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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.

CMS Extends Moratorium on Non-Emergency Ground Services

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

CMS Extends Temporary Moratorium on Non-Emergency Ground Ambulance Services in New Jersey and Pennsylvania

The Centers for Medicare & Medicaid Services (CMS) has announced that it intends to extend the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey and Pennsylvania.  The extended moratoria will run through January 29, 2019.  Notice of the extension of the temporary moratorium will appear in the Federal Register on August 2, 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.  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 moratoriums were subsequently extended on August 1, 2014, February 2, 2015, July 28, 2015, and February 2, 2016.

On August 3, 2016, CMS announced changes to the moratoria on the enrollment of new ground ambulance suppliers.  Specifically, CMS announced that: (1) the enrollment moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier and (2) the enrollment moratoria on non-emergency ambulance services would be expanded 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.  The revised moratorium on newly enrolling non-emergency ground ambulance providers was subsequently extended on January 9, 2017 and July 28, 2017.

On September 1, 2017, CMS issued a notice on its website indicating that it had elected to lift the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017.  CMS indicated that this decision was made to assist in the disaster response to Hurricane Harvey.  CMS published formal notice of the lifting of this moratorium on November 3, 2017.

On January 30, 2018, CMS announced an extension of the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in New Jersey and Pennsylvania.

CMS will need to make a determination on whether to extend or lift the enrollment moratorium on or before January 29, 2019.

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

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

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

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

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

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

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

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

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

 

 

OIG Report on Overpayments For Non-Emergency Transports

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

OIG Report – Overpayments For Non-Emergency Ambulance Transports To Non-Covered Destinations

The Office of the Inspector General released its report “Medicare Improperly Paid Providers for Non Emergency Ambulance Transports to Destinations Not Covered by Medicare“.

In sum, the OIG reviewed claims that Medicare paid for 2014 – 2016 non-emergency ambulance transports. The review focused on transports to non-covered destinations. OIG found that $8,633,940 was paid by Medicare for non-emergency ambulance transports under codes A0425 (ground mileage), A0426 (ALS non-emergency) and A0428 (BLS non-emergency) during this period of time.

The review was based solely on the claims and not based on a medical review or interviews of providers.

The claims that should not have been paid were to the following destinations:

  • 59% – to diagnostic or therapeutic sites other than a hospital or physician’s office, that did not originate at a SNF.
  • 31% – to a residence or assisted living facility (and not meeting the origin/destination requirement).
  •  6% – to the scene of an acute event.
  •  4% – to a destination code not used for ambulance claims or where no destination modifier was used.
  • <1% – to a physician’s office.

OIG recommended (and CMS agreed) that CMS:

  1. Notify the Medicare Administrative Contractors to recover that portion of the overpayment that is within the 4-year period in which claims can be re-opened.
  2. For the balance of the overpayment that is outside the 4-year period, CMS should provide the information needed for the MACs to notify the providers of the overpayments and have the providers exercise reasonable diligence to investigate and refund improper payments.
  3. Direct the MACs to review the origin/destination requirements for any overpayments following the audit period.
  4. Require the MACs implement edits to ensure they only pay for non-emergency transports that meet the Medicare requirements.

There is a chart in the report that indicates the improper payments for each jurisdiction. It is interesting to note that the overpayments range from a low of $515 (First Coast) to a high of $5,006,696 (Cahaba).

The report can be obtained at: https://go.usa.gov/xU5vf

Physician Fee Schedule Proposed Rule 2018

Written by Kathy Lester on . Posted in Cost Data Collection, Government Affairs, Medicaid, Member Advisories, Member-Only, News, Reimbursement.

On Thursday, July 12, the Centers for Medicare & Medicaid Services (CMS) released the “Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program” Proposed Rule (Proposed Rule).

As you know, the American Ambulance Association worked closely with the Congress to ensure passage of the Bipartisan Budget Act of 2018 (BBA) (Pub. L. 115-123, enacted on February 9, 2018). The BBA not only extended the ambulance add-ons for 5 years, but also authorized a cost collection system that would not be overly burdensome on ambulance providers and suppliers, but would provide sufficient information ideally to support the permanent extension of the add-ons and set the basis for new payment models, including alternative destinations, treatment/assessment without transport, and community paramedicine.

After passage of the BBA, the AAA engaged immediate with CMS to ensure the smooth implementation of these provisions. Those contacts resulted in guidance earlier this year implementing the add-ons retroactively to January 1, 2019.

Consistent with the statute and already-released guidance, the Proposed Rule extends the three add-ons: the 2 percent urban, 3 percent rural, and 22.6 percent super-rural add-ons.  The Proposed Rule would codify the extension of the add-ons through December 31, 2022.

The Proposed Rule would implement the increase in the reduction in rates for non-emergency ambulance transports to/from dialysis facilities for services furnished on or after October 1, 2018. The 10 percent reduction applies for these transports furnished during the period beginning on October 1, 2013 and ending on September 30, 2018. The reduction will increase to 23 percent to conform the regulations to the statutory requirement for services furnished on or after October 1, 2018.

CMS does not request any information about the cost collection system in the Proposed Rule, but has been soliciting comments and recommendations through informal provider/supplier calls.  Additionally, the AAA has been in regular contact with CMS on the structure, design, and data elements to ensure the successful implementation of this critically important system as well.

Ambulance Cost Data Collection is Coming

Written by Tristan North on . Posted in Cost Data Collection, News, Press, Reimbursement.

Although the most prominent ambulance provision passed in the Bipartisan Budget Act of 2018 (H.R. 1892) was the five-year extension of the Medicare add-ons, the Act also included important language directing the Centers for Medicare and Medicaid Services (CMS) to collect cost and other financial data from ambulance service suppliers and providers.

