The Centers for Medicare and Medicaid Services has scheduled a call for Thursday, December 5 from 1:30-3:00 PM Eastern to review the new Ambulance Cost Data Collection System. If you plan to attend, register here.
CMS Ambulance Cost Data Collection
The American Ambulance Association is pleased to announce the publication of its 2018 Medicare Payment Data Report. This report is based on the “Early Edition” of the 2018 Part B National Summary Data File (previously known as the Bess Report). The report consists of an overview of total Medicare spending nationwide, and then a separate breakdown of Medicare spending in each of the 50 states, the District of Columbia, and the various other U.S. Territories.
For each jurisdiction, the report contains two charts: the first reflects data for all ambulance services, with the second limited to dialysis transports. Each chart is further broken down by HCPCS code. The charts provide information on the total number of allows services and the total Medicare payments for CYs 2017 and 2018. Percentage changes will allow members to view payment trends over the past year.
2018 National & State-Specific Medicare Data
Questions? Contact Brian Werfel at bwerfel@aol.com.
CMS Releases List of Ambulance Organizations Selected for Data Collection
The Centers for Medicare & Medicaid Services (CMS) has released the list of ambulance service providers and suppliers selected to provide data in the first year of data collection. CMS has published the data by National Provider Identifier (NPI) number and the AAA has also sorted the data by state in alphabetical order.
On Friday, CMS had made public the final rule on the Establishment of an Ambulance Data Collection System. The AAA will be issuing a Member Advisory tomorrow on the details of the final rule and changes from the proposed rule.
To access the list by NPI number click here and to access the list by state click here.
On October 4, 2019, CMS issued Transmittal 4407 (Change Request 11497), which announced the Medicare Ambulance Inflation Factor (AIF) for calendar year 2020.
The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Starting in calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi-factor productivity index (MFP). The MFP reduction may result in a negative AIF for any calendar year. The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.
For the 12-month period ending in June 2018, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased 1.6%. CMS further indicated that the CY 2020 MFP will be 0.7%. Accordingly, CMS indicated that the Ambulance Inflation Factor for calendar year 2019 will be 0.9%.
On October 29, 2019, the Centers for Medicare and Medicaid Services (CMS) posted a notice in the Federal Register announcing an opportunity for the public to provide comments on the proposed national expansion of the prior authorization process for repetitive, scheduled non-emergent ground ambulance transportation. CMS refers to this process as its “RSNAT Prior Authorization Model.” The CMS Notice can be viewed in its entirety at: https://www.govinfo.gov/content/pkg/FR-2019-10-29/pdf/2019-23584.pdf.
Under the Paperwork Reduction Act of 1995, federal agencies are required to publish a notice in the Federal Register concerning each proposed collection of information, and to allow 60 days for the public to comment on the proposed action. Interested parties are encouraged to provide comments regarding the agency’s burden estimates and other aspects of the proposed collection of information, including the necessity and utility of the proposed information for the proper performance of the agency’s functions, and ways in which the collection of such information can be enhanced.
In this instance, CMS is indicating that it is pursuing approval to potentially expand the existing RSNAT Prior Authorization Model nationwide. Currently, the RSNAT Prior Authorization Model is in place in 8 states (DE, MD, NJ, NC, PA, SC, VA, and WV) and the District of Columbia. National expansion is contingent upon CMS’ determination that certain expansion criteria have been met. CMS is indicating that if the decision is made to expand the program, such expansion may occur in multiple phases. CMS intends to use the information collected pursuant to this notice to determine the proper payment for repetitive scheduled non-emergent ambulance transportation.
In plain English, CMS is soliciting comments from stakeholders as to the efficacy of the current process, including whether the existing paperwork requirements are sufficient to ensure that approved patients meet the medical necessity requirements for an ambulance. CMS is also seeking suggestions for how to best expand the program nationally, e.g., whether it makes sense to expand the program in phases, etc.
The AAA Medicare Regulatory Committee has been monitoring the current model for several years. As a result, the AAA is in a good position to provide constructive feedback to CMS regarding the potential national expansion of the RSNAT Prior Authorization Model. These suggestions will be included in the AAA’s comment letter. The AAA also encourages members to offer their own comments. The AAA anticipates providing members with a sample comment letter in early December that members can use to submit their own comments.
To be considered, comments must be submitted no later than 5 p.m. on December 30, 2019. Comments may be submitted electronically by going to: http://www.regulations.gov. Commenters would then need to click the link for “Comment or Submission,” and follow the instructions from there. Comments may also be submitted by regular mail to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier: CMS-10708, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
On Thursday, October 17, 2019, the HHS Office of the Inspector General (OIG) issued a proposed rule titled “Medicare and State Health Care Programs: Fraud and Abuse; Revisions to Safe Harbors Under the Anti-Kickback Statute, and Civil Monetary Penalties Regarding Beneficiary Inducements.” The proposed rule would amend the existing safe harbors to the Federal Anti-Kickback Statute (AKS) and the civil monetary penalty rules (CMPs). These changes are part of HHS’ Regulatory Sprint to Coordinated Care. The stated purpose of these changes is to reduce the regulatory barriers and accelerate the transformation of the healthcare system away from the traditional fee-for-service payment model, and towards a value-based system that rewards healthcare providers for better outcomes. The proposed rule can be viewed in its entirety at: https://www.govinfo.gov/content/pkg/FR-2019-10-17/pdf/2019-22027.pdf.
The proposed rule makes nearly a dozen major changes to the safe harbors under the AKS and the rules related to CMPs. Among these are revisions to the recently created safe harbor for local transportation. The proposed change to the safe harbor for free or discounted local transportation is discussed in greater detail below.
The OIG is soliciting comments on a wide range of topics raised in the proposed rule. The AAA is not taking any formal position with respect to the proposed changes or the requests for additional information set forth in this proposed rule. However, we encourage any member that wishes to comment to do so.
To be considered, comments must be submitted no later than 5 p.m. on December 31, 2019. Comments may be submitted electronically by going to: http://www.regulations.gov. Commenters would then need to click the link for “Submit a comment” and follow the instructions from there. Comments may also be submitted by courier or by regular, express, or overnight mail to the following address: Office of Inspector General, Department of Health and Human Services, Attention: OIG-0936-AA10-P, Room 5521, Cohen Building, 330 Independence Avenue SW, Washington, DC 20201.
Revisions to Safe Harbor for Free or Local Transportation
In 2014, the OIG created a new safe harbor for free or discounted local transportation provided to Federal health care program beneficiaries. This safe harbor applied to non-ambulance transportation (e.g., wheelchair van, bus and shuttle services, taxis, etc.) provided under the following conditions:
The safe harbor also permitted the use of “shuttle services” (i.e., a vehicle that runs on a set route, on a set schedule) if the following conditions are met:
In either situation, the safe harbor also requires the Eligible Entity to bear all costs of furnishing such transportation, i.e., they cannot shift that cost onto any Federal health care program, any other payer, or the individual.
In the current proposed rule, the OIG indicated that it received numerous comments from stakeholders that suggested that the 50-mile limit for residents of rural areas was insufficient, as many rural residents might need to routinely travel more than 50 miles to obtain certain medical services. As a result, the OIG is proposing to expand this limit to 75 miles.
