluded from SNF Consolidated Billing. Hospital claims for outpatient services that are submitted with one of these excluded codes bypass the existing CWF edits, and are then sent to the appropriate Medicare Administrative Contractor for further editing and payment. Hospital claims submitted without one of these codes are denied for SNF Consolidated Billing. For convenience, the list of HCPCS and CPT codes excluded from SNF Consolidated Billing is hereinafter referred to as the “Exempted Codes.”

The new edits for ambulance claims will compare Part B ambulance claims to the associated outpatient hospital claim to see whether or not that hospital claim is excluded from SNF Consolidated Billing.

Specifics related to new claims processing edits

Under these new edits, the CWF will reject an incoming ambulance claim whenever the beneficiary is determined to be in an SNF Part A stay if either:

  1. There is no associated outpatient hospital claims for the same date of service on file; or
  2. There is an associated outpatient hospital claim for the same date of service on file (paid or denied), but where that outpatient hospital claim does not contain at least one Exempted Code.

When an incoming ambulance claim is rejected by the CWF, it will be sent to the applicable Medicare Administrative Contractor and rejected (Part A Ambulance Providers) or denied (Part B Ambulance Suppliers) using the applicable Claim Adjustment Reason Code/Remittance Advice Remark Code for SNF Consolidated Billing.  In other words, the ambulance claim will be denied with an indication that youshould bill the SNF.

The Transmittal contains further instructions that the CWF be updated to identify previously rejected ambulance claims upon receipt of an associated hospital claim for the same date of service that contains an Exempted Code. Once identified, the Shared System Maintainer (SSM) is supposed to adjust the previously rejected or denied ambulance claim. At this point, the nature of that “adjustment” is unclear, i.e., it is unknown whether the SSM will automatically reprocess the ambulance claim for payment. The AAA is seeking additional clarification from CMS on this important point.

Potential concerns for ambulance providers and suppliers

Based on the current experience of hospital providers, the AAA is cautiously optimistic that the new edits can be implemented in a way that proper identifies ambulance transports associated with hospital outpatient claims that should be bundled to the SNF vs. those that correctly remain separately payable by Medicare Part B.

However, the AAA has some concerns with the manner in which CMS intends to apply these edits.  Ambulance providers and suppliers are typically in a position to submit their claims earlier than the corresponding hospital, many of which submit claims on a biweekly or monthly cycle.  This creates a potential timing issue. This timing issue arises because the edits will reject any ambulance claim that is submitted without an associated hospital claim on file.  In other words, even if the hospital outpatient service is properly excluded from SNF Consolidated Billing, the ambulance claim will still be rejected if it beats the hospital claim into the system. The hope is that CMS will subsequently reprocess the ambulance claim once the hospital claim hits the system. However, at this point in time, it is unclear whether these claims will be automatically reprocessed, or whether ambulance providers and suppliers will be forced to appeal these claims for payment.

One option available to ambulance providers and suppliers would be to hold these claims for a period of time, in order to allow the hospitals to submit their claims. By waiting for the hospital to submit its claim, you can ensure that your claims will not be denied solely due to the timing issue. This should eliminate the disruption associated with separately payable claims being rejected and then subsequently reprocessed and/or appealed. It would also give you a degree of certainty when billing the SNF for claims that are denied for SNF Consolidated Billing. However, holding claims carries an obvious downside, i.e., it will disrupt your normal cash flow.

To summarize, the implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on whether to hold claims to minimize the potential for problems, or to continue their existing submission practices and deal with any issues as they arise.

AAA webinar on new SNF Consolidated Billing edits

March 27, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Esq.
$99 for Members | $198 for Non-Members

Join AAA Medicare Consultant Brian Werfel, Esq., to go over the new SNF Consolidated Billing edits that go into effect April 1, 2019. These edits are being implemented by CMS in response to 2017 investigation by the HHS Office of the Inspector General that determined that CMS lacked the appropriate claims processing edits to properly identify ambulance transports provided in connection with hospital outpatient services that are not expressly excluded from SNF PPS. The implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on what to do with these claims moving forward. Sign up today to make sure your service is ready!

