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New Membership Referral Program!

Written by Amanda Riordan on . Posted in AAA HQ, Member-Only.

No one knows better than an AAA members the incredible value of membership. Consider sharing your AAA membership experience, and get rewarded for doing so!

Through our new Membership Referral Program, receive a free webinar registration for each new member organization you refer that successfully joins the association. Successfully sign up 6 new member organizations, and you’ll receive a free registration to the AAA Annual Conference & Trade Show! To participate, simply copy ariordan@ambulance.org on emails you send to colleagues inviting them to join. AAA staff will answer questions and help with follow up.

Not quite sure what to write? Here’s a sample email to get you started!

Dear Colleague’s Name,
I hope your year is off to a great start. I wanted to send a quick note to ask if Colleague’s Ambulance Servicemight be interested in membership to the American Ambulance Association?

My service is a proud member of AAA, and the advocacy work they do on behalf of our industry is more important now than ever. In addition to working toward fair reimbursement, AAA now offers free counseling and CISM for your staff, access to experts on operations and Medicare, and much more. I especially enjoy the sessions and networking at Annual Conference, as well as the ability to recognize my top field staff at Stars of Life. I have copied AAA’s membership staff on this message in case you have any questions about benefits or dues.

I hope that you’ll consider supporting the American Ambulance Association. Thanks for considering, and have a great one.

Your Name

Medicare Relief and Reform Letter by President Postma

Written by Mark Postma on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, Reimbursement.

This is a critical year for the legislative efforts of the American Ambulance Association and our members.  First and foremost, our temporary Medicare ambulance increases expire at the end of the year.  It is vital that we ensure the new 115th Congress makes these increases permanent, or at the very least approves another long-term extension.  To be successful, we will need all of your help in reaching out to your members of Congress in support of the increases.

The AAA and our partners have been also working to further the reform of the Medicare ambulance fee schedule.  To accomplish the first steps in this process, ambulance services need to be treated as providers of health care services rather than only suppliers of medical transportation.  In addition, we will need the cost data necessary for Congress, Centers for Medicare and Medicaid Services and the AAA to make data-driven decisions regarding the reform.

To achieve these goals, we are working with our champions in Congress to reintroduce a version of the Medicare Ambulance Access, Fraud Prevention and Reform Act (HR 745, S. 332 – 114th Congress).  We hope to have a bill reintroduced in the House and Senate in the coming weeks.  Only with your help in sustained outreach to your legislators will we be able to get the provisions of this bill passed.

Our absolute top priority this year is preventing the expiration of the Medicare add-on payments.  Building the increases into the base rates is also vital to the future of reform, as is provider standing and cost data collection.  These changes will lead, we hope, to the demonstration of the need for additional reimbursement as well as recognition of the role ambulance services can play in the larger health care picture.  The subsequent goal is coverage for services such as mobile integrated health and alternate destinations.

The AAA will also be closely following the debate and implications for our industry around repeal and replacement of the Affordable Care Act, potential Medicare and Medicaid reform, and other health care and broader initiatives of interest to us.  We will keep you posted of new developments as the process unfolds.

Since this is such a vital year for us in Congress, I ask that each of you respond to our Calls to Action for help with your members of Congress on the Medicare increases and other legislative priorities.  We will only be successful if we all push as one.

CMS Extends Temporary Moratorium (NJ, PA, TX)

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

On January 9, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a notice in the Federal Register extending the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey, Pennsylvania, and Texas. The extended moratoria will run through July 29, 2017.

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. On July 31, 2013, CMS used this new authority to impose a moratorium on the enrollment of new ambulance providers in Houston, Texas and the surrounding counties. On February 4, 2014, CMS imposed a second moratorium on newly enrolling ambulance providers in the Philadelphia metropolitan areas. These moratoria have been extended every six months thereafter.

However, on August 3, 2016, CMS announced changes to its existing moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that the moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier, but that it would expand the enrollment moratorium on non-emergency ambulance services to cover the entire states of New Jersey, Pennsylvania, and Texas. At the same time, CMS announced the creation of a new “waiver” program that would permit the enrollment of new non-emergency ambulance providers in these states under certain circumstances.

On or before July 29, 2017, CMS will need to make a determination on whether to extend or lift the enrollment moratorium.

Have a Medicare question? AAA members, send your inquiry to Brian Werfel, Esq. using our simple form!

GAO Report on Revised Provider Enrollment Screening Process

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

In March 2011, the Centers for Medicare and Medicaid Services (CMS) implemented a revised process for processing the enrollment of new Medicare providers and suppliers. This revised process also applied to existing Medicare providers and suppliers that were revalidating their enrollment information. This new process included assigning all providers and suppliers to one of three risk categories—limited, moderate, and high—based on the perceived risk of fraud and abuse. The risk category then determines the applicable screening process used for providers within that risk category.

Please note that ambulance providers and suppliers were placed in the moderate risk category. This risk category includes a verification of the information provided by the provider on its enrollment application, a check of the provider’s state licensure, a check of any adverse legal actions against the provider, and a site visit of the provider.

On December 15, 2016, the Government Accountability Office (GAO) released a report on the initial results of this revised provider enrollment screening process.