The OIG is also soliciting comments on whether the proposed 75-mile is sufficient, or whether an even larger expansion is warranted. To the extent you intend to submit comments arguing for a greater mileage limit, the OIG is asking that you submit data or other evidence to support a more appropriate mileage limitation for the safe harbor. The OIG is also specifically requesting information on how an Eligible Entity would provide transportation over distances in excess of 50 miles (e.g., shuttle services, bus or taxi fare, ride-sharing programs, mileage reimbursement programs, etc.).
Expansion of Safe Harbor for Transportation of Patients Being Discharged After an Inpatient Stay
The OIG is also proposing to eliminate any mileage restriction on transportation of patients back to their residence after being discharged from a facility where that patient had been admitted as an inpatient, regardless of whether the patient resides in an urban or rural area. The OIG is also proposing to eliminate the mileage restrictions on discharges to another residence of the patient’s choice (such as a friend or relative who will care for the patient post-discharge).
The OIG further indicated that it is considering protecting transportation to other locations of the patient’s choice, including another health care facility. The OIG is soliciting comments on the potential fraud and abuse risks associated with permitting free or discounted transportation to other health care facilities, and whether transportation should be protected (and, if so, under what circumstances) when the patient has not previously been admitted to an inpatient facility (e.g., where the patient had been seen as an outpatient in a hospital emergency department). Finally, the OIG is soliciting comments on whether the transportation of patients being discharged beyond the applicable safe harbor mileage limitations should be limited to patients with demonstrated financial or transportation needs, and, if so, what standards should apply to such demonstration of need.
Possible Expansion to Include Transportation to Non-Medical Services
In the 2014 final rule creating the new safe harbor for local transportation, the OIG declined to extend the safe harbor protections to transportation for purposes other than obtaining medically necessary services or items (although they permitted a qualifying shuttle service to make stops at locations that do not relate to a particular patient’s medical needs). The OIG has since received numerous comments suggesting that the safe harbor should protect transportation for non-medical purposes that may nevertheless improve or maintain health, e.g., transportation to food banks, social services, exercise facilities, support groups, etc. The OIG indicated that it considering a further expansion of the safe harbor to include such non-medical needs, and is therefore seeking comments on how the safe harbor could be expanded to such needs without creating an unacceptable risk of fraud and abuse.
Clarification of Policy Regarding the Use of Ride-Sharing Services
Finally, the OIG is clarifying its interpretation of the applicability of the existing safe harbor to the use of ride-sharing services. In the preamble to the 2014 final rule, the OIG discussed the possibility that patient transportation might be provided via taxi. In the proposed rule, the OIG indicates that, while it did not explicitly reference ride-sharing services, it views these services are being similar to taxi services for the purposes of the safe harbor. Specifically, the OIG noted that nothing in the language of the safe harbor expressly precludes their use (or the use of self-driving cars or other similar technology that may become available at some point in the future). The OIG is inviting anyone that disagrees with this approach to explain the possible basis for exclusion of ride-sharing services.
The OIG did reiterate that the prohibition of the marketing of such free or discounted transportation would still apply. The OIG indicated that it would be permissible for ride-sharing services to advertise that they provide transportation to medical appointments, and to recommend that patients contact their medical providers to determine if they qualified for free or discounted transportation. By contrast, the OIG indicated that it would not be appropriate for the ride-sharing service to advertise that it provided free or discounted transportation to particular health care providers.
Other Changes in the Proposed Rule
In addition to the revisions to the existing safe harbor for free or discounted transportation, the OIG is proposing:
On September 16, 2019, CMS published a notice in the Federal Register that it would be extending the prior authorization demonstration project for another year. The extension is limited to those states where prior authorization was in effect for calendar year 2019. The affected states are Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia and West Virginia, as well as the District of Columbia. The extension will run through December 1, 2020.
In its notice, CMS indicated that the prior authorization demonstration project is being extended “while we continue to work towards nationwide expansion.” This strongly suggests that CMS believes the program has met the statutory requirements for nationwide expansion under the Medicare Access and CHIP Reauthorization Act of 2015. However, CMS indicated that it would use the additional year to continue to test whether prior authorization helps reduce expenditures, while maintaining or improving the quality of care offered to Medicare beneficiaries.
CMS has also updated its CMS Ambulance Prior Authorization webpage to reflect the expansion of prior authorization in the existing states through December 1, 2020.
Section 1834(l)(3)(B) of the Social Security Act mandates that the Medicare Ambulance Fee Schedule be updated each year to reflect inflation. This update is referred to as the “Ambulance Inflation Factor” or “AIF”.
The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Starting in calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi-factor productivity index (MFP). The MFP reduction may result in a negative AIF for any calendar year. The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.
For the 12-month period ending in June 2019, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased by 1.65%.
CMS has yet to release its estimate for the MFP in calendar year 2020. However, assuming CMS’ projections for the MFP are similar to last year’s projections, the number is likely to be in the 0.6% range.
Accordingly, the AAA is currently projecting that the 2020 Ambulance Inflation Factor will be approximately 1.1%.
Cautionary Note Regarding these Estimates
Members should be advised that the BLS’ calculations of the CPI-U are preliminary, and may be subject to later adjustment. The AAA further cautions members that CMS has not officially announced the MFP for CY 2020. Therefore, it is possible that these numbers may change. The AAA will notify members once CMS issues a transmittal setting forth the official 2020 Ambulance Inflation Factor.
On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that it stated would better identify ground ambulance transports that were furnished in connection with an outpatient hospital service that would be bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime.
Unfortunately, the implementation of these new edits has been anything but seamless. Over the past few weeks, I have received numerous phone calls, texts, and emails from AAA members reporting an increase in the number of Medicare claims being denied for SNF Consolidated Billing.
This FAQ will try to explain why you may be seeing these denials. I will also try to provide some practical solutions that can: (1) reduce the number of claims denied by the edits and (2) help you collect from the SNFs, when necessary.
Please note that, at the present time, there is no perfect solution to this issue, i.e., there is nothing that you can do to completely eliminate these claim denials. The solutions discussed herein are intended only to minimize the disruption to your operations caused by these denials.
Under the SNF Consolidated Billing regime, SNFs are paid a per diem, case-mix-adjusted amount that is intended to cover all costs incurred on behalf of their residents. Federal regulations further provide that the SNF’s per diem payment generally the cost of all health care provided during the beneficiary’s Part A stay, whether provided by the SNF directly, or by a third-party. This also includes the majority of medically necessary ambulance transportation provided during that period. For these purposes, the “Part A Period” refers to the first 100 days of a qualified SNF stay.
However, medically necessary ambulance transportation is exempted from SNF Consolidated Billing (referred to hereafter as “SNF PPS”) in certain situations. This includes medically necessary ambulance transportation to and from a Medicare-enrolled dialysis provider (whether free-standing or hospital-based). Also excluded are ambulance transportations:
For a fuller description of the SNF Consolidated Billing Regime, including a discussion of when ambulance services may be separately payable by Medicare Part B, I encourage members to consult the AAA Medicare Reference Manual.
Purchase the 2019 Medicare Reference Manual
In 2017, the HHS Office of the Inspector General conducted an investigation of ground ambulance claims that were furnished to Medicare beneficiaries during the first 100 days of a skilled nursing home (SNF) stay. The OIG’s investigation consisted of a review of all SNF beneficiary days from July 1, 2014 through June 30, 2016 to determine whether the beneficiary day contained a ground ambulance claim line. The OIG excluded beneficiary days where the only ambulance claim line related to: (1) certain emergency or intensive outpatient hospital services or (2) dialysis services, as such ambulance transportation would be excluded from SNF Consolidated Billing.