Register for the Webinar

Update on Government Shutdown and Sequestration

Written by Aidan Camas on . Posted in Medicare, Member Advisories, Member-Only, News, Reimbursement, Uncategorized.

As the government shutdown drags on the negative impacts continue to grow. If the shutdown continues through January 24, 2019, which is looking likely at this point, current law will require the Trump Administration to cut about $839 million from non-exempt federal benefit programs to avoid increasing the deficit. This is a result of the “PAYGO” (pay as you go) law which requires spending increases or tax cuts to be offset with cuts to programs or additional revenue to avoid increasing the deficit. As the largest nonexempt benefit program, it is likely that Medicare would experience the worst of these cuts through sequestration.

While the Trump Administration has not yet issued a sequestration order, there is a distinct possibility that one could be issued if the shutdown continues much longer. A sequestration order would mean an additional across the board cut to all Medicare providers, including ambulance services. Ambulance service providers are still feeling the impact of the 2% sequestration cut that has been in effect the past few years. Any new cuts would likely start out being targeted at administrative tasks which could slow payments to providers. Temporary cuts would be expensive for the administration to facilitate and is made more challenging by the fact that many important staff members are currently furloughed. There are also some at the Office of Budget and Management (OMB) who believe that these cuts could not actually be administered until the government is reopen.

The AAA will keep members informed of any new developments.

Update on HHS OIG Reports on Ambulance Services

Written by Kathy Lester on . Posted in Member Advisories, Member-Only, News, Reimbursement.

Update on HHS Office of the Inspector General Reports on Ambulance Services

The HHS Office of the Inspector General (OIG) released an update to the Work Plan as the year comes to a close.  There are no new projects specific to ambulance services, but the update does provide a summary of three projects that have been completed or are in progress.

  • Medicare Part B Payments for Ambulance Services Subject to Part A Skilled Nursing Facility Consolidated Billing Requirements (expected release 2019). In this work, the OIG  seeking to determine whether ambulance services paid by Medicare Part B were subject to Part A SNF consolidated billing requirements. The OIG will also assess the effectiveness of edits in CMS’s Common Working File to prevent and detect Part B overpayments for ambulance transportation subject to consolidated billing. Prior OIG reports have identified high error rates and significant overpayments for services subject to SNF consolidated billing.
  • Ambulance Services – Supplier Compliance with Payment Requirements (partially completed; remainder expected release 2019). Prior OIG work has found that Medicare made inappropriate payments for advanced life support emergency transports. The OIG seeks to determine whether Medicare payments for ambulance services were made in accordance with Medicare requirements. 

The first report of this project found that Medicare made improper payments of $8.7 million to providers for nonemergency ambulance transports to destinations not covered by Medicare, including the identified ground mileage associated with the transports.  The report identified that the majority of the improperly billed claim lines (59 percent) were for transports to diagnostic or therapeutic sites, other than a physician’s office or a hospital, that did not originate from SNFs.

In this report, the OIG recommended that the CMS: (1) direct the Medicare contractors to recover the portion of the $8.7 million in improper payments made to providers for claim lines that are within the claim-reopening period; (2) for the remaining portion of the $8.7 million, which is outside of the Medicare reopening and recovery periods, instruct the Medicare contractors to notify providers of potential improper payments so that those providers can exercise reasonable diligence to investigate and return any identified similar improper payments, and identify and track any returned improper payments; (3) direct the Medicare contractors to review claim lines for nonemergency ambulance transports to destinations not covered by Medicare after the audit period and recover any improper payments identified; and (4) require the Medicare contractors to implement nation-wide prepayment edits to ensure that payments to providers for nonemergency ambulance transports comply with Federal requirements.