In its report, the GAO indicated that CMS applied its revised enrollment screening process to over 2.4 million newly enrolling and revalidating Medicare providers and suppliers from March 25, 2011 through December 31, 2015. Other relevant findings include:

  • The total number of enrolled Medicare providers and suppliers increased from 1.4 million in March 2011 to 1.9 million in December 2015, an increase of more than 30%.
  • CMS denied more than 6,000 applications for ineligible providers and suppliers. The most commonly cited reason for a denial was the failure of applicant to meet the provider/supplier type requirements. This included situations where the provider/supplier did not hold the required certification for that provider/supplier type.
  • CMS rejected 17,000 applications as incomplete. The GAO found that approximately 25% of the rejected applications were the result of the application being filed in error, either by the provider/supplier or the MAC. 21% of applications were rejected as being duplicates. Another 16% of rejections were the result of the provider/supplier failing to timely respond to the MAC’s request for additional information.
  • CMS screening of existing providers/suppliers resulted in more than 660,000 provider numbers being deactivated. This was typically (47%) the result of the provider failing to respond to the MAC’s request that they revalidate. Another 29% were the result of the provider/supplier voluntarily withdrawing from the Medicare program. Another 5% of deactivations were the result of the provider/supplier not submitting a claim to Medicare within the previous 12 months. The majority of these were likely individual practitioners (e.g., physicians) that either died, or who retired from professional practice, and who failed to inform the MAC at the time of retirement to request that their provider number be deactivated. This could also include organizational providers that were sold or otherwise no longer operational.
  • These were frequently the result of an individual practitioner (e.g., a physician) failing to deactivate his or her Medicare number upon their retirement, and their either not responding to a request to revalidate, or notifying the MAC of their retirement and agreeing to voluntarily withdraw
  • CMS revoked the billing privileges of 43,000 provider/suppliers. The most common reason cited (61%) was the failure of the provider/supplier to be professionally licensed. However, within the moderate risk category, which includes ambulance, 26% of all revocations were the result of a “CMS-approved revocation,” e.g., the result of some adverse legal action against the provider/supplier which was not properly disclosed to the MAC within 30 days.

 

CMS estimated that its revised screening procedures avoided $2.4 billion in Medicare payments to ineligible providers and suppliers over this period.

CMS also reported that it made several changes to its screening process over this period. This includes the implementation of a continuous license monitoring report in November 2013, and a continuous criminal monitoring report in July 2015. This also includes fingerprint-based criminal background checks for the owners and certain key employees of categorically high-risk providers and suppliers. In December 2015, CMS also began conducting site-visits for certain limited-risk providers and suppliers.

Despite the progress made by CMS, the GAO did find that certain program vulnerabilities still exist. For example, the GAO found that CMS had not established performance measures to monitor its ability to place providers and suppliers in the proper risk categories. The GAO recommended that CMS establish objectives and performance measures for assessing its progress in establishing better screening procedures for new enrollments and revalidations. CMS ultimately agreed with this recommendation.

Have a Medicare question? AAA members, send your inquiry to Brian Werfel, Esq. using our simple form!

 

OIG Releases Final Rule Revising Safe Harbor

Written by David Werfel on . Posted in Government Affairs, Member Advisories, Member-Only.

Office of the Inspector General – Final Rule – Revisions to the Safe Harbors for Waiving Coinsurance, et.al

On December 7, 2016, the Office of the Inspector General published a Final Rule (81 Federal Register 88368) and will be effective January 6, 2017.

The Final Rule includes technical corrections to the existing Safe Harbor for referral services, a new Safe Harbor for waiver of patient cost-sharing for emergency ambulance services, a new Safe Harbor for free or discounted local transportation services, and an amendment to the definition of “remuneration” for purposes of the Civil Monetary penalties for beneficiary inducements.  Since the Final Rule covers many issues that pertain to other providers and suppliers, such as pharmacies, outpatient hospital, Federally Qualified Health Centers, Medicare Advantage Plans, etc., this Member Advisory will focus on the two issues that impact ambulance services and transportation.

Safe Harbor – Cost Sharing Reductions for Emergency Ambulance Services

In recent years, we have seen a number of OIG Advisory Opinions that permitted public EMS entities to waive the cost-sharing obligations of Medicare beneficiaries in specified circumstances. The OIG is now adding these as a “Safe Harbor”. The regulation, at 42 C.F.R 1001.952, will protect certain reductions or waivers of beneficiary cost-sharing for emergency ambulance services provided by public entities, which are paid by Federal health care programs under a fee-for-service basis. However, to qualify, all of the following must be met:

  • The provider or supplier must be owned and operated by a State, political division of a state or a tribal health program. NOTE: While this protects government entities that own and operate their ambulance service, it does not protect a supplier who contracts with that government entity even when that government entity pays the supplier for patient cost-sharing obligations through tax funded revenues.  It also does not protect hospitals providing the emergency ambulance services.
  • The emergency ambulance services must be provided by a Part B provider or supplier. The definition of “Emergency” is the same one listed in 42 C.F.R. 414.605, which you use to determine whether to bill for an emergency base rate or a non-emergency base rate.
  • The reduction or waiver is not considered furnishing free services paid directly or indirectly by a government entity. It is not considered a free service if the government entity bills to the extent of insurance.
  • The reduction or waiver of cost-sharing is offered uniformly without considering patient- specific factors. NOTE:  The OIG allows residency to be considered. Thus, a city may choose to waive or reduce cost-sharing for residents but not for non-residents.
  • The provider does not later claim the amount waived as a bad debt, or shift the burden to a government program.

If all of the above items are met, the government entity providing the emergency ambulance service can reduce or waive the patient’s cost-sharing obligation.

Please note, there is no change here with respect to membership programs by a public or private ambulance service, nor is there any change in policy or the law concerning a government entity paying a private ambulance company for copayments of its residents.

Safe Harbor for Free or Discounted Local Transportation

A new Safe Harbor has been created at 42 C.F.R. 1001.952(bb) to protect free or discounted local transportation made available by an “eligible entity” for beneficiaries of Federal health care programs.  The key elements to this Safe Harbor are:

  • The transportation must be local. That is defined as up to 25 miles if urban and up to 50 miles if rural.
  • It can be provided to or from a provider of service.
  • It can be provided to the patient as well as to a person that assists the patient.
  • The transportation does not have to be scheduled ahead of time.
  • The entity can use a voucher program, if they want.
  • The transport cannot be provided by an air, luxury or ambulance level service.
  • An eligible entity cannot require an ambulance company to provide free or discounted transportation to its patients.
  • An eligible entity is defined as an individual or entity.
  • An “established” patient means a person who has selected and initiated contact with a provider or supplier to schedule an appointment or who has given consent to someone to do it for them.
  • The transportation cannot be advertised.
  • The transportation cannot be used to recruit patients.
  • The transportation must be for medically necessary services.
  • Eligible entities must have an established policy regarding the availability of transportation assistance and must apply it uniformly.
  • The eligible entity is not required to maintain documentation for each patient transported, but it would be a “best practice” to have such documentation.
  • Drivers cannot be paid on a per patient basis.
  • The eligible entity cannot have a sign saying “Donated by ___”, as that is marketing.
  • The eligible entity cannot shift the cost of the transportation to any government health care program.
  • Shuttles are permitted but the rules are slightly less stringent. The vehicle must be used for a set route or schedule, does not have to be for established patients, must be for local use (25 miles urban; 50 miles rural), it can make multiple stops and, while the entity cannot advertise, they can post a schedule.