The OIG determined that there were 58,006 qualifying beneficiary days during this period, corresponding to $25.3 million in Medicare payments to ambulance suppliers. The OIG then selected a random sample of 100 beneficiary days for review. The OIG determined that 78 of these 100 beneficiary days contained an overpayment for the associated ambulance claims, as the services the beneficiary received did not suspend or end their SNF resident status, nor was the transport for dialysis. The OIG determined that ambulance providers were overpaid a total of $41,456 for these ambulance transports. The OIG further determined that beneficiaries (or their secondary insurances) incurred an additional $10,723 in incorrect coinsurance and deductibles. Based on the results of its review, the OIG estimates that Medicare made a total of $19.9 million in Part B overpayments to ambulance suppliers for transports that should have been bundled to the SNFs under SNF Consolidated Billing regime. The OIG estimated that beneficiaries (and their secondary insurances) incurred an additional $5.2 million in coinsurance and deductibles related to these incorrect payments.
The OIG concluded that the existing edits were inadequate to identify ambulance claims for services associated with hospital outpatient services that did not suspend or end the beneficiary’s SNF resident status, and which were not related to dialysis. The OIG recommended that CMS implement additional edits to identify such ambulance claims.
The OIG’s report prompted CMS to issue Transmittal 2176 in November 2018. This transmittal instructed the CWF Maintainer and the Medicare Administrative Contractors (MACs) to implement a new series of edits, effective April 1, 2019.
Before we turn to the new edits, I think it is important to understand that CMS has had long-standing edits to identify outpatient hospital services that should be bundled to the SNF under SNF PPS. These edits work by comparing the Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes on the outpatient hospital claim to applicable lists of excluded codes. To the extent the HCPCS or CPT code appears on the applicable list of excluded codes, the outpatient hospital claim will bypass the edit for SNF PPS, and be separately payable by the MAC. To the extent the HCPCS or CPT code on the outpatient hospital claim does not appear on the applicable list of excluded codes, the claim will be denied as the responsibility of the SNF. The new CWF edits for ambulance claims simply extend the existing process one step further, i.e., they compare the ambulance claim to the associated hospital claim.
Conceptually, the new edits “staple” the ambulance claim to the outpatient hospital claim, with our coverage piggybacked on whether the outpatient hospital claim is determined to be bundled or unbundled.
Typically, the denial will be evidenced by a Claim Adjustment Reason Code on the Medicare Remittance Advice. The denial will typically appear as an “OA-190” code, with the following additional explanation: “Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. The “OA” stands for “Other Adjustment,” and is intended to notify you that the SNF is the correct payer. Note: in some instances, the denial may appear as “CO-190” on the remittance advice. However, the effect of the denial is the same, i.e., they are indicating that the SNF is financially responsible for payment.
Frequently, the denial will be accompanied by Remittance Advice Remark Code “N106,” which indicates “Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service.”
When CMS elects to implement a new edit to the CWF, it has to make some decisions on how to structure the edit. Two typical decisions that must be made are:
For these purposes, a conditional edit is one where the coverage or lack of coverage depends, in part, on the claims submitted by other health care providers that furnished services to the same beneficiary (typically on the same date). As you are probably aware, the Medicare rules for all Part B payments prohibit payment whenever the service has been paid for, directly or indirectly, under Medicare Part A. Thus, all edits for hospital and SNF bundling are conditioned, in part, on the patient’s Part A inpatient status at the time of transport.
By contrast, an unconditional edit is one that operates the same regardless of other types of claims for the same patient. For example, with respect to ambulance claims, the MACs medical necessity edits are unconditional, i.e., they apply to all ambulance claims, regardless of the patient’s inpatient status at a Part A facility. The edits for origin/destination modifiers are another example of an edit that is typically unconditional.
In addition, CMS has to decide whether to make an edit under- or over-inclusive. This is because no edit can be perfectly tailored to be applied to all qualifying claims, but no non-qualifying claims. An “underinclusive” edit is one that is designed to identify the majority – – but not all – – of the claims that should be denied based on the edit criteria. By contrast, an “overinclusive” edit is one that would deny not only all of the qualifying claims, but also some non-qualifying claims.
In many instances related to EMS coverage, the underlying facts and circumstances of the transport are ultimately what determines the coverage. It is frequently difficult – – if not impossible – – to fully describe these circumstances with enough specificity on the electronic claim for CMS to perfectly apply its edits. For that reason, CMS has historically elected to design its ambulance edits to be underinclusive.
Unfortunately, the new SNF edits are both conditional AND overinclusive. To further complicate matters, they are not only conditioned on the claim of a single Part A provider, but two separate Part A providers, i.e., in order for the new edits to work properly, CMS is reliant upon information from both the SNF and the hospital to properly apply its new edits.
They are. The denial was likely the result of your claim being submitted prior to Medicare’s receipt of the associated outpatient hospital claim.
As noted above, the new edits are both conditional and overinclusive. In this context, they are designed to deny the ambulance claim UNLESS there is a hospital outpatient claim for that same patient with the same date of service. If there is no hospital outpatient claim on file when your ambulance claim hits the system, the edit indicates that the MAC should deny your claim for SNF PPS.
In theory, no. The instructions in Transmittal 2176 make clear that the CWF should “adjust” the ambulance claim upon receipt of the associated hospital claim. For these purposes, that adjustment should take the form of re-processing the ambulance claim through the edits to compare it to the associated hospital claim, and to bypass the new CWF edits if the hospital claim contains an excluded code.
However, there is no timeframe for how quickly these adjustments should take place. Most ambulance providers are reporting that they are seeing few, if any claims, being reprocessed.
As noted above, the edits were designed to deny claims to the extent CMS was unable to determine whether they should be bundled to the SNF, i.e., to deny if the associated hospital claim was not already in the system. Therefore, in theory, it should be impossible for the ambulance provider to receive a payment and then a recoupment for SNF PPS.
I suspect the situation described above is one where the ambulance claim is submitted prior to CMS’ receipt of the associated SNF claim for the patient. As noted above, in order for the edits to work properly, both the associated hospital and SNF claims must be in the system. While CMS clearly contemplated the possibility that the ambulance claim might be submitted prior to the associated hospital claim, they do not appear to have considered the possibility that the ambulance claim might beat the associated SNF claim into the system.
When that happens, there is nothing in the CWF to indicate that the patient was in a Part A SNF Stay. As a result, the claim bypasses these new edits entirely, and frequently ends up being paid by the MAC. I suspect what happens next is that the SNF claim hits the system, and triggers CMS to automatically recoup the payment for the ambulance claim.
What should happen at that point is the ambulance claim should then be run through the new edits. If the hospital claim is already in the system, the ambulance claim gets “stapled” to that claim, and then either passes the edit or gets denied based on the information on the hospital claim. If the hospital claim is not in the system, the ambulance provider gets the “interim” denial discussed above, and the claim should be further adjusted if and when the hospital claim is submitted.
However, at this point, it is entirely possible that these claims are not being put through the edit. The AAA has asked CMS to look into whether the new edits are working as intended in these situations.