  • The third report is linked to a case study of the closure of the Rosebud Hospital Emergency Department. Rosebud is an Indian Health Service (IHS) hospital that discontinued emergency services. The closure of the Rosebud emergency department (ED) followed a notice of intent by the CMS to terminate Rosebud Hospital from the Medicare program. Representatives of the Rosebud Sioux Tribe raised concerns to OIG about the Rosebud ED closure and linked that closure to several patient deaths that occurred during ambulance transports to other facilities when emergency care was unavailable locally. In response to these concerns, the OIG seeks to examine factors considered and procedures involved in IHS’s decisions to close and later reopen the Rosebud ED. The OIG will also assess IHS’s management, coordination, and communication related to the closure and will identify lessons learned that IHS could apply to similar situations in the future.  The report was expected to be published in 2018, but has not as of this date. 

The AAA continues to monitor the OIG work plan and engage as appropriate with key officials.  Our goal is to provide educational background to address any misunderstandings or incorrect assumptions that may exist. 

CMS Posts 2019 Public Use File

Written by Brian Werfel on . Posted in Medicare, Member-Only, News, Reimbursement.

On November 28, 2018, CMS posted the 2019 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in calendar year 2019 for the various levels of ambulance service and mileage. These allowables reflect a 2.3% inflation adjustment over the 2018 rates.

The 2019 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.

Unfortunately, CMS has elected in recent years to release its Public Use Files without state and payment locality headings. As a result, in order to look up the rates in your service area, you would need to know the CMS contract number assigned to your state. This is not something the typical ambulance service would necessarily have on hand. For this reason, the AAA. has created a reformatted version of the CMS Medicare Ambulance Fee Schedule, which includes the state and payment locality headings. Members can access this reformatted fee schedule here.

View Reformatted Fee Schedule

CMS Announces 2019 Ambulance Inflation Factor

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

On November 30, 2018, CMS issued Transmittal 4172 (Change Request 11031), which announced the Medicare Ambulance Inflation Factor (AIF) for calendar year 2019.

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 2.9%. CMS further indicated that the CY 2019 MFP will be 0.6%. Accordingly, CMS indicated that the Ambulance Inflation Factor for calendar year 2019 will be 2.3%.

CMS Announces Extension of Prior Authorization Program

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

On November 30, 2018, CMS issued a notice on its website 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 2018. 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, 2019. 

CMS indicated that the extension will provide it with an additional year to evaluate the prior authorization program, and to determine whether the program meets the statutory requirements for nationwide expansion under the Medicare Access and CHIP Reauthorization Act of 2015.

CMS has also updated its Ambulance Prior Authorization FAQs and its Physician/Practitioner Letter to reflect the expansion of the program. The updated FAQ and Physician Letter can be downloaded from the CMS Ambulance Prior Authorization webpage by clicking here.

Rural Health Day Advocacy Update

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

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.

2017 National and State-Specific Medicare Data

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

The American Ambulance Association is pleased to announce the publication of its 2017 Medicare Payment Data Report. This report is based on the Physician/Supplier Procedure Summary Master File. This report contains information on all Part B and DME claims processed through the Medicare Common Working File and stored in the National Claims History Repository.

The report contains an overview of total Medicare spending nationwide in CY 2017, 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, while the second is limited solely to dialysis transports. Each chart lists total spending by procedure code (i.e., base rates and mileage). For comparison purposes, information is also provided on Medicare spending in CY 2016.

2017 National & State-Specific Medicare Data

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

 

President’s Perspective October 2018

Written by Aarron Reinert on . Posted in Government Affairs, Member-Only.

Dear Fellow AAA Members,

Aarron Reinert
President
American Ambulance Association

Since I assumed the office of president last month at our Annual Conference, I have been deeply moved by the selfless actions of ambulance services across the nation as they responded to natural disasters. As always, EMS answered the call to help with humanity, efficiency, and professionalism. My thoughts are with those impacted by the recent storms as well as the thousands of EMTs and Paramedics currently helping with Hurricane Michael recovery.