Read the entire Final Rule is 42 (Federal Register).

Free Post-Election Analysis Webinar for Members

Written by Aidan Camas on . Posted in Elections, Events, Government Affairs, Member-Only, Webinars.

Post-Election Analysis Webinar – Thursday, November 17th, 2:00pm EST

post-election-analysis

The recent elections resulted with Republicans taking control of the White House and retaining a majority in the House and Senate. In the first 100 days of the Trump Administration, we will see a major shift from the policy positions of the current administration. It is likely that there will be immediate efforts toward the repeal, amendment, and replacement of the Affordable Care Act as well as tax reform and infrastructure improvement. Join us for this free webinar, and hear former Members of Congress Bill Paxon (R-NY) and Vic Fazio (D-CA), whom both served in their respective party leadership, give their analysis of the elections and of where the new Administration and Congress go from here.

Register Now

Unable to Attend?

No problem! All webinars will be recorded and available to stream On-Demand. Register now and watch on your own time!

Questions?

Please contact Colleen Crowley at ccrowley@ambulance.org.

CMS SMR Contractor Audit Error

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

Over the past week, we have learned that several ambulance suppliers have received letters from the CMS Supplemental Medical Review Contractor (SMRC), StrategicHealthSolutions, LLC.  These letters indicate that the SMRC is conducting a medical review of their claims.

The letter contains a section that explains why the supplier has been selected for review.  That section contains the following explanation:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017, and modified the requirement for manual medical review for services over the $3,700 therapy thresholds.  MACRA eliminated the requirement for manual medical review of all claims exceeding the therapy thresholds and instead allows a targeted review process.  CMS has tasked the SMRC with performing post-payment medical review of Part B therapy claims for providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers for dates of service July 1, 2015 to the present. 

Our firm contacted the SMRC on behalf of a number of affected providers.  On November 14, 2016, StrategicHealthSolutions responded to our inquiry.  The SMRC indicated that its review was intended to be limited to suppliers of physical therapy services.  Accordingly, the SMRC confirmed that these audit letters were sent to ambulance suppliers in error. 

The SMRC further indicated that ambulance suppliers that received this audit letter in error will be notified by telephone that they were selected in error.  The SMRC will also be sending letters to affected ambulance suppliers notifying them of its error.  These letters are expected to be mailed tomorrow, Tuesday, November 15, 2016.

If your organization received a letter from StrategicHealthSolutions, LLC, please know that this letter was sent in error.  Your organization is not being audited by the Supplemental Medical Review Contractor.  You can expect to receive a phone call and/or a letter in the next few days formally notifying you of the contractor’s error.  That letter should formally withdraw the SMRC’s request for medical records. 

If you received a letter from the SMRC, and have any further questions, please feel free to contact Brian S. Werfel, Esq., the AAA’s Medicare Consultant.  He can be reached via email at bwerfel@aol.com.

CMS List of Medically Unlikely Edits for Ambulance Services

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

On October 1, 2016, the Centers for Medicare and Medicaid Services (CMS) updated its list of Medically Unlikely Edits (MUEs). The MEU program is designed to reduce the paid claims error rate for Part B claims. The program operates by estimating the maximum number of units of service that a provider/supplier would report under most circumstances for a single beneficiary on a single date of service. A claim that submits units of service in excess of this threshold will typically be denied by the Medicare Administrative Contractor.

For additional information on the CMS Medically Unlikely Edit Program, click here.

Effective October 1, 2016, claims for ambulance services will be subject to the following MUE edits:

HCPCS Code MUE Threshold
A0425 (Ground Ambulance Mileage) 250
A0426 (Ground Ambulance, ALS Non-Emergency) 2
A0427 (Ground Ambulance, ALS Emergency) 2
A0428 (Ground Ambulance, BLS Non-Emergency) 4
A0429 (Ground Ambulance, BLS Emergency) 2
A0430 (Air Ambulance, Fixed Wing) 1
A0431 (Air Ambulance, Helicopter) 1
A0432 (Ground Ambulance, Paramedic Intercept) 1
A0433 (Ground Ambulance, ALS-2) 1
A0434 (Ground Ambulance, Specialty Care Transport) 2
A0435 (Air Ambulance, Fixed Wing Mileage) 999
A0436 (Air Ambulance, Helicopter Mileage) 300

 

AAA Posts 2015 National and State-Specific Medicare Data

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

The American Ambulance Association is pleased to announce the publication of its 2015 Medicare Data Payment 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 2015, 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 2014.

CMS Announces 2017 Inflation Factor

Written by David Werfel on . Posted in Government Affairs, Medicare, Member Advisories, Member-Only, Regulatory, Reimbursement.

The Centers for Medicare and Medicare Services (CMS) issued Transmittal 3625 officially announcing that the inflation factor for payments under the Medicare ambulance fee schedule for 2017 will be 0.7%.

The calculation for determining the Medicare ambulance inflation factor is as follows: Consumer Price Index – Urban (which is the change in the CPI-U from June to June) minus the non-farm business multi-factor productivity adjustment (MFP) as projected by the Secretary of HHS (10-year average). The CPI-Urban for 2017 is 1.0% with a MFP of 0.3% which equals the 0.7% inflation factor. As part of the Affordable Care Act, a productivity adjustment is subtracted from the CPI-Urban for the final inflation update.