Not really a question, but you are not wrong.
I think it is important to distinguish between: (1) denials that are correct based on the HCPCS or CPT codes on the associated hospital claim and (2) denials that are based solely on the timing of your claim, i.e., denials based on your claim being submitted prior to the submission of the associated hospital claim. For these purposes, I will refer to the latter category as “interim denials.”
At the onset, I think all members should recognize that there is nothing you can do to eliminate denials for claims that are properly bundled to the SNF based on the HCPCS or CPT codes on the associated hospital claim.
For numerous reasons, I think the proper focus should be on reducing the interim denials. First and foremost, the difficulty with an interim denial is that you don’t know whether that denial will ultimately prove to be correct, or whether the claim will ultimately be reprocessed and paid by the MAC. Second, even if the claim will be reprocessed, there currently appears to be a significant delay in “when” that reprocessing takes place. Finally, without knowing whether the claim will be reprocessed (and whether that reprocessing will result in a payment), you can’t know whether you should be billing the SNF.
You would need to know the following data points prior to the submission of your claim:
If you knew with certainty that the patient was not in the Part A Period of their SNF stay, you would know that the new edits would be inapplicable to your claim, and you could submit it to Medicare as part of your normal billing workflow.
If you also knew the specific procedure/service the patient received at the hospital, you would also be in a position to know whether the service was the financial responsibility of the SNF, assuming the patient was in the Part A Period. When you know the claim is the financial responsibility of the SNF, you could then immediately invoice the claim to the SNF. If your arrangement with the SNF requires you to first obtain a Medicare denial, you would also have the option of submitting the claim and getting the proper OA-190 denial, and then invoicing the SNF. Note: in these situations, you would receive the oA-190 denial regardless of whether your claim was submitted prior to the hospital claim.
By contrast, when you know the patient is in the Part A Period AND the procedure/service is one that would be excluded from SNF PPS, you can avoid the interim denial by ensuring that your claim is not submitted until after the associated hospital claim. In other words, this is a situation where holding your claim for a reasonable period of time might be beneficial.
First, they are absolutely permitted to share this information with you. Both you and the SNF are “covered entities” under the HIPAA Privacy Rule. In this instance, information on the patient’s Part A status would be helpful to you in managing your payment practices. The regulations at 45 C.F.R. 164.506(c)(3) permit one covered entity to share protected health information with another covered entity for the payment activities of that entity.
However, it is important to note that, while the SNF may share that information with you, the Privacy Rule does not require them to provide you with this information absent a written authorization from the patient.
This information is critical to navigating the new edits. If you haven’t been asking for it up until this point, I would strongly encourage you to consider having a discussion with the local SNFs to explain why you will be asking for this information in the future. You may also want to consider developing a specific form that they must complete (similar to the PCS form) that would provide this information.
I understand. I would try to explain to the SNF that the reason you are asking for this information is to be able to make an intelligent determination on whether the transport is likely to the be financial responsibility of the SNF. This information allows you to avoid denials in certain instances where they would otherwise not be responsible. If they don’t provide you with this information, the foreseeable consequence is that you will end up getting interim denials from Medicare, which may leave you no choice but to bill the SNF for the transport.
You do. I would try to insert language into your agreements with the SNFs that obligate them to provide you with this information. You could also try to insert language that makes them financially responsible whenever they fail to provide this information.
One of the foreseeable consequences of this new edit is that it will increase the frequency with which you bill the SNFs. One of the most common complaints I hear is that SNFs refuse to pay their bills. In most instances, the problem is that the ambulance service lacks a written agreement with the SNF, and, as a result, they frequently end up in disputes about when the SNF is responsible. A written agreement that clearly spells out when the SNF is responsible can not only minimize the potential for misunderstandings, but also afford you greater remedies when the SNF refuses to pay.
You should consult with your local attorney regarding the applicable language. However, conceptually, you want to include language that indicates that a Medicare denial is conclusive evidence that the SNF is financially responsible. This provision could then go on to provide that, in the event Medicare should reprocess and pay a particular claim, then you would refund the SNF’s payment.
The AAA is currently conducting a survey of members to help get a sense of the magnitude of the issues created by these new edits. If you would like to participate in the survey, you can click here.
Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.
On August 5, 2019, the Center for Medicare and Medicaid Innovation (CMMI) announced that it had opened its Request for Application (RFA) Online Portal. The Online Portal can be found on the ET3 Model website. The Online Portal can also be accessed directly by clicking here.
As a reminder, CMMI will be hosting a webinar about the Online Portal on Thursday, August 8, 2019. This webinar will take place from 12:00 p.m. to 1:30 p.m. EDT. If you are interested in participating in this webinar, you can register by clicking here.
Today, CMS has released the proposed rule that would establish the ambulance fee schedule cost collection system as required by statute. The AAA is currently reviewing the rule and will provide a more detailed summary in the coming days.
On Tueusday, July 30 at 12:00pm Eastern, the AAA will be hosting a free webinar during which AAA counsel will provide an overview of the proposals in the rule. Do not miss out on this chance for the most up to date information.
If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.
Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025
Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027
Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026
Thank you for your continued membership and support.
It is with great sadness the American Ambulance Association announces the passing of long-time member and leader Joe Huffman.
Obituary
Joe (Joel Claude) Huffman, a long- time member of the American Ambulance Association Board of Directors answered his Last Call July 1, 2019. after a long battle with Leukemia.
Born August 11, 1954, Mr. Huffman died at his home in Garland surrounded by his family and friends.
From his funeral service at First United Methodist Church of Richardson Mr. Huffman was taken in an ambulance rather than a hearse to Grove Hill Memorial Park in Dallas The funeral procession included 17 ambulances and 14 command vehicles, as well as a police honor guard and other mourners. Following a rendition of Amazing Grace on bagpipes first responders performed The Last Call ceremony.
A licensed paramedic, Mr. Huffman was also active in professional organizations, serving on the board of directors of American Ambulance Association for 18 years and as a member many more years.
He served as president of the Texas Ambulance Association for two years, and was on its executive board many of the more than 30 years he was a member
While president of the Texas Ambulance Association, Mr. Huffman was instrumental in drafting legislation which established standards for Emergency Medical Services in Texas.
At the time of his death Mr. Huffman had been Special Events Coordinator of American Medical Response for 16 years, providing standby service at Cowboy Stadium, ATT stadium, the Cotton Bowl, Lone Star Park in Grand Prairie as well as many others.
Mr. Huffman had worked at the State Fair of Texas First Aid Station for 45 years, never missing a day. Twenty-three of those years he was director of the station. He formerly owned Dallas Ambulance for 11 and a half years. Adding these years of service, Mr. Huffman packed 142 ½ years of service into the 64 years and 10 months of his life.
The son of a locomotive engineer, Mr. Huffman was an avid collector of model trains and railroad memorabilia. He was a lifetime member of the American Museum of Railroads at Frisco, Tx., where he has donated his extensive collection of model trains and railroad memorabilia.
Mr. Huffman graduated from W.W. Samuel High School, attended SMU and earned an A.A. degree at Eastfield Community College.
Memoriam gifts may be sent to the Leukemia and Lymphoma Society of North Texas.