Annual Conference & Trade Show

Thanks to each of you who attended, exhibited at, or sponsored this year’s impressive Annual Conference & Trade Show. We appreciate your support and participation—it could not have been such a success without you. Once again, congratulations to our AMBY and AAA award winners! I would also like to welcome our new board members and thank those who continue to serve. At the conference, I took a few minutes to share my thoughts about the future of our association. If you missed it, you can catch up via video or essay on the AAA site.

We can’t wait to see you in Nashville next November 4-6, 2019! Please check back at www.annual.ambulance.org early next year for more attendee information.

Opioids

The AAA continues to press policy initiatives with Congress and the Administration that are important to our members. The AAA is pleased to report that language we supported on grant funding for opioid protection training for first responders has passed both the House of Representatives and the Senate and is now headed to the President’s desk. The Senate passed the Opioid Crisis Response Act with a bipartisan vote of 98-1 in the last necessary needed action before being signed into law by the President. The impact of this legislation on the ambulance industry includes providing resources and training so that first responders and other key community sectors, including emergency medical services agencies, can appropriately protect themselves from exposure to drugs such as fentanyl, carfentanil and other dangerous licit and illicit drugs. The legislation also allows the Department of Labor to award grants to states that have been heavily impacted by the opioid crisis to assist local workforce boards and local partnerships in closing the gaps in the workforce for mental health care and substance use disorder.

Dialysis

The AAA is also working on legislation that would restructure the additional cuts dialysis transport reimbursement that went into effect on October 1, 2018. 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. In the Senate, Senator Bill Cassidy (R-LA) had previously agreed to drop a companion Bill. Thanks to the help of the AAA’s members in Alabama, Senator Doug Jones (D-AL) just agreed to co-sponsor this legislation with Senator Cassidy. The AAA will announce the Senate Bill number as soon as it is introduced.

Veterans Affairs

The AAA has also been working on improving the timely reimbursement of emergency ambulance services by the Department of Veterans Affairs (VA). Currently, the VA is the only major payer that does not follow the prudent layperson standard. This happens despite this standard being included in their own regulations regarding reimbursement for emergency care for veterans.

To help address this problem, Congressman Mike Coffman (CO-06) introduced H.R. 1445 the Veterans Reimbursement for Emergency Ambulance Services Act (VREASA). VREASA would clarify the prudent layperson standard and should hopefully correct the issue of improperly denied claims or delays in reimbursement.

The AAA continues to work closely with Sen. John Boozman (R-AR) to get a similar Bill introduced in the Senate during the next Congress. The AAA and representatives from Maine also met with Sen. Susan Collins (R-ME) and her staff who helped include some critical language related to this issue in the Senate’s FY2019 MilCon-VA Appropriations Bill (S. 3024). The language can be found in the Senate’s Committee Report on that Bill. This is a crucial step in the right direction to ensure that our veterans receive the highest quality care and that ambulance service providers are adequately reimbursed in a timely manner.

The AAA’s data analyst estimates that since ambulance services are already covered services that there should be no score (cost) for this Bill. Additionally, if the Congressional Budget Office were to account for those claims that the VA is improperly denying, the estimated cost would be $270 million over ten years.

Cost Data Collection

The continues to work closely with Congress and the CMS on the creation and implementation of the new cost collection system for ambulance services. The AAA spent the last four years thinking about how CMS should collect data from ambulance service suppliers and providers, and how we can assist in helping services prepare and respond to the cost data survey. We’re developing material and resources to help ambulance service suppliers and providers prepare for being selected to provide their cost data. Though many of the finer specifics of the framework and data elements are still to be confirmed by CMS, the AAA has an in-depth and insider understanding of the anticipated process and elements.

For information on the AAA resources, please access the ambulance cost data collection webpage at www.ambulancereports.org. The AAA will announce new developments in the cost collection system via email. Although the possibility of your organization being selected to provide data is still a couple of years away, it’s important that you start preparing now.