This week, an editorial from AAA Senior Vice President of Government Affairs Tristan North was featured in the June issue of JEMS‘s “EMS Insider”. Read the full article►

Spotlight: Gold Cross Ambulance Celebrates 50 Years in Business

Written by Aidan Camas on . Posted in News, Service, Spotlight.

Gold Cross Ambulance Celebrates 50th Anniversary!

 

When Gene Moffitt founded Gold Cross Ambulance in March 1968, he didn’t know that 50 years later the company would be where it is today, the longest-running and largest private ambulance service in Utah.

At its core, Gold Cross is a family-run business. In fact, Gold Cross started out of the Moffitts’ home after he rented two Cadillac ambulances. In the beginning, Moffitt and two or three other employees responded to calls from the family home, where his wife, Julia, oversaw dispatch operations while caring for their young children. Julia has been central to the business since the beginning and has played an essential role in Gold Cross’s continued success.

Today Gold Cross employs over 500 people, operates around 140 ambulances, and responds to hundreds of 911 calls a day. Despite this growth, Gold Cross remains a family business with deep roots in the community—something that the Moffitts are very proud of.

Gene Moffitt
Early Days of Gold Cross Ambulance

Moffitt points to a couple of factors that have made Gold Cross’s journey a successful one. First, he’s always had a knack for being in the right places at the right time. But he believes that being honorable to the commitment he has made to provide high-quality healthcare to the people of Utah has been critical to his company’s ongoing success. “Success has not come to Gold Cross without much sacrifice over the years,” Moffitt says. “Growing and expanding has not been an easy process, but with dedication and a bit of luck, Gold Cross has been able to overcome the many trials and tribulations we’ve faced.”

Of course when you’ve been in business for 50 years, you’ll have seen many changes to your industry. Moffitt says one of the biggest changes he’s witnessed has been the buyouts of many ambulance services over the years, and that’s something he believes has been both good and bad for the industry. “When large companies buy out smaller ones,” he explains, “the connection of the ambulance service to the community that there was in the past is lost.” Moffitt notes that Gold Cross has never tried to go into another area unless it has been asked to. “Going into a new area to provide service is a delicate process,” he says. ”You must re-prove yourself to the community while being sensitive to the locals and to employees who may come over from the previous provider.” As a family-run business, nurturing the bond between Gold Cross and the communities it serves has always been very important to the Moffitt family.

Looking back on a more personal level, Moffitt has many memories he is proud of. The other day he came across a photo of one of the first babies that Gold Cross transported by ambulance in 1968 or 1969. Gold Cross worked closely with Dr. Larry Jung, a pioneering neonatologist, to help him provide life-saving care to children in Utah. “I’m in awe of how the medical community has really evolved over the last 50 years to give sick newborns and infants a better chance to live,” Moffitt says, smiling. “The baby in that photo would now be 50 years old!”

Gold Cross was also involved in the first heart transplant that took place in Utah. Gold Cross helped the hospital move the patient back and forth with the tremendous amount of equipment necessary for the procedure. The company also played a large role in the Salt Lake City Olympics back in 2002.

Moffitt also made many lifelong friendships because of his involvement with the AAA, including through  his work as a past President of the association. He notes that the early AAA days were very important to his work at Gold Cross, giving his ambulance service access to resources and information that Gold Cross would not have had on its own. “The AAA helps foster a friendly relationship amongst providers,” he adds, “and members are very willing to share information about best practices and other experiences.”

Moffitt is working on bringing the company’s past and present together very visually, while giving a confident nod to the future. Gold Cross is refurbishing its remaining 1960 Cadillac ambulances and has also purchased a new ambulance to celebrate the 50th anniversary. When the brand-new ambulance is shown off alongside the 1960s ambulance, it will give a clear picture of where Gold Cross has come from and where the company is going.

Gold Cross Restored Cadillac Ambulance
New Gold Cross 50th Anniversary Ambulance

And of course there will be numerous celebrations with staff and family, both of whom have been critical to Gold Cross’s success over the years.

One thing that has stayed exactly the same? Moffitt’s vision for Gold Cross—“to provide quality medical care and customer service to anyone, regardless of race, creed, color, religion, or the ability to pay.”

Please join the AAA in congratulating Gene, Julia, the Moffitt family, and Gold Cross Ambulance on 50 years of providing high-quality healthcare to the people of Utah.

Congratulations, and here’s to many more successful years!

Summary of March 2018 Ambulance Open Door Forum

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

CMS held its latest Open Door Forum on Wednesday, March 7, 2018. As with past Open Door Forums, CMS started the call with the following series of announcements:

Medicare Fee Schedule – CMS indicated that the Bipartisan Budget Act of 2018, enacted on February 9, 2018, contained several provisions that impacted the payment of ambulance claims under the Medicare Ambulance Fee Schedule:

  • Temporary Add-Ons for Ground Ambulance – CMS indicated that Section 50203(a) of the bill extended the temporary add-ons for ground ambulance services for an additional five years, retroactive back to January 1, 2018.  As extended, these add-ons will expire on December 31, 2022.  These add-ons increase Medicare’s allowable for ground ambulance base rates and mileage by 2% in urban areas, 3% in rural areas, and by 22.6% (over the applicable rural rate) for services provided in so-called “super rural” areas.
  • Cost Reporting – CMS indicated that Section 50203(b) of the bill would require ground ambulance providers and suppliers to submit cost data to CMS. CMS noted that the new law requires CMS to develop, no later than December 31, 2019, a data collection system to collect cost, revenue, utilization, and certain other information related to ground ambulance services. The law provides that cost data will be collected using a survey methodology, with a representative sample of ambulance providers and suppliers being asked to submit cost data in any given year.  Finally, CMS noted that, starting on January 1, 2022, providers or suppliers that fail to submit the requested cost data would be subject to a 10% reduction in their Medicare payments, unless otherwise exempted on the basis of significant hardship.
  • Additional Reduction in Medicare Payment for Dialysis Transports – Section 53108 of the bill provides that the Medicare allowable for non-emergency, basic life support transports to and from dialysis will be subject to a further 13% reduction.  This reduction would go into effect for dialysis transports with dates of service on or after October 1, 2018. This would be on top of the existing 10% reduction in Medicare’s payment for dialysis transports, for a total reduction of 23%.