A lifelong resident of Dallas, Mr. Huffman is survived by his Beloved Cheryl Hale of Tyler; a sister, Joyce Huffman Prock, of Bedford; two brothers, Jack W. Huffman and his wife, Donna of Richardson; and James (Jimmy) Huffman of Dallas.
Also, four nieces, Dana Huffman and Melanie Bullock of Richardson; Leslie Prock Norton and husband Andrew, of Bedford; and Angel Marie Huffman Dellinger and husband, Scott, of Crandall. Two nephews Erik Prock of Ft. Worth and Jason Huffman, of Richardson, who is deceased. Great nieces Jaylyn Scott Norton of Bedford; Denise Marie Dellinger of Crandall; and Caroline Huffman of Richardson. Three great nephews, Jack Michael Huffman of Richardson; Dylan Scott Dellinger and Devon Scott Dellinger of Crandall. He was preceded in death by his parents, James J. (Happ) Huffman and Florence Bolin Huffman.
Educating your members of Congress about ambulance industry issues makes them much more likely to support your efforts. An easy and effective way to educate them is to invite them to participate in a local Ambulance Ride-Along!
Congress is scheduled to adjourn on July 27 for their August congressional recess with members of Congress returning home to their districts and states. This is the perfect opportunity for you to educate your members of Congress about those issues, in particular the Public Safety Officers Benefit (PSOB), permanent ambulance relief and ambulance cost data collection which are important to your operation. The most effective way to deliver these key messages is to host your member of Congress or their staff on a tour of your operation and an ambulance ride-along. The AAA has made the process of arranging a ride-long or scheduling a meeting easy for you with our 2019 Congressional Ride-Along Toolkit.
Are you willing to host a Member of Congress at your service but unsure of how to set it up? Email or call Aidan Camas at acamas@ambulance.org – (202) 802-9026 and Aidan can help you set up a meeting.
Everything you need to arrange the ride-along or schedule a meeting is included in the Toolkit. Act now and invite your elected officials to join you on an Ambulance Ride-Along!
The American Ambulance Association has been working hard to accomplish the legislative goals of the membership in the 116th Congress. The AAA would like to take this opportunity to provide an update on what we have accomplished thus far in the 116th Congress.
Balance/surprise billing is a hot button issue that recently came into the spotlight at the start of the 116th Congress. With the President’s announcement calling for Congress to pass legislation that would end surprise billing for patients, there has been an increase in Congressional action on the issue including introduced legislation, discussion drafts and hearings in all committees of jurisdiction. The AAA has been working tirelessly with the Congressional committees of jurisdiction to educate Members and staff on the unique characteristics of EMS systems and that it would be inappropriate to apply the same restrictions on balanced billing to ground ambulance services.
The AAA has formed a working group comprised of AAA member volunteers that have worked on policy and messaging on balance billing. The working group has submitted comments to the Energy and Commerce Committee and Senate HELP committees advocating that the ambulance industry is unique from other stakeholders, and as such, should be looked at differently. Ambulance service providers and suppliers are required by law to treat and transport all patients, regardless of their ability to pay and are heavily regulated at the local level. The AAA has been working to communicate these factors that place the ambulance industry in a different situation than many other stakeholders.
The Public Safety Officers Death Benefit (PSOB), a one-time benefit paid to families of first responders killed in the line of duty, is an issue that the AAA has passionately advocated for over many years. In the 116th Congress, the AAA has secured introduction of legislation in the House of Representatives, H.R. 2887, the Emergency Medical Service Providers Protection Act. H.R. 2887 would extend the PSOB to first responders employed by private for-profit EMS agencies. The AAA was able to secure several commitments from Members of Congress to cosponsor the legislation during Stars of Life meetings in Washington, DC. In addition to taking action to move H.R. 2887 through the legislative process, the AAA will be engaging in an outreach campaign in the next few weeks.
The AAA has worked toward reintroduction of legislation to restructure the offset that was passed into law in the Bipartisan Budget Act of 2018 (H.R. 1892) in the 115th Congress. This offset included a total cut of 23% to the Medicare reimbursement for basic life support (BLS) non-emergency transports performed by all ambulance service suppliers and providers to and from dialysis centers. This cut served as an offset to the 5-year extension of Medicare add on payments that our industry worked hard to get extended.
The AAA has secured introduction of legislation in both the House and Senate. H.R. 3021 was introduced by Representatives LaHood (R-IL) and Sewell (D-AL) and S. 228 by Senators Cassidy (R-LA) and Jones (D-AL). If passed, this legislation would change the cut that is currently in place so that it applies specifically to companies conducting over 50% ESRD non-emergency transports. Those ambulance services with over 50% ESRD transports would get a cut of 29.5%, while those doing less would receive a 15.5% cut. The AAA will continue to work toward movement and passage of this legislation that would better distribute the reduction to those providers which do almost exclusively non-emergency dialysis transports and thus have a lower cost of providing services.
The AAA has crafted legislation that is specifically aimed at addressing major Medicare ambulance industry issues. The issues that will be included in future legislation include making Medicare ambulance add-ons permanent, implementing a prior-authorization program across the nation, allowing for transportation to alternative destinations, reducing regulatory burdens, and providing relief through maintaining many zip codes as rural following the next census. The AAA is working to get this Medicare priorities legislation introduced in the coming months so that we can get to work on solving these Medicare issues that impact our industry as a whole.
Another priority that that the AAA has been diligently working toward getting introduced is Veterans Affairs (VA) legislation. The Veterans Reimbursement for Emergency Ambulance Services Act (VREASA) introduced by Congressman Tipton (R-CO) would provide veterans with reimbursement for emergency ambulance services when a Prudent Layperson would have a reasonable expectation that a delay in seeking immediate medical attention will jeopardize the life or health of the veteran. This legislation was introduced as a result of the VA consistently requiring all medical records be provided, including the records of treatment after the emergency service has taken place. Should those records show that it was not a life threatening emergency or a false alarm, the claim for reimbursement is being denied. The VA legislation would mandate that the VA apply the “prudent layperson” definition of emergency to determine coverage of ambulance claims.
The AAA is also working toward addressing two other issues with the VA to enforce more prompt payment by the VA and treating the VA as the first payor, similar to Medicare, as it is determined whether there is a different primary payor. The AAA has been working with Senators Collins and Tester on language help solve this ongoing and serious reimbursement issue.
In our next update, we will be reporting on the progress the AAA has made this year on regulatory issues.
If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.
Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025
Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027
Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026
Thank you for your continued membership and support
On May 22, 2019, the Center for Medicare and Medicaid Innovation (CMMI) released a preview of the Request for Applications (RFAs). This documentation will be used by ambulance providers and suppliers to apply for inclusion as “Participants” in the Emergency Triage, Treat, and Transport (ET3) pilot program.
June 13, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Kathy Lester, Rebecca Williamson, Asbel Montes
$99 for Members | $198 for Non-Members
On February 14, 2019, CMMI announced the creation of a new 5-year pilot program designed to give participating EMS agencies greater flexibility to address the needs of Medicare beneficiaries following a 911 call. The ET3 model would create a new payment model under which participating EMS agencies will be eligible for Medicare reimbursement for: (1) transportation to alternative treatment destinations and (2) treatment at the scene. At the time, CMMI indicated that it anticipated starting the ET3 model in early 2020. To that end, CMMI anticipated soliciting Requests for Participation in the Summer of 2019.