At the AAA’s Annual Conference & Tradeshow last month in Las Vegas, CMS, through its contractor the RAND Corporation, convened a focus group where they selected several AAA members to talk directly with the contractor. The discussion centered around characteristics of ambulance services that matter for determining costs. The group also talked about how data is currently captured at the state and local levels, as well as how data is tracked within ambulance services. There was also a lot of discussion about the importance of standardizing data elements and not relying upon different state or local definitions, which could confound the data and make it impossible to compare costs across states. CMS is now reaching out to others in the industry for input. If you receive an email or a phone call from RAND Corporation, please respond. If you have questions about, or would like assistance with this project, please contact Tristan North at tnorth@ambulance.org.

SIREN Act

Lastly, the AAA is the working to ensure that the SIREN Act (S. 2830, H.R. 5429) which would reauthorize the Rural EMS Grant program and makes all provider types eligible to apply for these grants.

Membership Renewal Time

Membership is the fuel that powers our advocacy engine and enables us to offer the innovative benefits your service has come to rely on. If you have already renewed, please accept our most sincere thanks for your continued support. If you have not yet submitted payment for this year’s membership, I encourage you to renew online or reach out to staff at info@ambulance.org for assistance. AAA needs your support through membership to continue our industry-advancing work.

Thank you for entrusting me to serve as the president of your association. It is my pleasure to lead such a talented cadre of dedicated healthcare professionals. I wish you a happy Halloween and a wonderful holiday season.

Aarron Reinert
President
American Ambulance Association

 

 

 

 

MedPAC Examines Beneficiary Use of Emergency Departments

Written by Kathy Lester on . Posted in Medicare, Member Advisories, Member-Only, Regulatory, Reimbursement.

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.

Talking Medicare: CMS Implements Further Dialysis Cuts

Written by Brian Werfel on . Posted in Advocacy Priorities, Member-Only, News, Reimbursement, Talking Medicare.

Talking Medicare: CMS Implements Further Cuts in Reimbursement for Dialysis Services; Medicare Payment Data Shows Continued Reduction in Overall Spending on Dialysis Transports, but Net Increase in Dialysis Payments in Prior Authorization States

On October 1, 2018, CMS implemented an additional thirteen (13%) cut in reimbursement for non-emergency BLS transports to and from dialysis. This cut in reimbursement was mandated by Section 53108 of the Bipartisan Budget Act of 2018. This on top of a ten (10%) cut in reimbursement for dialysis transports that went into effect on October 1, 2013. As a result, BLS non-emergency ambulance transports to and from dialysis that occur on or after October 1, 2018 will be reimbursed at 77% of the applicable Medicare allowable.

In related news, CMS has released its national payment data for calendar year 2017. This data shows a continued reduction in total Medicare payments for dialysis transports. Medicare paid $477.7 million on dialysis transports in 2017, down from $488.9 million in 2016. This continues a downward trend that has seen total payments decline from a high of more than $750 million in 2013 (see accompanying chart to the right). Not coincidentally, it was in 2013 that our industry saw its first reduction in Medicare’s payments for dialysis transports.

The payment reduction is partially the result of the reduction in the amounts paid for dialysis services. However, it is also reflective of an overall decline in the number of approved dialysis transports. For this, we can look primarily to the impact of a four-year demonstration project that requires prior authorization of dialysis transports in 8 states and the District of Columbia.

As a reminder, the original prior authorization states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress. The chart below shows total spending on dialysis in those states in the years immediately preceding the implementation of the prior authorization project up through 2017, the third year of the demonstration project. While the three states had very different trajectories prior to 2015, each showed a significant decrease in total payments for dialysis under the demonstration project.

However, it is the trajectory of these changes that I want to discuss in this month’s blog. In previous blogs, I discussed the impact of the particular Medicare Administrative Contractor on the outcomes under prior authorization. Specifically, I noted that, while dialysis payments dropped in each state, the decline was far more dramatic in the states administered by Novitas Solutions (NJ, PA) than in the South Carolina, which was administered by Palmetto GBA. This trend continued in the second year of the program, which saw prior authorization expanded into five additional states and the District of Columbia. Those states administered by Novitas (DE, MD) saw far greater declines than the states administered by Palmetto (NC, VA, WV).