Temporary Enrollment Moratorium – CMS indicated that the temporary moratorium on the enrollment of new ground non-emergency ambulance providers in Texas was lifted on September 1, 2017. CMS further indicated that the enrollment moratorium was extended for the states of New Jersey and Pennsylvania for an additional six months on January 29, 2018. CMS will need to make a determination on or before July 29, 2018 on whether to lift the moratorium or extent it for an additional six months in that state.

Following the announcements, CMS moved into a brief Question & Answer period.  Most of the questions were not answered on the call; instead, CMS took the contact information of the person asking the question, and indicated that they would respond directly to them at a later date.  However, the following questions were answered:

  1. CMS indicated that a Change Request had been sent to all Medicare Administrative Contractors (MACs) informing them of the new, adjusted fee schedule amounts. CMS further indicated that this Change Request, which it indicated was confidential, provided further instructions to the MACs on when and how to adjust claims initially paid at the original 2018 rates.
  1. CMS confirmed that the adjusted rates are retroactive to January 1, 2018. Accordingly, CMS indicated that claims paid at the original 2018 rates will be adjusted by the MACs at some future date.
  1. CMS indicated that it recently released its First Interim Evaluation Report on the Medicare Prior Authorization Model for repetitive, non-emergency ground ambulance transports. CMS further indicated that it was still reviewing this report, and that no decision has yet been made on the extension of this model within the existing 9 states and the District of Columbia and/or the expansion of the model to additional states.

Have questions? Please write to the Werfels at bwerfel@aol.com.

AAA Releases Updated 2018 Medicare Rate Calculator

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

CMS Posts Updated 2018 Public Use File; OIG Guidance on Waiver of Small Cost-Sharing Balances Updated AAA 2018 Medicare Rate Calculator Now Available!

The Centers for Medicare and Medicaid Services (CMS) has posted an updated version of the 2018 Medicare Ambulance Fee Schedule Public Use Files (PUF). These files contain the Medicare allowed base rate reimbursement amounts for the various levels of ambulance service and mileage rates. These files reflect the restoration, retroactive to January 1, 2018, of the temporary add-ons for ground ambulance services (2% for urban transports, 3% for rural transports, and the “super-rural” bonus) pursuant to the Bipartisan Budget Act of 2018, which was enacted on February 9, 2018.

2018 Fee Schedule

Accuracy of Rates and AAA Fee Calculator

The American Ambulance Association has reviewed the rates in this file and confirmed that the rates are accurate. The AAA has also revised its Medicare Ambulance Rate Calculator to reflect the five-year extension of the ambulance add-ons as well as other policy changes including the two-year extension (2026 and 2027) of the 2% Medicare provider cut under sequestration and the additional 13% (23% total) cut to BLS nonemergency transports to and from dialysis centers. The additional dialysis transport cut takes effect on October 1, and as a modifier, is not included in the Public Use File.

Download the 2018 Rate Calculator

Reformatted Version of PUF

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 ambulance services would necessarily know off-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 on the AAA website.

CMS has yet to announce a timetable for adjusting claims that were paid at the original fee schedule amounts. It is anticipated that CMS will make an announcement on this timetable in the next few weeks.

Coinsurance

One issue that frequently arises in these situations is how ambulance providers and suppliers should treat the additional coinsurance amounts that are generated when CMS and its contractors adjust claims from the original allowed amounts to the now higher allowed amounts. These additional coinsurance amounts are typically quite small. Ambulance providers and suppliers may determine that the costs associated with trying to collect these small amounts would likely exceed the amounts they could reasonably hope to collect. The question is whether writing off these small balances could be construed as a routine waiver of cost-sharing amounts, a practice prohibited under Medicare’s rules.

In 2010, the HHS Office of the Inspector General (OIG) issued guidance on this issue. Specifically, the OIG indicated that it would not seek to impose administrative sanctions on Medicare providers and suppliers that waive these amounts provided the following conditions are met:

• The waiver is limited to the increased cost-sharing amounts generated upon adjustment of claims previously paid at the lower allowable, i.e., it does not apply to cost-sharing amounts associated with claims paid at the increased allowables;
• The waiver is limited to the small balances created by the adjustment of claims, i.e., it does not apply to the cost-sharing amounts originally imposed on the beneficiary when the claim was paid at the lower amounts;
• The waiver must be offered uniformly to all affected beneficiaries;
• The waiver must not be advertised; and
• The waiver must not be conditioned on the beneficiary’s receipt of any items, suppliers, or services.

Assuming the above-referenced conditions are met, ambulance providers and supplier can safely write-off these small balances. Please note that the OIG is not indicating that ambulance providers and suppliers must write-off these amounts. Rather, the OIG is simply indicating that this is an option available to health care providers and suppliers impacted by retroactive adjustment of claims.

Download the 2018 Rate Calculator

2018 Fee Schedule

VA Issues Rule Expanding Coverage of Ambulance Services

Written by Brian Werfel on . Posted in Member Advisories, News, Reimbursement, Veterans Affairs.

Veterans Administration Issues Interim Final Rule Expanding
Coverage of Ambulance Services under Millennium Bill

On January 9, 2018, the Department of Veterans Affairs issued an interim final rule that would amend its policy for payment of Millennium Bill claims. The Millennium Bill authorizes the Veterans Administration (VA) to pay for emergency care provided to veterans in non-VA facilities — including emergency ambulance transportation — provided the veteran has no other health insurance that would cover the costs of such emergency care. These changes were necessitated, in part, by a recent decision of the U.S. Court of Appeals for Veterans’ Appeals (Staab v. McDonald, 28 Vet. App. 50, 2016).