Participation in this pilot program is voluntary. Regardless of whether an ambulance provider or supplier participates in the pilot program, payment for ambulance transportation currently covered under the Medicare Ambulance Fee Schedule will not be affected.
The RFA provides a good deal of additional information regarding the proposed operation of the ET3 Model. These additional details are summarized below.
To be eligible to participate, you must be a Medicare-enrolled ambulance provider or supplier. In addition, CMMI is limiting eligibility to ambulance providers and suppliers that are located in a state or state in which at least 15,000 Medicare FFS emergency ambulances took place in calendar year 2017. Note: based on this restriction, ambulance providers and suppliers in the State of Alaska would not be eligible for participation in the ET3 Model.
CMMI previously indicated that the existing medical necessity requirements would apply to ambulance transportation to alternative treatment destinations. In the RFA, CMMI reiterated this requirement. As a result, EMS agencies will only be eligible for reimbursement for transportation to alternative treatment destinations to the extent the beneficiary’s condition is such that safe transport by other means is contraindicated.
CMMI indicated that beneficiaries that do not meet the medical necessity requirements for ambulance transportation may still meet the medical necessity requirements for a Medicare-covered item or service furnished by a qualified health care practitioner, and, therefore, may allow an EMS agency to receive payment for treatment at the scene under the ET3 Model.
The ET3 Model provides for a number of new payment streams. The two payment streams being made available to participating EMS agencies are: (1) payment for transportation of Medicare beneficiaries to alternative treatment destinations and (2) payment for treatment of the Medicare beneficiary at the scene, where such care was rendered by a qualified health care practitioner either at the scene or via telehealth.
When the ET3 Model was first announced, CMS indicated that the reimbursement to EMS agencies for providing transportation to alternative treatment destinations would be based on the corresponding BLS “base rate” in the area. However, in the RFA, CMMI indicates that the payment for transportation to an alternative treatment destination will now be made at either the applicable BLS emergency or ALS emergency base rate. In order to qualify for payment at the applicable ALS emergency rate, the EMS agency must meet Medicare’s definition of “Advanced Life Support” (i.e., the provision of valid ALS intervention and/or the provision of a qualifying ALS assessment). The payment for this base rate would include the current adjustments for transports provided in urban, rural, or super-rural areas.
The EMS agency would also be eligible for payment for all loaded mileage, at the applicable Medicare mileage rate. This payment would include all current adjustments, including the “bonus” paid for the first 17 rural miles.
Note: CMMI indicated that it would be creating an exception to general Medicare requirement that patients be transported to the nearest appropriate facility. Based on the language in the RFA, it appears clear that CMMI would cover all of the mileage to an alternative treatment destination, even where transportation to the nearest hospital ED would have been shorter.
Based on the language in the RFA, it appears that claims for transportation to alternative treatment destinations will be submitted using the normal ambulance HCPCS codes (i.e., A0427 for an ALS emergency and A0429 for a BLS emergency).
When the EMS agency facilitates in-person treatment by a qualified health care practitioner (QHP), the EMS agency will be paid an amount equivalent to the BLS emergency or ALS emergency base rate. In order to qualify for payment at the applicable ALS emergency rate, the EMS agency must provide medically necessary supplies and services and either a qualifying ALS assessment or the provision of at least one ALS intervention. When the EMS agency facilitates treatment in pace via telehealth, the EMS agency will be paid a modified “telehealth originating site facility fee” equivalent to the applicable BLS emergency or ALS emergency base rate.
Claims submitted for treatment at the scene, whether by the QHP in person or via telehealth, will be submitted using a model-specific code (yet to be announced).
EMS agencies that provide transportation to alternative treatment destinations and/or treatment at the scene may be eligible for performance-based payment adjustments of up to 5%, based upon meeting certain performance and reporting metrics. These adjustments will become available no earlier than Year 3 of the ET3 Model, and are not guaranteed. Performance-based payment adjustments would be based on performance during the previous year (e.g., if the EMS agency meets the performance criteria in Year 3, it would see an increase in Year 4). These performance-based payment adjustments apply only to payments under the ET3 Model, i.e., they do not apply to Medicare payments made under the current Medicare Ambulance Fee Schedule.
When an EMS agency transports a patient to an alternative treatment destination, that facility will bill Medicare for the services it renders to the beneficiary using its normal claims submission procedures.
A QHP that partners with an EMS agency to provide treatment at the scene will bill Medicare using the applicable HCPCS code for the services it furnished under existing Medicare FFS rules. When that service is furnished via telehealth, the QHP must submit a claim to Medicare for telehealth services furnished from the distant site. QHPs that provide services to Medicare beneficiaries during non-business hours (defined as being from 8:00 p.m. to 8:00 a.m. local time) will be eligible for a 15% increase in the payment rates normally applicable to their in-person or telehealth services.
Separate from the RFA process, CMMI expects to allocate funding to governmental entities and their designees that operate 911 dispatch centers. The purpose of this funding is to support the successful implementation of medical triage lines integrated into the local 911 system. These Notice of Funding Opportunity (NOFOs) will be released following the first round of Participant selection (i.e., likely in the Fall/Winter of 2019).
The RFA is the first of up to three potential RFAs that will be used to select EMS agencies to participate in the ET3 Model as “Participants.” CMMI is indicating that it hopes to select enough EMS agencies to participate to capture up to 30% of the existing volume of Medicare FFS emergency ground ambulance transports. Additional RFAs will be considered based on available funding and evidence that the ET3 Model is working as intended.
CMMI is not currently accepting applications. Round 1 applications will be accepted via an application portal that will be opened at a later date. Information on the applicable process, including the date the application portal will be opened will be posted on the ET3 Model website: https://innovation.cms.gov/initiatives/et3
If you elect to apply for participation in the ET3 Model, you will be required to identify a “region” in which you propose to implement the model. CMMI indicates that this region should be a county or equivalent entity, or multiple counties or equivalent entities.
In selecting Participants, CMMI indicated that it will give preference to applicants who propose a region that includes at least one county (or county-equivalent) where at least 7,500 Medicare FFS emergency ground ambulance transports occurred in 2017. CMMI provided a list of the number of Medicare FFS emergency ground ambulance transports that occurred in each county (organized by state) That list can be obtained by clicking here.
Applicants will be required to participate in the transportation to alternative treatment destination (ATD) portion of the program. Applicants will have the option – – but not be required – – to propose the creation of a program to provide treatment at the scene in conjunction with QHPs. Note: CMMI indicated that applicants that elect to implement the treatment at the scene intervention will earn additional points towards their overall application score.
In order to implement the ATD portion, you will be required to partner with alternative destination sites (e.g., Urgent Care Centers), which must be enrolled in Medicare or employ or contract with Medicare-enrolled practitioners, and which must be able to accept and treat Medicare FFS beneficiaries. If you elect to implement the treatment at the scene portion, you must also partner with QHPs to provide treatment at the scene. These contractual partners are referred to in the RFA as “Non-Participant Partners” (NPPs). To qualify, you must contract with NPPs that can ensure the availability of services for ET3 Model beneficiaries on a 24 hours per day, 7 days a week basis. CMMI will have the right to accept or reject a proposed Non-Participant Partner.
Applicants will also be required to describe their strategy for engaging other payers in their proposed service area, or explain how they can successfully implement the model for Medicare FFS beneficiaries only.