CMS Issues Transmittal on Changes to Ambulance Staffing Requirements

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

CMS Issues Transmittal on Changes to Ambulance Staffing Requirements; Clarifications to Service Level Definitions for Ground Ambulance Services

On September 12, 2016, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 226.  This Transmittal incorporates the recent changes to the vehicle staffing requirements into the Medicare Online Manual System.  The Transmittal is also intended to provide clarification on the definitions for certain levels of ground ambulance service.  The changes made by this Transmittal go into effect on December 12, 2016. 

 Vehicle Staffing Requirements

 In the CY 2016 Physician Fee Schedule final rule (November 16, 2015), CMS revised its regulations related to the staffing of ground ambulance services.  Previously, the Medicare regulations at 42 C.F.R. 410.41 required that all ground ambulances be staffed by a minimum of two crewmembers, at least one of whom must be certified as an EMT-Basic and who must be legally authorized to operate all of the lifesaving and life-sustaining equipment on board the vehicle.  For ALS vehicles, there was a further requirement that at least one of the two crewmembers must be certified as a paramedic or EMT and qualified to perform one or more ALS services.

In the 2016 final rule, CMS revised the regulation to further require that the ambulance supplier meet all applicable state and local laws related to the staffing of vehicles.  CMS indicated that these changes are intended to address jurisdictions that impose more stringent requirements on ambulance providers (e.g., a requirement that both staff members be certified as EMTs).  CMS further indicated that these changes were prompted, in part, by a report from the HHS Office of the Inspector General, which expressed concern over the fact that the current regulations do not set forth licensure or certification requirements for the second crew member.

In this Transmittal, CMS is updating Section 10.1.2 of Chapter 10 of the Medicare Benefit Policy Manual to reflect the changes to the underlying regulations.  Specifically, the Manual Section now makes clear that BLS and ALS vehicles must meet the staffing requirements under state and local laws.  For BLS vehicles, the new definition also clarifies that at least one of the crewmembers must be certified at a minimum at the EMT-Basic level by the state or local authority where the services are being furnished.  For ALS vehicles, the new definition clarifies that at least one of the crewmembers must be certified as an EMT-Intermediate or EMT-Paramedic by the state or local authority where the services are being furnished.

Note: A number of AAA members have expressed concern with the reference to “EMT-Intermediate” in the paragraph defining the staffing requirements for ALS vehicles.  These members note that their state may be moving away from the “EMT-I” designation, in favor of the “Advanced EMT,” “EMT-Enhanced,” or other similar designation.  These members expressed concern that Medicare contractors may interpret this clarification literally, and therefore downgrade claims properly billed ALS based on the services provided by Advanced EMTs or other higher EMT certifications.

The AAA recognizes the concerns expressed by these members.  It should be noted that the Manual changes being made by this Transmittal accurately reflect the current wording of the regulation.  It should also be noted that these changes do not impact the definition of “Advanced Life Support (ALS) personnel” set forth in 42 C.F.R. §414.605.  While that definition also makes reference to the EMT-Intermediate licensure, the definition makes clear that any individual trained to a higher level than the EMT-Basic licensure qualifies as an ALS crewmember.

Ground Ambulance Service Definitions

 The Transmittal also makes a number of clarifications to the ground ambulance services definitions set forth in Section 30.1.1 of Chapter 10 of the Medicare Benefit Policy Manual.  These changes are summarized below:

  • Basic Life Support (BLS) – CMS is revising the definition to align with the new minimum staffing requirements discussed above.
  • Basic Life Support (BLS) – Emergency – The current definition of the BLS emergency level of service reads as follows:

“When medically necessary, the provision of BLS services, as specified above, in the context of an emergency response.  An emergency response is one that, at the time the ambulance provider or supplier is called, it responds immediately.  An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.”

 CMS is removing the second and third sentences of the current definition.  In their place, CMS is inserting a parenthetical referencing the definition of an “emergency response” later in this same section of the manual.

  • Advanced Life Support, Level 1 (ALS1) – CMS is revising the definition to align with the new minimum staffing requirements discussed above. It is also clarifying that the ALS assessment must be provided by ALS personnel.
  • Advanced Life Support Assessment – The existing definition in the CMS Manual ends with the following sentence: “An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.” In recent years, a number of Medicare contractors have interpreted this sentence to mean that the provision of a valid ALS assessment would not necessarily entitle the ambulance supplier to bill for the ALS emergency base rate, unless the documentation clearly established the provision of an ALS intervention.

CMS is adding a sentence to the end of the definition that clarifies that an ambulance supplier would be permitted to bill for the ALS emergency base, even if the ALS assessment results in a determination that the patient would not require one or more ALS interventions.  CMS further clarified that the ability to bill for an ALS emergency base rate is predicated on the ambulance transport otherwise meeting the medical necessity requirement.

  • Advanced Life Support, Level 1 (ALS1) – Emergency – Similar to the change to the definition of BLS emergency discussed above, CMS is removing the second and third sentences of the current definition, and replacing them with a parenthetical reference to the definition of an “emergency response.”
  • Advanced Life Support, Level 2 (ALS2) – CMS is rewording the definition, without making any substantive change. ALS-2 continues to be billable in situations involving a medically necessary transport of a patient, where the crew either: (1) provides one of the seven listed ALS-2 procedures (manual defibrillation/cardioversion, endotracheal intubation, etc.) or (2) the administration of three or more medications by IV push/bolus or continuous infusion.  The changes largely relate to how you count, for purposes of determining whether you can bill ALS-2, multiple administrations of the same IV medication.  Conceptually, CMS is indicating that a single “dose” requires a suitable quantity and amount of time between administrations, in accordance with standard medical protocols.  CMS is further indicating that a deliberate attempt to administer a standard dose in increments would not qualify as ALS-2.  In sum, to the extent a medication is administered in standard doses in accordance with pre-existing protocols, each separate administration would count separately towards the ALS-2 standard of three or more administrations; however, any attempt to cut the standard dose into multiple administrations would count as only a single administration for purposes of determining whether the ALS-2 standard was met.
  • Specialty Care Transport (SCT) – CMS is rewording the language in the “Application” section of this definition, without making any substantive change.
  • Paramedic Intercept (PI) – CMS is revising the definition to reflect the change in how a “rural area” is identified. The old definition included any area: (1) designed as rural by a state law or regulation or (2) any area outside a Metropolitan Statistical Area (MSA) or in New England, outside a New England County Metropolitan Area.  Under the new definition, an area is considered rural to the extent it is designated as such by state law or regulation or to the extent it is located in a rural census tract of an MSA using the most recent version of the Goldsmith Modification.
  • Services in a Rural Area – CMS is eliminating the reference to New England County Metropolitan Areas, as these areas are no longer relevant to a determination of rural. Under the new definition, an area will be considered rural to the extent: (1) it is located outside a Metropolitan Statistical Area (MSA) or (2) is identified as rural using the most recent version of the Goldsmith Modification, even though the area falls within an MSA.
  • Emergency Response – CMS is adding language clarifying that the nature of an ambulance provider’s response (i.e., emergent or non-emergent) does not independently establish medical necessity for the ambulance transport.
  • Interfacility Transport – CMS is adding a new definition for the purposes of billing SCT, which establishes that the interfacility transportation requirement is met whenever the origin and destination are both one of the following: (1) a hospital or skilled nursing facility that participates in the Medicare program or (2) a hospital-based facility that meets Medicare’s requirements for provider-based status.