The two major changes being made by the interim final rule are: (1) the expansion of payment eligibility to include veterans who received partial payment or reimbursement from a health plan for their non-VA emergency care and (2) the expansion of payment eligibility for emergency transportation associated with a veteran’s receipt of emergency treatment in a non-VA facility.

These changes went into effect on January 9, 2018.

Relevant Background

38 U.S.C. §1725 authorizes the VA to reimburse veterans for the costs of emergency treatment for non-service connected conditions furnished in a non-VA facility, provided certain criteria were met. One requirement was that the veteran be personally liable for the costs of that emergency treatment. As originally enacted in 1999, the statute indicated that the veteran would be personally liable if the veteran: (1) has no entitlement to care or services under a health-plan contract and/or (2) the veteran had no contractual or legal recourse against a third party that would, in part or in whole, extinguish such liability. The VA historically interpreted its payment obligations under the Millennium Bill to be limited to situations where the veteran had no entitlement to coverage under their health insurance or any other contractual or legal recourse against a third party.

The Expansion of Veteran Eligibility for Reimbursement Act of 2010 amended the requirements related to non-health insurance payments to remove the phrase “in part”. As a result, the VA revised its regulations to permit it to make a payment under the Millennium Bill in situations where automobile or other forms of non-health insurance made a partial payment, and where the veteran remained liable for the balance of the health care provider’s bill. However, there was no corresponding change made to the provisions related to health insurance contracts. As a result, the VA continued to view partial payment by a health plan as a bar to payment by the VA.

In Staab, the Court of Appeals adopted a more lenient interpretation of the statute, i.e., a more restrictive view of the VA’s statutory bar on reimbursement. Specifically, the Court held that the reimbursement bar would only apply when the payment from the health plan fully extinguished the veteran’s liability. The practical effect was to place health insurance plans on equal footing with other forms of insurance. The Court remanded the case back to the lower court for further proceedings.

The VA subsequently appealed the Court of Appeals decision. However, on June 14, 2017, Veterans Affairs Secretary David Shulkin announced that the Department would drop its appeal.  Reversing course, Secretary Shulkin indicated that the VA had drafted regulations to implement the expanded Millennium Bill coverage. Those regulations form the basis of this interim final rule.

Provisions of Interim Final Rule

Partial Payment from Health Insurance Plan

The VA revised its regulations at 38 C.F.R. §17.1002(f) to indicate that the VA will make payment under the Millennium Bill to the extent the veteran otherwise qualifies for coverage to the extent that the veteran “does not have coverage under a health-plan contract that would fully extinguish the medical liability for the emergency treatment.” The VA retained the reimbursement bar for situations where the veteran would have been covered under a health plan had the veteran or the provider failed to comply with the requirements of that health plan, e.g., by failing to submit a timely claim. This change will apply to: (1) all claims pending with the VA as of April 8, 2016 or (2) submitted after that date.

Expansion of Payment Authority for Emergency Transportation

The VA historically viewed emergency ambulance transportation to the non-VA facility as part of the overall emergency treatment of the veteran. As a result, the VA believed that a health plan’s payment for the hospital care, in whole or in part, triggered its reimbursement bar. One common situation that impacts ambulance suppliers involves veterans that have Medicare Part A benefits (which cover the costs of their hospital care), but where the veteran has elected to forego paying for Medicare Part B.  In these situations, Medicare would pay for the hospital care. The VA took the position that this triggered the reimbursement bar, and therefore prevented it from making payment for the emergency ambulance transportation.

Because the interim final rule expands Millennium Bill coverage to include situations where a health plan makes a partial payment, the VA found it necessary to amend its regulations governing the payment of ambulance claims. Specifically, the VA amended its regulations at 38 C.F.R. 17.1003 to provide that ambulance providers will now be eligible for payment provided the following conditions are met:

  1. Payment for emergency care provided at the non-VA facility is authorized or would have been authorized had:
  2. The veteran’s personal liability for the emergency treatment was not fully extinguished by payment by the health plan or other third-party; or
  3. Death not occurred before emergency treatment (at the hospital) could be provided);
  4. The veteran is financially liable to the ambulance provider;
  5. The veteran does not have coverage under a health insurance plan that would fully extinguish the medical liability for the emergency transport (and further provided that the veteran or the provider has timely filed a claim with the health plan);
  6. If the emergency transportation is the result of an accident or work-related injury, the veteran must have reasonably exhausted his remedies against a third-party payor (e.g., auto insurance policy or workers’ compensation policy); and
  7. The veteran remains liable for all copayments and deductibles.
Effect of Coinsurance and Deductibles

The A.A.A. has confirmed that the VA does not consider the coinsurance or deductible obligations imposed by a veteran’s health plan for the purposes of determining whether the veteran’s liability has been fully extinguished by the health plan’s payment.

Therefore, in situations where the veteran has health care coverage, payment by the VA is likely to be limited to situations where the ambulance provider is permitted under state and local laws to bill patients for the difference between their billed charges and the amounts allowed by the health insurer, i.e., those areas that currently permit balance billing. This would also mean that the VA would be unlikely to have any payment responsibility in situations where Medicare has made payment on the ambulance claim (although it leaves open the possibility that the VA may be responsible for non-covered Medicare services such as excess mileage).