Participants in the ET3 will be required to report certain metrics to CMMI and its contractors. You will also be required to participate in what CMMI is calling a “Learning System.” This is a structured approach to sharing, integrating, and actively applying quality improvement concepts, tactics, and lessons designed to improve the likelihood of success of the model. At a minimum, this will include consistent participation in monthly ET3 Model learning activities, and participation in at least one in-person event, with the location to be determined by CMMI at a later date.
The above is a brief summary of the new information available regarding the ET3 Model. It is not intended to be a complete discussion of all of the requirements for participation. AAA Members are strongly encouraged to read the RFA for themselves to determine whether they want to participate in the ET3 Model.
This morning Ruth Hazdovac and Aidan Camas of AAA staff and Kathy Lester, Esq, Healthcare Consultant to the AAA attended a briefing held by the House Energy & Commerce Committee on the issue of surprise/balance billing. At the briefing, staff for Chairman Frank Pallone (D-NJ) and Ranking Member Greg Walden (R-OR) announced that they would be releasing a bipartisan discussion draft, the No Surprises Act, which would “protect consumers from surprise medical bills and increase transparency in our health care system.”
As of now, ground and air ambulances are NOT included in the discussion draft. However, the committee is asking for comments on ground and air ambulance and recommendations on how to provide relief to the consumer in this area. The AAA has a Balance Billing Work Group that is hard at work developing a policy recommendation that will work for our members.
The House Ways and Means Health Subcommittee Chairman Lloyd Doggett also announced today that the Health Subcommittee will hold a hearing next week entitled “Hearing on Protecting Patients from Surprise Medical Bills.” AAA Staff will be at the briefing and provide a timely update to membership on any developments.
The AAA team will be submitting comments and policy recommendations based off the work of the Balance Billing Work Group to both the Energy & Commerce and Ways & Means Committee to ensure that the views of our members are well represented. We will also be reaching out to AAA members in the states of key policymakers on the Committees to submit comments, as well. The AAA will also provide members with key talking points in the event they are contact by their Members of Congress or their staff.
If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.
Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025
Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027
Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026
Thank you for your continued membership and support.
The Centers for Medicare and Medicaid Services (CMS) held its latest Open Door Forum on Wednesday, March 28, 2019. As with past Open Door Forums, CMS started the call with the following announcements:
Following the announcements, CMS moved into a Question & Answer period. The majority of the questions related to the ET3 pilot program. As is typical, many questions were not answered on the call; instead, CMS asked the individual to submit their question in writing. However, the following questions were answered on the call:
Questions? Email Brian at bwerfel@aol.com
On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions.
The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions.
Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include the requirement that the patient have CHF and either: (1) be currently admitted as an inpatient at Requestor’s hospital or (2) be a patient of Requestor’s outpatient cardiology department, and who had been admitted as an inpatient at Requestor’s hospital within the previously 30 days. The clinical nurses would identify those patients at higher risk of hospital admission based on a widely used risk assessment tool. The clinical nurses would also determine whether the patient had arranged to receive follow-up care with Requestor’s outpatient CHF center. Patients that do not intend to seek follow-up care with the CHF center, or who have indicated that they intend to seek follow-up care with another health care provider, would not be informed of the current program. Eligible patients would be informed of the current program, and offered the opportunity to participate. The eligibility criteria for the expanded program for COPD patients would operate in a similar manner.
Eligible patients that elect to participate in the current program or the expanded program would receive in-home follow up care for a thirty (30) day period following enrollment. This follow up care would consist of two visits every week from a community paramedic employed by the Requestor. As part of this in-home care, the community paramedic would provide some or all of the following services:
The community paramedic would use a clinical protocol to deliver interventions and to assess whether a referral for follow-up care is necessary. To the extent the patient requires care that falls outside the community paramedic’s scope of practice, the community paramedic would direct the patient to follow up with his or her physician. For urgent, but non-life threatening conditions, the community paramedic would initiate contact with the patient’s physician.
The Requestor certified that the community paramedics would be employed by the Requestor on either full-time or part-time basis, and that all costs associated with the community paramedic would be borne by the Requestor or its affiliates. The Requestor further certified that no one involved in the operation of the program would be compensated based on the number of patient’s that enroll in the programs. While one of the states in which the Requestor operates does reimburse for community paramedicine services, Requestor certified that it does not bill Medicaid for services provided under the program.
The question posed to the OIG was whether any aspect of the program violated either the federal anti-kickback statute or the prohibition against the offering of unlawful inducements to beneficiaries.
In analyzing the program, the OIG first determined that the services being offered under the program offer significant benefit to enrolled patients. The OIG specifically cited the fact that one state’s Medicaid program reimbursed for similar services as evidence of this value proposition. For this reason, the OIG concluded that the services constitute “remuneration” to patients. The OIG further concluded that this remuneration could potentially influence a patient’s decision on whether to select Requestor or its affiliates for the provision of federally reimbursable items and services. Therefore, the OIG concluded that the program implicated both the anti-kickback statute and the beneficiary inducement prohibition.
The OIG then analyzed whether the program would qualify for an exception under the so-called “Promoting Access to Care Exception.” This exception applies to remuneration that improves a beneficiary’s ability to access items and services covered by federal health care programs and which otherwise pose a low risk of harm. The OIG determined that while some aspects of the program would likely fall within this exception, other aspects would not. Specifically, the OIG cited the home safety assessment as not materially improving a beneficiary’s access to care.
Having concluded that there was no specific exception that would permit the arrangement, the OIG then analyzed the arrangement under its discretionary authority, ultimately concluding that the program posed little risk of fraud or abuse. In reaching this conclusion, the OIG cited several factors:
OIG advisory opinions are issued directly to the requestor of the opinion. The OIG makes a point of noting that these opinions cannot be relied upon by any other entity or individual. Legal technicalities aside, the OIG’s opinion is extremely helpful to the industry, as it lays out the factors the OIG would consider in analyzing similar arrangements. Thus, the opinion is extremely valuable to ambulance providers and suppliers that current operate, or are considering the operation of, similar mobile integrated health and/or community paramedicine programs.
In a Member Advisory issued last week, the AAA provided an update on a series of new Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019.
In our discussion of the implementation specifics, we attempted to answer the question of what would happen when an ambulance claim is submitted prior to the receipt of the associated hospital outpatient claim, and where the associated hospital claim eventually hit Medicare’s system. Specifically, we indicated as follows:
“The Transmittal contains further instructions that the CWF be updated to identify previously rejected ambulance claims upon receipt of an associated hospital claim for the same date of service that contains an Exempted Code. Once identified, the Shared System Maintainer (SSM) is supposed to adjust the previously rejected or denied ambulance claim. At this point, the nature of that “adjustment” is unclear, i.e., it is unknown whether the SSM will automatically reprocess the ambulance claim for payment. The AAA is seeking additional clarification from CMS on this important point.”
On March 15, 2019, CMS responded to our request for clarification. Specifically, CMS indicated that it has instructed the SSM and/or its Medicare Administrative Contractor (MAC) to automatically reprocess claims that were rejected for lack of an associated hospital outpatient claim.