When a Capitated Payment Arrangement Makes Sense

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

Question

We operate a mid-sized ambulance services in the Midwest. Recently, one of our local hospitals entered into an agreement to become part of a large health system. We are increasingly being asked to transport patients from this local hospital to an affiliated facility in the neighboring city. These patients are being transported for consultations, medical tests, etc., and then being transported back to the local hospital. These transports become the financial responsibility of the health system, which has resulted in our monthly invoices to the hospital increasing nearly ten-fold over the past year. Recently, the hospital approached us with a proposal to move to a capitated payment arrangement. Are these arrangements permissible? And, if so, are there any “dos” and “don’ts” we should know about?

Answer

As the AAA’s Medicare Consultant, I am probably asked this question, or some variation of this question, several times a month. To me, these questions are a natural reaction by our industry to one of the larger tectonic shifts in health care over the past decade, namely the increasing footprint of national and regional hospital health care systems. According to the American Hospital Association, approximately 65% of hospitals nationwide were part of a larger health system in 2016. This is up from 51% in 1995. As these health systems have grown larger, ambulance providers are increasingly looking for alternatives to the traditional fee-for-service payment models.

Broadly defined, a “capitated payment” arrangement is any arrangement where the facility pays the ambulance provider a set amount to cover all or a portion of the transportation costs it incurs during a period of time, without regard to the specific volume of transports. A simple example would be a flat monthly fee for all transportation costs.

There is nothing in federal law that prohibits the use of capitated payment arrangements. The HHS Office of the Inspector General has signed off on capitated payment arrangements in numerous contexts, including the compensation paid to insurers under the Medicare Advantage Program (Medicare Part C). In fact, it could be argued that the Medicare Ambulance Fee Schedule includes some principles of capitation, e.g., it does not reimburse ambulance providers separately for certain ancillary services.

Therefore, capitated payment arrangements are something ambulance services can consider offering to their facility counterparties. However, you should aware that the normal prohibitions under the federal anti-kickback statute continue to apply. To the extent the OIG has a concern related to capitated payment arrangements, that concern would be that the capitated payment amount is used as a means of disguising an otherwise impermissible discount being offered to a potential referral source. In other words, the capitated payment must be structured in a way that avoids any improper remuneration to a potential referral source.

The arrangements do offer several advantages to both the ambulance provider and the facility. For the ambulance provider, the primary advantage is a stable, steady source of cash. However, there are other advantages, including the administrative benefits associated with submitting a simple monthly invoice, rather than a detailed invoice listing numerous transports. Many providers also find that a flat rate reduces tensions with the facilities, as they don’t have to engage in negotiations over why a particular transport is being billed to the facility. For the facility, the primary benefit is that it fixes their costs for transport during each measuring period. An ancillary benefit is that it offers a measure of insurance against unforeseen events (e.g., an MRI machine at hospital breaks down for an extended period of time, and as a result, the hospital is forced to incur the costs of sending patients to an affiliated facility for testing). Generally speaking, as the total volume of services rises, the benefits to moving away from a fee-for-service model also increases.

As noted above, capitated payment arrangements come in many forms, ranging from relatively simple to mind-numbingly complex. However, all arrangements share certain common features. The first is an estimate of the volume of services the facility would be purchasing from the ambulance service during any particular measuring period (hereinafter referred to as the “volume benchmark”). To the extent you are currently the facility’s vendor, this could be calculated based on past volume. This is then multiplied by the “price” of each service to arrive at the amount of the capitated payment. For example, if past history indicates that a facility pays for an average of 100 ambulance transports per month, and the parties agree to a rate of $200 per trip, then the monthly payment would be $20,000 per month. This monthly rate would stay the same regardless of whether the facility ends up responsible for 20 trips in the next month, or 200.

This brings us to one of the key features to a properly structured capitation agreement, i.e., both parties should have some degree of “risk” under the arrangement. In the example listed above, the facility runs the risk that the actual volume of services it would have otherwise been responsible for is less than the estimated 100. If so, it would have essentially paid more than $200 per transport. The ambulance provider bears the opposite risk, i.e., if the number of transports the facility would have paid for ends up being more than 100, it ends up receiving less than $200 per transport. As long as both parties bear risk, the arrangement is permissible.

If, however, one party bears no actual risk under the arrangement (e.g., because the monthly payment is based on an unreasonably low volume benchmark), the OIG could see the arrangement as a disguised way of rewarding the facility for other referrals. Thus, the key to any capitated arrangement is a good-faith estimate of the number of services involved. Please note that there is nothing wrong within incorporating language to adjust the monthly payment if the actual volume over any period of time is radically different than the volume benchmark. For example, I frequently include language that calls for the monthly payment to be recalculated if the actual volume is 20% more or less than the volume benchmark over any calendar quarter. These adjustments can be made prospectively (i.e., they only apply to future monthly payments) or they can be paid retroactively. To the extent you want to include an adjustment mechanism, the guiding principle is that any adjustment should be for the purpose of better estimating the volume benchmark.