Amount of Payment

 When the VA pays under this expanded Millennium Bill authority, its payment will be based on the following methodology:

  1. When the veteran has no coverage under a health plan or other third-party payor, the VA will pay the lesser of: (a) the amount for which the veteran is personally liable or (b) 70% of the applicable Medicare allowable;
  2. When partial payment is made by a health plan or other third party payer, the VA will pay the difference between: (a) the amount the VA would have paid under the preceding bullet point (typically 70% of the Medicare allowable) or (b) the amount paid (or payable) by the health plan or other third-party payor; provided that amount is greater than zero;
  3. If the calculation in the preceding bullet point would not result in the VA making a payment (i.e., because the resulting amount would be less than zero), the VA will pay the lesser of: (a) the veteran’s personal liability after the third-party payment (excluding deductibles and copayments) and (b) 70% of the applicable Medicare allowable;
  4. In the absence of a corresponding allowable, the VA will be the lesser of: (a) the amount for which the veteran is personally liable or (b) the amount calculated by the VA Fee Schedule in 38 C.F.R. 17.56(a)(2)(i)(B).

Payment from the VA is generally considered to be payment-in-full, and extinguishes the veteran’s remaining liability to the provider for unpaid amounts. Note: the veteran would remain liable for unpaid co-payments and deductibles. If the provider does not wish to accept the VA’s payment, it has 30 days from its receipt of such payment to reject and refund the payment.

Have any Medicare questions? Contact Brian at bwerfel@aol.com

CMS Extends Moratorium on Non-Emergency Ground Services

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

CMS Extends Temporary Moratorium on Non-Emergency Ground
Ambulance Services in New Jersey and Pennsylvania

On January 30, 2018, 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 and Pennsylvania. The extended moratoria will run through July 29, 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. 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 moratoriums were subsequently extended on August 1, 2014, February 2, 2015, July 28, 2015, and February 2, 2016.

On August 3, 2016, CMS announced changes to the moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that: (1) the enrollment moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier and (2) the enrollment moratoria on non-emergency ambulance services would be expanded 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. The revised moratorium on newly enrolling non-emergency ground ambulance providers was subsequently extended on January 9, 2017 and July 28, 2017.

On September 1, 2017, CMS issued a notice on its website indicating that it had elected to lift the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017. CMS indicated that this decision was made to assist in the disaster response to Hurricane Harvey.  CMS published formal notice of the lifting of this moratorium on November 3, 2017.

On or before July 29, 2018, CMS will need to make a determination on whether to extend or lift the enrollment moratorium.

Have any Medicare questions? Contact Brian at bwerfel@aol.com

Alert: Medicare Increases Will Expire For Now: What You Need to Know

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

While the Congress succeeded in passing the Republican tax bill and keeping the federal government open with a short-term continuing resolution that included a temporary extension for the State Children’s Health Insurance Program (CHIP), it did not act upon the several Medicare extenders that expire on December 31, 2017. This extenders package includes the ambulance add-ons for urban, rural, and super-rural areas, as well as a moratorium on therapy caps, extenders for hospitals, and several other extenders important to other Medicare providers.

Despite the fact that the Congress left town, there is still strong bipartisan support for reinstating these extenders – including the ambulance extenders – early in January 2018. The most likely time frame will be for the extenders to be added to the next government funding legislation, which must be passed by January 19.

First, do not panic. As you may have already heard, CMS is telling providers and suppliers that the add-ons will expire at the end of the month. Technically that is true. The Agency is simply stating the obvious; but no one should imply from such statements that the Congress will not fix them or not make them retroactive. Historically, CMS has followed this pattern of indicating the add-ons have expired until legislation extending the add-ons has passed both chambers of Congress and the President has signed the bill into law.  CMS will make similar statements relative to the other Medicare extenders as well.

Second, prepare. To the extent you are able to do so, you may hold your claims. Medicare requires providers to files claims no later than 12 months after the date when the services were provided. (See Medicare: File a Claim; see also section 6404 of the Affordable Care Act). While this may not work for all claims, holding claims will reduce the number that would have to be reprocessed once the add-ons become law. If CMS believes at some point the legislation will pass, it may also break with its own precedent and indicate that has asked the contractors to hold claims for a short period of time as well. It did this in 2014 when it discovered errors in a final fee schedule rule. Once the claims are processed, so long as the add-ons have been extended by law, the add-on dollars will appear in the reimbursement amounts sent to providers and suppliers.

Third, retroactivity can be expensive, but CMS can mitigate the costs. CMS did this most recently in May of 2017. Then, CMS announced that it would implement the retroactive extension of a transitional payment for durable medical equipment suppliers by having the contractors automatically reprocess claims from the period when the transitional payment was made retroactive. This approach reduced the burden on providers and suppliers by eliminating the need to resubmit claims.

Despite the fact that there are ways to mitigate the problem, the American Ambulance Association (AAA) remains deeply concerned that the Congress did not extend the add-ons before they left for the holidays. We understand that for ambulance services across the country receiving timely payments from Medicare can be the difference between being able to make payroll or not. Having the dollars from the add-ons is also crucial to ensuring adequate cash flow. Therefore, while we advise you to think through your options and take the steps that best meet your needs and the needs of your employees, patients, partners, and businesses, we also ask that you reach out to the Congress and let them know how important it is to get the add-ons extended as early in January as possible. Make your voice heard by going to the AAA’s grassroots page. There you can send an email or reach out through social media to your Members of Congress.  We need everyone, including your employees, patients, and others who support high quality ambulance services, to reach out today.

Write to Your Members of Congress

The AAA will continue our direct efforts on Capitol Hill to make sure these add-ons are extended and overly burdensome new requirements are not placed on ambulance services. With your help, we can get the add-ons extended. For more information please visit https://ambulance.org/advocacy/.

Build Your Future with a Career in EMS

Written by Mark Postma on . Posted in News, Press, Recruitment & Retention.

The U.S. Bureau of Labor Statistics expects career opportunities for EMTs and Paramedics to grow another 15 percent by 2026, far outpacing most other professions… With EMS agencies hungry for skilled providers, there has never been a better time to chart your career path in mobile healthcare.