Given these declines, the data from the third year is somewhat surprising. The states administered by Palmetto continued to see declines in total dialysis payments, with the only exception being West Virginia. However, in the states administered by Novitas, we saw total dialysis payments increase, particularly in New Jersey, which saw nearly a 33% increase in total dialysis payments.

Three years into the prior authorization program, it is starting to become clear that the two MACs have approached the problem of overutilization of dialysis transports using two different approaches. Palmetto appears to have adopted a slow-and-steady approach, with total payments declining in a consistent manner year after year. By contrast, Novitas adopted more of a “shock the system” approach, where it rejected nearly all dialysis transports in the first year, and has adopted a somewhat more lenient approach in subsequent years.

Key Takeaways

 Last year, I wrote that two years of data under the prior authorization program permitted two conclusions: (1) the implementation of a prior authorization process in a state will undoubtedly result in an overall decrease in the total payments for dialysis within that state and (2) the size of that reduction appears to be highly dependent on the Medicare contractor.

With an additional year of data, I think both conclusions remain valid, although I would revise the second to suggest that the initial reduction has more to do with the Medicare contractor. The evidence from the third year of the program suggests that the trends tend to equalize after the first few years. It is also possible that Novitas felt a more aggressive approach was needed in the first few years to address evidence of widespread dialysis overutilization in the Philadelphia metropolitan area.

This has potential implications beyond the demonstration project, as CMS looks towards a possible national expansion of the program. Among other issues, it suggests that the AAA must continue its efforts to work with CMS and its contractors on developing more uniform standards for coverage of this patient population.

What the AAA is Doing

The AAA continues to work on legislation that would restructure this cut to dialysis transport reimbursement. The AAA strongly supports the NEATSA Act (H.R.6269) introduced by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) that 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. AAA members and the AAA are working to get a Senate companion bill introduced shortly. The goal of this legislation would be to have the restructured offset go into effect as soon as possible. Thank you to the dozens of AAA members who have already contacted their members of Congress voicing their support for this critical legislation.

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

Preliminary Calculation of 2019 Ambulance Inflation Update

Written by Brian Werfel on . Posted in Member Advisories, Member-Only, News, Reimbursement.

Section 1834(l)(3)(B) of the Social Security Act mandates that the Medicare Ambulance Fee Schedule be updated each year to reflect inflation.  This update is referred to as the “Ambulance Inflation Factor” or “AIF”.

The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Starting in calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi-factor productivity index (MFP). The MFP reduction may result in a negative AIF for any calendar year. The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.

For the 12-month period ending in June 2018, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased by 2.87%.

CMS has yet to release its estimate for the MFP in calendar year 2019. However, assuming CMS’ projections for the MFP are similar to last year’s projections, the number is likely to be in the 0.5% range.

Accordingly, the AAA is currently projecting that the 2019 Ambulance Inflation Factor will be approximately 2.4%. 

Cautionary Note Regarding these Estimates

Members should be advised that the BLS’ calculations of the CPI-U are preliminary, and may be subject to later adjustment. The AAA further cautions members that CMS has not officially announced the MFP for CY 2019. Therefore, it is possible that these numbers may change. The AAA will notify members once CMS issues a transmittal setting forth the official 2019 Ambulance Inflation Factor.

LifeWorks October Feature: Work-Life Balance and Productivity

Written by Lifeworks on . Posted in Employee Wellness, Member-Only, Uncategorized.