Capitated payment arrangements may not be appropriate for all ambulance providers. However, as fee-for-service becomes an increasingly smaller portion of your facility partners’ operations, it may make sense to consider these arrangements.

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

Novitas – Denials

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

This advisory is for members who have Novitas as their Medicare Administrative Contractor.

On August 17, 2016, Novitas called me to let me know that they are seeing many ambulance claims denied due solely to the diagnosis codes that are listed on claims. Novitas requires a minimum of two ICD-10 codes, as follows:

  • A primary diagnosis code that describes the patient’s medical condition at the time of transport, AND
  • A secondary diagnosis code that reflects the patient’s need for the ambulance at the time of transport.

The list of primary ICD-10 codes was published by Novitas in their Ambulance Local Coverage Article A54574. While the ICD-10 codes in A54574 are not the only codes that will be accepted, it is highly recommended that you use one of those as your primary code, whenever possible.

Novitas also requires a secondary “diagnosis code”. This list is in their Ambulance Local Coverage Determination (LCD) Policy L35162. That has the four “Z” codes, at least one of which must be used as the secondary diagnosis code:

  • Z74.01 – Bed Confined
  • Z74.3 – needs continuous supervision (includes EKG)
  • Z78.1 – physical restraints (patient safety, danger to self/others)
  • Z99.89 – dependence on enabling machines (includes IV fluids, active airway management)

If the claim does not list a primary AND a secondary code, the claim is automatically denied. While the claim can be corrected and resubmitted for processing, that delays cash flow and adds time and expense for the ambulance supplier. Therefore, please make sure you list an appropriate primary code AND an appropriate secondary code.

 

AAA 2016 State Balanced Billing & Direct Pay Survey Results Released

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

Just Released!

View the AAA 2016 State Balanced Billing Survey Results

View the AAA 2016 State Direct Pay Survey Results

The AAA is providing its members with the results of two important surveys conducted of state laws impacting ambulance services.  The first chart entitled “2016 State Balance Billing Survey” shows whether a state restricts balancing billing of patients.  The second entitled “2016 State Direct Pay Survey” lists whether a state has a law requiring an insurer to send payment directly to a non-contracted ambulance service or a law allowing the insurer do send payment to the patient.  We thank AAA Medicare Consultant Brian Werfel for compiling the data and members of the AAA Medicare Regulatory Committee and the AAA membership to which Brian reached out for their assistance.

CMS Moratoria Update

Written by Kathy Lester on . Posted in Government Affairs, Medicaid, Medicare, Member Advisories, Member-Only, Regulatory.

The Centers for Medicare & Medicaid Services Lifts Moratoria on Enrollment of Part B Emergency Ground Ambulance Suppliers in All Geographic Locations; Moratoria for Part B Non-Emergency Ground Ambulance Suppliers Extended

Effective July 29, the Centers for Medicare & Medicaid Services (CMS) has lifted the temporary moratoria in all geographic locations for Part B emergency ground ambulance suppliers.  Beginning in 2013, CMS placed moratoria on Medicare Part B ground ambulance suppliers in Harris County, Texas, and surrounding counties (Brazoria, Chambers, Fort Bend, Galveston, Liberty, Montgomery, and Waller).  In February 2014, CMS announced it would add six more months to these moratoria and add Philadelphia, Pennsylvania, and surrounding counties (Bucks, Delaware, and Montgomery), as well as the New Jersey counties of Burlington, Camden, and Gloucester.  Since that date, CMS extended the moratoria four additional times, most recently in February of this year.

CMS considers qualitative and quantitative factors when determining if there is a high risk of fraud, waste, and abuse in a particular area and whether or not it should establish a moratorium.  If CMS identifies an area as posing an increased risk to the Medicaid program, the State Medicaid agency must impose a similar temporary moratorium as well.  CMS also consults with the Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) when identifying potential areas and providers/suppliers that should be subject to a temporary moratorium.  Finally, CMS also considers whether imposing a moratorium would have a negative impact on beneficiary access to care.  In areas where there is a temporary moratorium, the policy does not apply to changes in practice location, changes to provider/supplier information (e.g., phone number, address), or change in ownership.  Temporary moratoria remain in place for six months, unless CMS extends the policy through notice in the Federal Register.

CMS may lift a moratorium at any time if the President declares an area a disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, if circumstances warranting the imposition of a moratorium have abated, if the Secretary of HHS has declared a public health emergency, or if, in the judgment of the Secretary of HHS, the moratorium is no longer needed.  After a moratorium is lifted, providers/suppliers previously subject to it will be designated to CMS’s “high screening level” for six months from the date on which the moratorium was lifted.

CMS has announced it will lift the moratoria on new Part B emergency ambulance suppliers in all geographic locations because the Agency’s evaluation has shown the primary risk of fraud, waste, and abuse comes from the non-emergency ambulance supplier category and that there are potential access to care issues for emergency ambulance services in the areas with moratoria.  New emergency ambulance suppliers seeking to enroll as Medicare suppliers will be subject to “high risk” screening.  If enrolled, these suppliers will be permitted to bill only for emergency transportation services.  They will not be permitted to bill for non-emergency services.

The moratoria remain in place for Medicare Part B non-emergency ground ambulance suppliers for all counties in which moratoria already are in place in New Jersey, Pennsylvania, and Texas.

 

A Preliminary Estimate of 2017 Medicare Rates

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

 On July 15, 2016, the Bureau of Labor Statistics released its monthly report on inflation.  This release includes the change in the Consumer Price Index for all urban consumers (CPI-U) for June 2016.  As a result, it is now possible to make a preliminary estimate of the Ambulance Inflation Factor (AIF) for calendar year 2017.  The AIF is main factor that determines the increase (or decrease) in Medicare’s payment for ambulance services.

Calculating the 2017 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.  For 2017, this means the 12-month period ending on June 30, 2016.  Starting in calendar year 2011, the change in the CPI-U is 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 resulting AIF is then applied to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.