This week, an editorial from AAA President Mark Postma was featured in a special Media Planet section on healthcare careers. Read the full article►

Summary of December 2017 Ambulance Open Door Forum

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

On December 14, 2017, CMS held its latest Open Door Forum. As usual, it started with a few announcements, as follows:

  1. Ambulance Inflation Factor – CMS announced that it had published Transmittal 3893 on October 27, 2017, which sets forth the Ambulance Inflation Factor (AIF) for calendar year 2018. In that Transmittal, CMS indicated that the CY 2018 AIF would be 1.1%. This is based on an increase in the CPI-U of 1.6%, and a multi-factor productivity adjustment of 0.5%.
  1. Expiration of Temporary Adjustments – CMS indicated that the current temporary adjustments for urban (2%), rural (3%) and super rural ground ambulance transports are set to expire on December 31, 2017. CMS also indicated that they were aware of proposed legislation that would extend these adjustments for 2018 and beyond, but that they have yet to be enacted into law.
  1. CY 2018 Public Use File – CMS indicated that the Public Use File on its website has been updated to include Medicare allowables for 2018. CMS made a point of noting that the 2018 rates do not include the temporary adjustments, as they are set to expire on December 31, 2017.
  1. Prior Authorization Demonstration Project – CMS indicated that it had decided to extend the Prior Authorization Demonstration Project for schedule, non-emergency ground ambulance transportation of repetitive patients for another year. The extension is limited to the 8 states (DE, MD, NJ, NC, PA, SC, VA, and WV) and the District of Columbia in which the program was in effect in 2017.  CMS further indicated that the extension would be effective for dates of service on or after December 5, 2018.  As a result, claims for dates of service between December 2 and December 4 would not be subject to prepayment review if a prior authorization was not received; however, ambulance providers in these states would be permitted to request prior authorization for those dates. CMS further indicated that it had developed a “streamlined” process to allow for prior authorization of transports in situations where the patient was approved for transport, but where the duration of the authorization was shortened from the normal 60-day period to account for the program’s scheduled expiration on December 1, 2017. An example would be an authorization that was granted for transports starting on November 1, 2017. The provider was likely given authorization for only a 30-day period. The streamlined process would allow them to submit a request to allow that 30-day authorization to be extended to a fully 60 days. CMS indicated that the streamlined process would not require the submission of medical records to establish medical necessity for the ambulance.

As with previous forums, CMS then fielded questions from the audience. The majority of these questions focused on the prior authorization process. As with previous ODFs, CMS declined to answer most of the questions on the call, instead asking the provider to submit their questions to CMS via email.

CMS did answer the following questions on the call:

  1. CMS was asked when it anticipated issuing its report on the effectiveness of the Prior Authorization Demonstration Program.  CMS responded that it expected to issue that report during the first quarter of 2018.
  2. CMS was asked when it expected to expand the Prior Authorization Demonstration Program to additional states and/or the nation as a whole.  CMS responded that it was still evaluating the effectiveness of the program.  Therefore, CMS indicated that no decision on national expansion had been made at this time.

Have questions? Please write to the Werfels at bwerfel@aol.com.

AETNA/CVS Deal Along with Uber Concepts May Finally Change Ambulance Industry

Written by Mark Postma on . Posted in Community, Government Affairs, News, Press, Private Insurance, Reimbursement.

Mark Postma, AAA President & Asbel Montes, AAA Payment Reform Chair

The recent merger of Aetna/CVS may be the catalyst that finally brings the change that the ambulance industry has been advocating for over the past several years. This new healthcare strategy supports the ambulance industry’s ideas that alternative patient destinations are needed in EMS.

To explain this better, one must understand the current state of ambulance reimbursement via the 911 system or equivalent. At this point in time most commercial payers of healthcare (Insurance) as well as Medicare will not pay for 911 ambulance transportation to any destination other than the “nearest appropriate” hospital based emergency room; arguably, the most expensive and least efficient form of healthcare. The continuation of this policy discounts the advanced capabilities of both EMS and new clinical settings and the savings that can be achieved through innovative change. In addition, at the same time that the cost of healthcare in general is increasing, reimbursement from all payers is decreasing, creating a significant challenge for providers. Medicare consistently pays providers below cost for providing life-saving services and state Medicaid agencies are consistently underfunding the critical services to the un- and under-insured populations that have allowed intermediaries to delay or not pay ambulance services.

Much of the U.S. population believes that vital 911 EMS services or the equivalent are provided free or included in their local property taxes. This is generally not the case. While EMS services must be at the ready on a 24/7/365 basis, they are not paid for being on call, but only when the service is used.

Many communities have governing rules that require 911, or the equivalent, paramedic services to arrive on-scene within 8-12 minutes of receiving the call. This cost of readiness is VERY expensive. Skyrocketing personnel costs, ambulances, equipment, and other high cost drugs only exacerbate an already fragile reimbursement structure. Although recent articles about calling Uber or Lyft sound intriguing, these drivers and cars are not prepared for any type of injury. Nor can they alert the hospital in critical situations to have the heart cath lab ready or a trauma surgeon on standby, shortening the time to definitive care when time matters most. Emergency paramedics are highly trained, are nationally and/or state certified, and provide services on state regulated ambulances equipped to manage all types of emergencies. Ambulances are also often strategically placed to arrive in that 8-12 minute response time requirement. However, there is one piece missing from the ambulance scenario that allows for Uber/Lyft to succeed; your personal credit card is on file with them. NO GUARANTEED PAYMENT, NO TRANSPORT. The cost of providing ambulance services “on call” with life-saving equipment, medications, and personnel at the ready is steep. When you consider the many regulations providers must adhere to outside of patient care, the cost increases even more. This misunderstanding of the cost often results in patients being stunned when they receive a bill for services provided and feel that it is excessive. However, comparing the cost of a life-saving ambulance transport to an Uber/Lyft ride is like comparing the cost of building a house to putting up a tent.