October Feature: Work-Life Balance and Productivity

Ten Tips for Fitting Work and Life Together

Would you like to move beyond feeling stressed or overwhelmed by your personal and work responsibilities? Or learn how to achieve personal and professional success on your own terms? “Knowing how to manage the way work and life fit together is a modern skill set we all need to succeed,” says Cali Williams Yost, an internationally recognized flexible workplace strategist and author of the books Tweak It: Make What Matters to You Happen Every Day and Work+Life: Finding the Fit That’s Right for You. Here are Yost’s 10 strategies:

  1. Remember that work-life fit is unique for each of us. “Simply put, there is no work-life balance or perfect 5050 split between your work and your personal life,” Yost says. “If you do happen to hit a balance, you can’t maintain it because your realities are always changing, personally and professionally.” There’s also no “right way” to achieve a good work-life fit. Your goal is to find your unique, ever-changing fit, the way your work and personal realities fit together day-to-day and at major life transitions. Don’t compare yourself to others. Find the fit that’s right for you.
    It’s also important to keep in mind that during major life changes — like becoming a parent, caring for an aging relative, relocating with a partner, going back to school, or easing your way into retirement — you may find yourself rethinking how you define success related to money, prestige, advancement, or caregiving. Throughout life, you may need to align and adjust your work and personal realities so they match with your vision and goals for the future.
  2. Harness the power of small actions or “tweaks”. Even small actions can have positive and lasting effects. When you’re feeling overloaded, for example, commit to taking two or three small but meaningful steps toward a better work-life fit. Plan a long weekend away with friends. Clean out your hall closet. Take an online class to learn a new skill. Then do it again and again. Small actions can have a big impact on your sense of well-being and control. To get started, check out more than 200 small, doable get-started actions suggested by 50 work, career, and personal life experts in Yost’s book Tweak It.
  3. Create a combined calendar and priority list. On top of a busy job and home life, how will you fit everything else into your schedule? There’s exercise, eating well, vacation, sleep, career development, time with family and friends, caregiving responsibilities, and just general life maintenance. You can’t do it all. But you can be more intentional and deliberate about how you spend your time.
    First, pull together all your work and personal to-dos and priorities into one combined calendar and list. This will help you determine how you want to prioritize the tweaks — small, meaningful work, career, and personal actions and priorities — to add to your work-life fit. For example, tweaks might include planning all meals and shopping for your groceries on Sunday or getting to exercise class every Tuesday and Saturday. Or they might include researching a vacation one afternoon, going to the movies with your sister, or attending a networking event. Building actions into your schedule makes it far more likely they’ll happen. And you’ll feel better as a result.
  4. Take care of yourself in small ways. Small changes can make a big difference in how you feel. Manage stress during the day by closing your eyes for 15 seconds and taking a few deep breaths. Try to eat more healthfully by adding a vegetable to two of your meals during the day. Turn off the television and your electronic devices an hour before you go to bed to help you get the rest you need.
  5. Preview a skill online before you pay to take a class. In a rapidly changing world, all of us need to keep updating our skills to meet new work and other realities. But going back to school can be expensive and time consuming. Before you invest a substantial amount of money in a class, try to preview a skill online. Watch or listen to any of the hundreds of thousands of videos or podcasts on an infinite number of topics that you can preview by downloading or streaming them. Watch them while you’re commuting, or listen to them while you walk. If you want or need more help than the video or podcast provides, invest in a class
  6. Collect ideas for vacations — then take one. Taking a break to reenergize is more important than ever in our on-the-go world. And many people don’t take vacations just because they don’t know where to go. It takes some research to find a destination that you can afford, and some of us don’t do this until it’s too late. To get inspired, keep a jar or small box where you can store vacation ideas. Every time you hear a friend or relative talk about a wonderful vacation, write down what appeals to you about it and put it there. When you read an article about a place that sounds interesting, put that in the box or jar, too. Once a year, pick a destination from all of the vacation ideas you’ve accumulated.
  7. Get things done while you’re enjoying family and friends. Cook dinner with your kids. When you prepare a meal together, you’re also spending time together. Take a walk with your close friend before work or a tae kwon do class with your partner on the weekend. You’ll be exercising while spending quality time together. At holiday times, plan a cookie exchange and donate some of the cookies to a women’s shelter.
  8. Have 10 technology-free minutes each day with your children. Give the kids time when you aren’t distracted by electronic gadgets. Sit on the floor and do a puzzle. Ask teenagers how their day went, and just listen. Check your email only at certain times of the day, so you aren’t always on it when children need you. When you’re on the phone, turn around and face away from your computer so you aren’t distracted by email. Looking away from the screen will force you to pay attention to the person you’re talking with.
  9. Plan for future caregiving responsibilities. Get a head start if you’re taking care of a grandparent or may be caring for a parent or other relative in the future. Sit down with the adults in your life who may require care. Try to clarify what they want, understand their financial resources, and come up with a plan for meeting their needs and wishes. Try to include in the meeting any family and friends who form a broader network of care, so you don’t have to do it all on your own. Don’t wait for a crisis.
  10. Keep on top of everyday maintenance. Clean as you go, so the work doesn’t pile up. Put a load of laundry in the washing machine in the morning before you leave for work, and put it in the dryer when you get home. Keep a small bucket of cleaning supplies in the bathroom, and wipe down the shower, mirror, and toilet every morning. Set a timer for 10 minutes each weekend and assign each member of your family a task — vacuuming, dusting, straightening up. Check the owner’s manual of your car for the recommended maintenance schedule and write it on your calendar.