Upon reprocessing, the claims will pass the edits to the extent the associated hospital claim contains a HCPCS or CPT code that indicates that the hospital outpatient service was excluded from SNF Consolidated Billing. Such claims would then be forwarded to the MAC for further editing, and either paid or denied. By contrast, when the associated hospital outpatient claim contains HCPCS or CPT codes that suggest the hospital services should be bundled to the SNF, the claim will be reprocessed and denied by the MAC with a remittance advice code indicating that the SNF is financially responsible.
March 27, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Esq.
$99 for Members | $198 for Non-Members
Join AAA Medicare Consultant Brian Werfel, Esq., to go over the new SNF Consolidated Billing edits that go into effect April 1, 2019. These edits are being implemented by CMS in response to 2017 investigation by the HHS Office of the Inspector General that determined that CMS lacked the appropriate claims processing edits to properly identify ambulance transports provided in connection with hospital outpatient services that are not expressly excluded from SNF PPS. The implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on what to do with these claims moving forward. Sign up today to make sure your service is ready!
On November 2, 2018, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 2176 (Change Request 10955), which would establish a new series of Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019.
In 2017, the HHS Office of the Inspector General conducted an investigation of ground ambulance claims that were furnished to Medicare beneficiaries during the first 100 days of a skilled nursing home (SNF) stay. Under the SNF Consolidated Billing regime, SNFs are paid a per diem, case-mix-adjusted amount that is intended to cover all costs incurred on behalf of their residents. Federal regulations further provide that, with limited exceptions, the SNF’s per diem payment includes medically necessary ambulance transportation provided during the beneficiary’s Part A stay. The OIG’s report was issued in February 2019.
The OIG conducted a review of all SNF beneficiary days from July 1, 2014 through June 30, 2016 to determine whether the beneficiary day contained a ground ambulance claim line. The OIG excluded beneficiary days where the only ambulance claim line related to: (1) certain emergency or intensive outpatient hospital services or (2) dialysis services, as such ambulance transportation would be excluded from SNF Consolidated Billing. The OIG determined that there were 58,006 qualifying beneficiary days during this period, corresponding to $25.3 million in Medicare payments to ambulance suppliers.
The OIG then selected a random sample of 100 beneficiary days for review. The OIG determined that 78 of these 100 beneficiary days contained an overpayment for the associated ambulance claims, as the services the beneficiary received did not suspend or end their SNF resident status, nor was the transport for dialysis. The OIG determined that ambulance providers were overpaid a total of $41,456 for these ambulance transports. The OIG further determined that beneficiaries (or their secondary insurances) incurred an additional $10,723 in incorrect coinsurance and deductibles.
Based on the results of its review, the OIG estimates that Medicare made a total of $19.9 million in Part B overpayments to ambulance suppliers for transports that should have been bundled to the SNFs under SNF Consolidated Billing regime. The OIG estimated that beneficiaries (and their secondary insurances) incurred an additional $5.2 million in coinsurance and deductibles related to these incorrect payments.
The OIG concluded that the existing edits were inadequate to identify ambulance claims for services associated with hospital outpatient services that did not suspend or end the beneficiary’s SNF resident status, and which were not related to dialysis. The OIG recommended that CMS implement additional edits to identify such ambulance claims.
In response to the OIG’s report, CMS issued Transmittal 2176, which implements a new series of claims processing edits to identify ambulance claims associated with outpatient hospital services that should be bundled to the SNF. As noted above, these edits will go into effect on April 1, 2019.
These new claims processing edits are somewhat complicated. In order to properly understand how these claims edits will work, it is helpful to understand that CMS already has claims processing edits in place to identify hospital outpatient claims that should be bundled to the SNF. These CWF edits operate by referencing a list of Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes that correspond to outpatient hospital services that are expressly excluded from SNF Consolidated Billing. Hospital claims for outpatient services that are submitted with one of these excluded codes bypass the existing CWF edits, and are then sent to the appropriate Medicare Administrative Contractor for further editing and payment. Hospital claims submitted without one of these codes are denied for SNF Consolidated Billing. For convenience, the list of HCPCS and CPT codes excluded from SNF Consolidated Billing is hereinafter referred to as the “Exempted Codes.”
The new edits for ambulance claims will compare Part B ambulance claims to the associated outpatient hospital claim to see whether or not that hospital claim is excluded from SNF Consolidated Billing.
Under these new edits, the CWF will reject an incoming ambulance claim whenever the beneficiary is determined to be in an SNF Part A stay if either:
When an incoming ambulance claim is rejected by the CWF, it will be sent to the applicable Medicare Administrative Contractor and rejected (Part A Ambulance Providers) or denied (Part B Ambulance Suppliers) using the applicable Claim Adjustment Reason Code/Remittance Advice Remark Code for SNF Consolidated Billing. In other words, the ambulance claim will be denied with an indication that youshould bill the SNF.
The Transmittal contains further instructions that the CWF be updated to identify previously rejected ambulance claims upon receipt of an associated hospital claim for the same date of service that contains an Exempted Code. Once identified, the Shared System Maintainer (SSM) is supposed to adjust the previously rejected or denied ambulance claim. At this point, the nature of that “adjustment” is unclear, i.e., it is unknown whether the SSM will automatically reprocess the ambulance claim for payment. The AAA is seeking additional clarification from CMS on this important point.
Based on the current experience of hospital providers, the AAA is cautiously optimistic that the new edits can be implemented in a way that proper identifies ambulance transports associated with hospital outpatient claims that should be bundled to the SNF vs. those that correctly remain separately payable by Medicare Part B.
However, the AAA has some concerns with the manner in which CMS intends to apply these edits. Ambulance providers and suppliers are typically in a position to submit their claims earlier than the corresponding hospital, many of which submit claims on a biweekly or monthly cycle. This creates a potential timing issue. This timing issue arises because the edits will reject any ambulance claim that is submitted without an associated hospital claim on file. In other words, even if the hospital outpatient service is properly excluded from SNF Consolidated Billing, the ambulance claim will still be rejected if it beats the hospital claim into the system. The hope is that CMS will subsequently reprocess the ambulance claim once the hospital claim hits the system. However, at this point in time, it is unclear whether these claims will be automatically reprocessed, or whether ambulance providers and suppliers will be forced to appeal these claims for payment.
One option available to ambulance providers and suppliers would be to hold these claims for a period of time, in order to allow the hospitals to submit their claims. By waiting for the hospital to submit its claim, you can ensure that your claims will not be denied solely due to the timing issue. This should eliminate the disruption associated with separately payable claims being rejected and then subsequently reprocessed and/or appealed. It would also give you a degree of certainty when billing the SNF for claims that are denied for SNF Consolidated Billing. However, holding claims carries an obvious downside, i.e., it will disrupt your normal cash flow.
To summarize, the implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on whether to hold claims to minimize the potential for problems, or to continue their existing submission practices and deal with any issues as they arise.
AAA webinar on new SNF Consolidated Billing edits
March 27, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Esq.
$99 for Members | $198 for Non-Members
Join AAA Medicare Consultant Brian Werfel, Esq., to go over the new SNF Consolidated Billing edits that go into effect April 1, 2019. These edits are being implemented by CMS in response to 2017 investigation by the HHS Office of the Inspector General that determined that CMS lacked the appropriate claims processing edits to properly identify ambulance transports provided in connection with hospital outpatient services that are not expressly excluded from SNF PPS. The implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on what to do with these claims moving forward. Sign up today to make sure your service is ready!