On the other hand, these highly trained paramedics, with vehicles that are comprehensively (medically) equipped to meet the highest safety standards, have no credit card on file. They do not treat you based on your ability to pay. In fact, approximately less than half of ambulance patients have insurance, and when commercial insurance does pay, they are increasingly paying only a percentage of the total bill, leaving their insured left to pay the balance. In a time of an emergency, insurers should not place an additional burden on their insured through underpayment or claiming out of network status. In addition, although many emergency 911 calls begin as a “frantic call for help,” not all are life threatening and require the highest level of care; however, they do need some type of a health care intervention.

It is this high volume of low acuity patients who do not have primary care physicians and who currently by law must be transported to hospitals that continue to bottleneck emergency rooms. This bottleneck then requires ambulances to be “on the wall” at local hospital emergency rooms. The cost to the 911 EMS system rapidly begins a domino effect where all the patients begin to be diverted/directed to other hospitals causing an overflow to the next hospital. In large EMS systems, this domino effect can bring emergency rooms at all available hospitals to capacity quickly. EMS units are unable to go on additional emergency calls because they are caring for a patient while waiting on hospital staff to become available to take over. They also cannot leave that hospital with the patient to go to another hospital due to federal laws that prohibit this movement.

So why does the AETNA/CVS excite the leaders of EMS organizations? Most people assume that since this acquisition just occurred, Walgreens will probably follow suit with another insurer. Other local pharmacy “CVS types” may partner with local hospitals or medical insurance cooperatives as well. This leads the ambulance industry to believe that the capacity to transport patients to alternative locations could greatly change the landscape of EMS. The idea that local CVS/Walgreens/clinics could receive low acuity patients breaks open the bottleneck and can provide several benefits for the ambulance service and patient. One benefit is that adding these stores/clinics greatly increases the resources for caring for low acuity patients and could potentially double the locations an ambulance can transport to, which will allow for quicker transport times and increase efficiencies. Lastly, and most importantly, diverting the low acuity patients to these additional community resources would reduce overflow in the emergency departments and allow true emergency patients to be transferred over more quickly to receive the higher level of care they require. This scenario is also a win for the patient. They could be transported to the most appropriate location to care for their needs and therefore can be billed more accurately for services they require rather than the emergency department fees which are usually costlier.

To make this happen, obviously the CVS system needs to evolve to receive these patients. More importantly, ambulance reimbursement by federal, state, and private payers must evolve to meet the demands of the market. Due to the complexities of how EMS services are provided because of state and local regulations, mandatory response times, service area parameters, and others, reimbursement for these services must be adequately paid for by Medicare, Medicaid, and private insurers. Today EMS agencies can only “hope” that their patients have a source of payment!

Although one would think that this state of concern for EMS services is being monitored, it currently has only a very small voice in the healthcare continuum. Federal agencies seem to want to look at what EMS will look like in 10 to 25 years rather than where EMS is today and where it can develop over the next few years. EMS reform needs to happen soon to save these systems from bankruptcy and/or the public from higher taxation.

We hope that this merger will be the beginning of alternative EMS/ambulance destinations with allocated reimbursements that meet the costs of providing high quality, efficient, and necessary 911 ambulance services.

Mark Postma, COO, Sunstar Paramedics
American Ambulance Association, President
Works for Sunstar Paramedics, Florida’s largest EMS provider
MPostma@sunstarems.com, 727-224-0295

Asbel Montes, Vice President, Acadian Ambulance Service, Inc.
American Ambulance Association, Chair-Payment Reform Committee
Works for Acadian Ambulance Service, Inc., Louisiana’s largest EMS provider
Asbel.Montes@acadian.com, 337-291-3310

CMS Extends Prior Authorization for 2018

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

CMS Announces Extension of Prior Authorization for Repetitive Non-Emergency Ground Ambulance Transports

On December 4, 2017, CMS posted a notice on its website indicating that it would be extending the prior authorization demonstration project for another year. The extension is limited to those areas where prior authorization was in effect for calendar year 2017. 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, 2018.

Read the Full CMS Notice

In its notice, CMS indicated that claims with dates of service between December 2 and December 4, 2017 would not be subject to prior authorization or prepayment review, but that ambulance providers could elect to submit a request for prior authorization for these transports. All repetitive non-emergency transports on or after December 5, 2017 would require prior authorization.

Response to Kaiser Health News Ambulance Billing Article

Written by Mark Postma on . Posted in Medicaid, Medicare, News, Press, Private Insurance, Reimbursement.

Below is the American Ambulance Association’s Response to a recent Kaiser Health News article on ambulance billing. It was reprinted in several metropolitan areas on November 20, 2017.

To the Editor:

I write today in response to Melissa Bailey’s November 20 piece about ambulance balance (“surprise”) billing. While we disagree with the characterization of ambulance services in the article, we welcome the ongoing public dialogue about how unsustainable reimbursement for emergency medical services results in cost-shifting to patients.

Missing from the article is a true understanding of the sky-high cost of readiness for emergency medical services. Ambulance service providers offer their communities 24/7/365 on-demand mobile healthcare. Skilled staff and ambulances—high-tech emergency rooms on wheels—are ready to respond to a 9-1-1 call at a moment’s notice to help patients with issues ranging from stroke to heart attack to trauma to childbirth. EMS is also on the very front lines of the surge in opioid overdoses, providing naloxone (Narcan) to hundreds of patients each day. Keeping supplies, medications, equipment, and personnel at-the-ready requires a significant ongoing investment, regardless of whether or not an ambulance is out responding to a call. Cost comparisons between EMS and the rideshare app Uber may make for catchy sound bites, but they are misleading and misguided.

The piece states that our nation’s 14,000 ambulance service providers received 1,200 Better Business Bureau complaints spread over three years. While certainly not optimal, this is a tiny, unrepresentative fraction of the tens of millions of responses ambulance service providers conduct annually. In fact, BBB 2016 statistics show that ambulance services receive far fewer complaints than hospitals, physicians, dentists, and many other trusted healthcare providers.