For more tips like these, listen to the recording Fitting Work and Life Together on the LifeWorks platform.

Free, confidential counseling for employees of AAA member organizations.

LifeWorks is your employee assistance program (EAP) and well-being resource. We’re here for you any time, 24/7, 365 days a year, with expert advice, resources, referrals to counseling, and connections to specialists including substance abuse and critical incident stress management professionals. If you could benefit from professional help to proactively address a personal or work-related concern, you can turn to LifeWorks.

  • Counseling is available at no cost to you. (Up to three sessions per issue.)
  • To meet individual needs and preferences, counseling is available face-to-face AND live by video.
  • All our counselors are experienced therapists with a minimum Master’s degree in psychology, social work, educational counseling, or other social services field.

Call LifeWorks, toll-free, 24/7, at 800-929-0068.
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CMS Announces Revisions to Provider Enrollment Waiver Demonstration (PEWD) Program

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

CMS Announces Revisions to Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) Program

On August 20, 2018, the Centers for Medicare & Medicaid Services (CMS) published a notice in the Federal Register that it would be revising the terms of its Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) Program. These revisions became effective on August 20, 2018.

Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse. Based on this authority, CMS has implemented temporary moratoria on the enrollment of new non-emergency ambulance providers in the states of New Jersey and Pennsylvania.

Under the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) Program, CMS has the authority to grant waivers to statewide enrollment moratorium on a case-by-case basis in response to access to care issues.  However, since the implementation of the PEWD Program in 2016, CMS has identified a handful of technical issues that have complicated the implementation of the PEWD Program.  The revisions in this notice are intended to resolve these technical issues.

The specific revisions CMS is making include:

  1. In December 2016, Congress enacted the 21st Century Cures Act. Section 17004 of that law prohibits payment for items or services furnished within moratoria areas by any newly enrolled provider or supplier that falls within a category of health care provider that is subject to the enrollment moratoria.  This provision became effective on October 1, 2017.  CMS is revising the PEWD Program to waive the requirements of Section 17004 of the Cures Act with respect to providers and suppliers who were granted waivers under the PEWD.
  2. CMS is further revising the PEWD to create a second category of waivers for those providers or suppliers that had submitted an enrollment application prior to the implementation of the moratoria, but who were denied as a result of the implementation of the moratoria. CMS indicated that this new waiver authority was necessary to protect providers and suppliers that spent substantial amounts of time and money preparing for enrollment at the time the enrollment moratoria were county-based, only to be denied once the moratoria were expanded to the entire state.
  3. CMS is revising the PEWD to provide additional discretion regarding the effective date of billing privileges for providers and suppliers granted waivers under the PEWD.

Government Affairs Update

Written by Tristan North on . Posted in Advocacy Priorities, Government Affairs, Member-Only, News, Regulatory.

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.

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