The formula used to calculate the change in the CPI-U is limited to positive increases.  Therefore, even if the change in the CPI-U was negative over a 12-month period (a rarity in the post-war era), the change in the CPI-U cannot be negative.  However, when the MFP reduction is applied, the statute does permit a negative AIF for any calendar year.  That is precisely what occurred in 2016, where the change in the CPI-U was 0.1% and the MFP was 0.5%.  As a result, the industry saw an overall reduction in its Medicare rates of 0.4%.

Fortunately, it seems unlikely that we will see a negative AIF in 2017.  For the 12-month period ending in June 2016, the Bureau of Labor Statistics (BLS) currently calculates the change in the CPI-U to be exactly 1.00%.

CMS has yet to release its estimate for the MFP in calendar year 2017.  However, assuming CMS’ projections for the MFP are similar to last year’s projections, the 2017 MFP is likely to be in the 0.5% range.

Therefore, at this time, my best guess is that the 2017 Ambulance Inflation Factor will be a positive 0.5%.

Please note that this estimate assumes the Bureau of Labor Statistics does not subsequently revise its inflation estimates.  Please note further that this projection is based on the MFP being similar to last year.  To the extent either of these numbers changes in the coming months (up or down), my estimate of the 2017 AIF would need to be adjusted accordingly.  Ultimately, the 2017 AIF will be finalized by CMS by Transmittal, which typically occurs in the early part of the 4th quarter.

Impact on the Medicare Ambulance Fee Schedule

 Assuming all other factors remained the same, calculating your 2017 Medicare rates would be a relatively simple exercise, i.e., you would simply add 0.5% to your 2016 rates.  However, as part of its 2017 Physician Fee Schedule Proposed Rule (issued on July 15, 2016), CMS proposed extensive changes to the GPCIs.   These changes can be viewed by going to the Physician Fee Schedule page on the CMS website and clicking the link for the “CY 2017 PFS Proposed Rule GPCI Public Use Files” (located in the Downloads section).  You would then need to open the file for “CY 2017 Proposed Addendum E.”

If the PE GPCI in your area is proposed to increase, you can expect your 2017 Medicare rates to increase by slightly more than 0.5%.  If the PE GPCI in your area is proposed to decrease, you can expect your 2017 Medicare rates to increase by slightly less than 0.5%.

If you are looking for a more precise calculation of your rates, you will need to use the following formulas:

Ground Ambulance Services

Medicare Allowable = (UBR x .7 x GPCI) + (UBR x .3)

Air Ambulance Services

Medicare Allowable = (UBR x .5 x GPCI) + (UBR x .5)

 In this formula, the “UBR” stands for the unadjusted base rate for each HCPCS code.   These are calculated by multiplying the national conversation factor by the relative value unit assigned to each base rate.  To save some time, estimates for the 2017 unadjusted base rates are reproduced below:

Base Rate (HCPCS Code)

 2017 Unadjusted Base Rate
BLS non-Emergency (A0428)                     $221.84
BLS emergency (A0429)                     $354.95
ALS non-emergency (A0426)                     $266.21
ALS emergency (A0427)                     $421.51
ALS-2 (A0433)                     $610.08
Specialty Care Transport (A0434)                     $721.00
Paramedic Intercept (A0432)                     $388.23
Fixed Wing (A0430)                     $3,010.52
Rotary Wing (A0431)                     $3,500.17

 

Plugging these UBRs into the above formulas will result in adjusted base rates for each level of ground and air ambulance service.  The final step would be to apply the current adjustments for urban (2%), rural (3%) and super-rural (22.6% over the corresponding rural rate).

2017 Projected Rates for Mileage:

At this time, I am estimating the following rates for Medicare mileage:

Base Rate (HCPCS Code) 2017 Unadjusted Base Rate
Ground Mileage – Urban                     $7.28
Ground Mileage – Rural Miles 1 – 17                     $11.02
Ground Mileage – Rural Miles 18+                     $7.35
Fixed Wing Mileage – Urban                     $8.54
Fixed Wing Mileage – Rural                     $12.81
Rotary Wing Mileage – Urban                     $22.79
Rotary Wing Mileage – Rural

 

                     $34.19

Please keep in mind that a number of assumptions went into these projections.  The Bureau of Labor Statistics can revise its inflation figures in the coming months.  CMS may announce an MFP projection that differs from what we expect.  CMS may also announce that it is electing not to finalize its proposed changes to the GPCI (highly unlikely).   If any of these assumptions was to change, these projections would need to be revised.  Therefore, I would suggest that you view these as rough estimates at best.  The AAA will update members as more information becomes available in the coming months. 

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

Save big on ZOLL with Savvik!

Written by Amanda Riordan on . Posted in Member-Only, Operations.

Use the Savvik Buying Group discount included with your AAA membership to save on the ZOLL products you are already buying. Simply ask your ZOLL sales representative to apply the Savvik contract rates to your next purchase. That’s it!

AAA’s ZOLL discount program through Savvik Buying Group can save you BIG!

Automated External Defibrillators, Related Equipment, Accessories & Product Upgrades

  • 32% discount on AED Plus defibrillators
  • 32% discount on AED Pro defibrillators
  • 25% discount on all accessories and disposables
  • 25% discount on product upgrades
  • Multiple Unit Sales: Additional discounts available for 2 or more units in a single purchase order

ZOLL_logoALS Monitors / Defibrillators and Automated CPR Devices Related Equipment, Accessories & Product Upgrades

  • 2% discount on AutoPulse
  • 18% discount on X Series defibrillators and related accessories
  • 18% discount on Propaq MD defibrillators and related accessories
  • 25% discount on M Series & E Series related accessories and disposables
  • Multiple Unit Sales: Additional discounts available for 2 or more units in a single purchase order

Ask your ZOLL rep to use the AAA’s Savvik Buying Group contract to receive these savings. It’s that easy!

Questions? Contact office@savvik.org to learn more, or for full pricing information.

MedPAC Issues June 2016 Report to the Congress

Written by Kathy Lester on . Posted in Finance, Government Affairs, Medicare, Member Advisories, Member-Only, Regulatory.