The article also offhandedly mentions that balance billing occurs when private insurers and ambulance service providers are unable to agree about fair reimbursement rates. This glosses over the dark reality that it would be hard to categorize the process that occurs between the insurer and ambulance services as a “negotiation.” Instead, insurers often present an all-or-nothing proposition to force ambulance service providers to accept contracts at unsustainably low reimbursement rates. Unlike the multi-billion dollar insurance behemoths, most ambulance services are small and operate on razor-thin margins. In fact, 73% of ambulance services provide fewer than 1,000 Medicare transports per year—just three per day. Ambulance services do not turn down insurance network contracts out of greed, but instead out of necessity. Facing reimbursement rates below the cost of the services they provide, they must decline these agreements in order to keep their doors open and continue to provide healthcare to their communities. Unfortunately, this sometimes creates a situation where out-of-network ambulance costs are shouldered by patients via balance billing, instead of insurers.

In addition to challenges receiving fair compensation from private insurance, EMS is stretched thin by ultra-low Medicare and Medicaid reimbursement rates. In fact, in 2007 and 2012 GAO studies showed that without temporary, Congress-authorized percentage increases in EMS payments, ambulance services would receive reimbursement from government payors below the cost of operations. These are often the very same unsustainable rates that private insurers are attempting to strong-arm EMS providers into accepting for network contracts.

Finally, when someone calls 9-1-1 in need of emergency medical care, it is key to recall that, unlike in other industries, an ambulance responds regardless of the patient’s ability to pay. In many cases, the patient does not have insurance and is financially unable to reimburse the ambulance service provider. Therefore, EMS provides a significant amount of uncompensated care, the cost of which must be spread across all payors in order for them to continue their life-saving operations.

Ambulance services provide an essential, on-demand healthcare benefit to their communities. Unfortunately our current healthcare payment structure means that much of this care is not compensated equitably, resulting in the necessity of balance billing patients. While there are no quick fixes for this issue, we encourage consumers to educate themselves about their own insurance coverage. We also ask for your support of legislation that provides sustainable reimbursement for ambulance providers, including the bipartisan US Senate Bill 967. Together, we can ensure the future of mobile healthcare in our great nation.

Mark Postma
President
American Ambulance Association
“Representing EMS In America”

 

Time to handle 911 call demands with Paramedics

Written by Scott McConnell on . Posted in Community, Legislative, Medicaid, Medicare, News, Training.

When discussing this new and growing field of pre-hospital care, there seems to be two unique paths that services are following. The first is the hospital-owned or contracted service, where community providers seek ways to decrease readmission rates for CHF, COPD, Pneumonia, Sepsis, MI and other chronic illnesses.

When a patient discharged with one of these targeted conditions is readmitted within a 30 day window, “hospitals face penalties of up to 3 percent of Medicare payments in 2018” (Gluck, 2017, para. 10). That is a lot of money. Consider, “Lee Health, Southwest Florida’s largest hospital operator, which is expected to lose $3.4 million in payments” (Gluck, 2017, para. 2). This model represents the if, or, and type of service, meaning if we can do it for less and there are providers willing to do this type of medicine, then we can save the expensive penalties from CMC.

The other model of community paramedicine is 911 abuse reduction. For years EMS has conditioned the public to call 911 for any emergency. But today, what we consider an emergency is far from the public’s perception of an emergency. “EMS has experienced a 37% increase in 911 calls since 2008.” (White, 2016, para. 6) Yet have we increased staffing proportionally to meet the demand? Afraid not since “only 50% of EMS services in 2008 were fully staffed, and more than 63% had a volunteer component as part of their staffing level” (“Critical Staffing Shortages,” 2015, para. 2).

The article references increasing wages to help compensate for the decrease in trained providers by attracting more professionals to the field. With the CMC limiting payments and the major insurance companies following suit, doubtful this will be an option in the near future.

To reduce calls and increase levels of service, we can try to reeducate the public to what is a true emergency, but that is a long and slow process. For example, Philadelphia has started the trend and placed several billboards up around neighborhoods that contribute an ordinarily high amount of non-emergent 911 calls. Will this work? Time will tell but I would believe not enough to affect the volume of calls.

What about enlisting Community Paramedics in these situations? I believe this is a viable solution with nurses triaging the low acuity calls in the 911 center. Dispatching Community Paramedics armed with not only the usual equipment, but also the knowledge base to connect these patients with primary care physicians, social workers, and the programs that are available to them. This will help people receive the long-term care they deserve.

Scott F. McConnell is Vice President of EMS Education for OnCourse Learning and one of the Founders of Distance CME. Since its inception in 2010, more than 10,000 learners worldwide have relied on Distance CME to recertify their credentials. Scott is a true believer in sharing not only his perspectives and experiences but also those of other providers in educational settings.

References
* Critical Staffing Shortages (2015)
* Gluck, F. (2017, February 7th, 2017). Lee Health will lose $3.4 million in Medicare payments because of readmission rates. USA Today
* White, D. (2016, February 16th, 2016). Community paramedic? program intended to reduce 911 calls. Manatee Technical College

CMS Lifts Moratorium Enrollment Non-Emergency Providers (TX)

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

In order to assist with the disaster response to Hurricane Harvey, CMS has announced that it has lifted the temporary moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017. The lifting of this moratorium applies to new enrollments in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). CMS indicated that it will publish a notice in the Federal Register to formally announce the lifting of the moratorium.

As a result, Part B ambulance suppliers that are not otherwise already enrolled as non-emergency ambulance provider in the State of Texas will be permitted to enroll in the Medicare Program. The lifting of the moratorium will also permit companies that are already enrolled as non-emergency ambulance suppliers to add additional practice locations throughout the state. CMS has indicated that both new enrollments and changes in enrollment to add additional practice locations will be subject to “high” screening under 42 C.F.R. §424.518(c)(3)(iii).

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