MedPAC Issues June 2016 Report to the Congress with Chapter on Improving Efficiency and Preserving Access to Emergency Care in Rural Areas

Medicare Payment Advisory Commission (MedPAC or the Commission) has issued its June 2016 Report to the Congress.   The June report includes recommended refinements to Medicare payment systems and identifies issues affecting the Medicare program, broader changes in health care delivery, and the market for health care services.

Chapter 7 focuses on preserving access to emergency care in rural areas.  The Commission recognizes that access to inpatient and emergency services in rural areas is threatened because of the dwindling populations.  Declining populations can lead to fewer hospital admissions and reduced efficiencies that can create financial and staff problems for hospitals.  The Report notes that “[d]eclining volume is a concern because low-volume rural hospitals tend to have worse mortality metrics and worse performance on some process measures.” In addition, “low-volume CAHs have the difficult job of competing with each other for a shrinking pool of clinicians who want the lifestyle of operating an outpatient practice during the day, covering inpatient issues that arise at night, and covering the emergency department.”

Under current policies, most rural hospitals are critical access hospitals (CAHs).  They receive a cost-based payment for providing inpatient and outpatient services to Medicare beneficiaries.  To receive these payments, a hospital must maintain acute inpatient services.  In rural areas, many small towns do not have a sufficient population to support such a model.  Yet eliminating these services would mean giving up the supplemental payments that their hospitals receive through the CAH cost-based payment model.

The hospital prospective payment system serves as the payment model for other hospitals.  Rural providers receive supplemental payments, which are also linked to providing inpatient services.

MedPAC highlights the concerns with cost-based payment models:

  • Cost-based payments do not direct payments toward isolated hospitals having the greatest financial difficulty, but rather reward hospitals in high-income areas with higher non-Medicare margins by providing them with higher Medicare payments.
  • Cost-based payments encourage providers to expand service lines with high Medicare and private-payer shares rather than primarily focus on services that are needed on an emergency basis.
  • Cost-based models reduce the incentive for hospitals to control their costs, which can lead to unnecessary growth in capital costs, despite declining volumes.

In light of these challenges, MedPAC sets forth a two of options that would give isolated rural hospitals the option of converting to an outpatient-only model while maintaining their special payment arrangements.  These models seek to ensure access to essential services:

  • Establishing a 24/7 emergency department model; and
  • Adopting a clinic with ambulance services model.

Under the 24/7 emergency department model, the hospital would be paid under the outpatient prospective payment rates and would receive an annual grant/fixed payment from Medicare to cover the standby costs associated with 24/7 emergency services.  The current supplemental payments would be redirected to support this annual grant/fixed payment amount.  If a hospital chose to use inpatient beds as skilled nursing facility (SNF) beds, it would be reimbursed under the Medicare SNF prospective payment system.  The hospital could be required to use the fixed payment for emergency standby capacity, ambulance service losses, telehealth capacity, and uncompensated care in the emergency department.

Under the clinic and ambulance model, hospitals could convert their existing inpatient facilities into primary care clinics.  These clinics would be “affiliated” with an ambulance service.   Medicare would pay the prospective rates for primary care visits and ambulance transports.  Medicare would provide an annual grant/fixed payment to support the capital costs of having a primary care practice, the standby costs of the ambulance service, and uncompensated care costs.

The Commission recognizes that the “low population density would also make it difficult to retain primary care providers and support an ambulance service.”  It could also be difficult to describe the exact level of primary care and ambulance access that is required to receive the fixed Medicare payment.

MedPAC reiterates its position that “supplemental payments beyond the standard PPS rates should be targeted to isolated rural providers that are essential for access to care.”  Thus, it states that a program to support stand-alone emergency departments should be limited to facilities that are a minimum distance in road miles from the nearest hospital.

 

Prior Authorization Pilot Program – Status Update

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

CMS released preliminary data on the impact of the prior authorization demonstration program on Medicare payments for ambulance services.  This data is limited to the three states (NJ, PA, and SC) that were included in the demonstration program’s first year.

CMS noted that it has observed a dramatic decrease in expenditures for repetitive non-emergency ambulance transports since the program’s implementation.  CMS released the following data for the first 10 months of the program (i.e. December 2014 – September 2015), comparing that data to the first 11 months of 2014:

  • Payments for repetitive non-emergency ambulance transportation in these states averaged $5.4 million per month, down from nearly $18.9 million per month prior to the program’s implementation. This is a reduction of more than 70%.
  • In the states that were not part of the demonstration program, payments have decreased very slightly for the 10 months in 2014 and are very similar to the payments in the 11 months prior to the program beginning in SC, NJ and PA.
  • 18,367 prior authorization requests were received and finalized by Medicare’s contractors. Of these, 6,430 (35.0%) were approved.

CMS is closely monitoring these results to evaluate its effectiveness. Here is the full status update.

New Member Benefit: StateTrack

Written by Aidan Camas on . Posted in Government Affairs, Legislative, Member-Only, Regulatory.

Introducing the AAA’s newest member benefit, StateTrack, powered by CQ Roll Call. StateTrack will give AAA members the ability to easily track crucial legislation and regulations in one state or all of them as well as the Federal Government.

StateTrack Map

AAA StateTrack

StateTrack will show you a map of the entire United States. Click on the state you are interested in tracking and you will see a list of all regulations and legislation impacting the following areas:

► Affordable Care Act
► Ambulance
► Community Paramedicine
► EMT
► Medicaid
► Medicare
► Mobile Integrated Health
► Paramedic

Click on the key words above to narrow down your search to only legislation and regulations that contain those terms.

Members will be able to view the full text of each piece of legislation as well as edits that have been made to the text, bill number, status of the bill and the representative who introduced it. StateTrack will make it easier for AAA members to keep track of legislation and regulations on the state level that could have enormous impacts on their ambulance services. States that are white, are either out of session or do not have any pending legislation or regulations that fall under the AAA search criteria.

Please contact Aidan Camas at acamas@ambulance.org if you have any questions.

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