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ET3 Model Moves Forward Starting January 1, 2021

The Centers for Medicare & Medicaid Services (CMS) has announced that the first performance period for the Emergency Triage, Treat, and Transport (ET3) Model will begin on January 1, 2021. As we reported previously, CMS delayed the start of ET3 Model, consistent with its delaying or pausing other payment models, because of the COVID-19 public health emergency (PHE).

To start this effort, CMS has indicated that it will post a revised Participation Agreement (PA) to the ET3 Model Portal by mid-October 2020. Participants must upload signed PAs to the ET3 Model Portal by December 15, 2020. CMS will also post an Implementation Plan Template (IPT). Participants must submit their IPT CMS by November 15, 2020 to allow CMS to review and accept the IPT prior to beginning their participation in the Model.

CMS plans to provide additional guidance, including:  an Orientation Overview fact sheet, Billing and Payment fact sheets, Model Participation During the PHE fact sheet, a Who’s Who fact sheet, and an ET3 Model Portal User Guide. These documents will be available to participants through the ET3 Model Portal during the next several weeks.

The re-engagement on the ET3 Model prior to the end of the PHE is something that the American Ambulance Association (AAA) has supported in discussions with CMS. While it does not address some of the gaps in reimbursement and treatment that our members are seeing nationwide, for those who are participating in the model, it will be an enormous benefit.

The AAA also continues to work with CMS to identify new models that will allow other ground ambulance providers and suppliers to participate in innovative models, even though there were not able to meet the ET3 participation requirements.

CMS Updates Cost Data Collection FAQs and Data Collection Instrument

The Centers for Medicare & Medicaid Services (CMS) has released printable version of the ground ambulance data collection instrument and an expanded FAQ. Both updated documents address some of the more common questions that CMS has heard over the past months, many of which the American Ambulance Association raised.  Importantly, CMS announces through the FAQs the registration process will begin December 2021.

The topics covered in the FAQs include:

  • General questions related to the rationale for collecting data, definitions, and how the information will be used and reported;
  • Sampling and notification questions related to how ground ambulance organizations will be selected to participate in the data collection system;
  • Data collection and reporting timelines and effort questions, which focus on the timelines for collecting and reporting the information, as well as the projected effort required;
    • There are three new FAQs in this section about the impact of the delay due to the pandemic (the questions and answers are below)
  • Requirement to report questions, which focus on the types of information that must be reported and responding to requests from MACs;
    • There is a new FAQ in this section about applying for a hardship exemption (the questions and answers is below)
  • Reporting information questions, which include who within an organization should report the information, the data tool, and how to address technical problems;
    • There are two new FAQ in this section about the pause in data collection due to the pandemic (the questions and answers are below)
    • Importantly, CMS announces that the registration will begin December 2021
  • Data collection scope and principles questions, which discuss the specific type of information and level of specificity that is required;
    • There are several new FAQs in this section about using current accounting practices, municipality practices, and accounting good and services provided by another organization (the questions and answers are below)
  • Reporting information on staffing and labor costs questions, which address issues such as volunteer staff, staff with multiple duties, calculating hours worked;
    • There are three new FAQs in this section about total hours worked, staff training, and paid time off (the questions and answers are below)
  • Reporting other information, such as service area, service mix/service volume, facilities, vehicles, equipment/supplies, and revenue.


New FAQs

 Question: Will the modification listed in the COVID-19 Emergency Declaration Blanket Waiver issued by CMS on May 15, 2020 allow ground ambulance organizations selected in year 1 the option to continue with their current data collection period that started in early 2020 or choose to select a new data collection period starting in 2021? [Added 7/31/2020]

    • Answer: No. The ground ambulance organizations that were selected in year 1 do not have an option and must select a new data collection period starting in 2021. CMS cannot permit this option because the data collected in 2020 during the public health emergency may not be reflective of typical costs and revenue associated with providing ground ambulance services.
  • Question: When will sampled organizations report information? [Updated 7/31/2020]
    • Answer: Sampled organizations will report information within a 5-month reporting period that starts at the end of the organization’s collection period. For example, if your organization begins collecting information on January 1, 2021, your organization’s collection period will run until December 31, 2021 and your organization must report information during the 5- month period between January 1, 2022 and May 31, 2022.
  • Question: How are data collection and reporting dates adjusted for organizations selected in Year 1 given the modification listed in the CMS COVID-19 Emergency Declaration Blanket Waiver? [Added 7/31/2020]
    • Answer: CMS issued a COVID-19 Emergency Declaration Blanket Waiver delaying data collection and reporting requirements for ground ambulance organizations selected in Year 1 by one year. The organizations selected in Year 1 will now collect data during a continuous 12-month period starting in 2021 (rather than 2020) and will now report information during a 5-month period starting in 2022 (rather than 2021). As an example, a Year 1 organization that previously would have collected information from January 1, 2020 to December 31, 2020 and reported information between January 1, 2021 to May 31, 2021 will now collect information from January 1, 2021 to December 31, 2021 and report information between January 1, 2022 and May 31, 2022. Organizations in the Year 1 sample will not report any information collected to date in 2020.
  • Question: Can you provide examples of different data collection periods and the data reporting periods depending on my accounting period start date? [Updated 7/31/2020]
    • Answer: Example of a Data Collection and Reporting Period for a Ground Ambulance Organization with a Calendar Year Accounting Period:

Examples of Data Collection and Reporting Periods for a Ground Ambulance Organization with Accounting Period not based on a Calendar Year:

  • Question: Can my organization request a hardship exemption from the payment reduction? [Updated 7/31/2020]
    • Answer: Yes. Organizations that did not report sufficient data due to a significant hardship, such as a natural disaster, bankruptcy, or other similar situations may request a hardship exemption. To request a hardship exemption after the ground ambulance organization receives notification that it will be subject to the 10 percent payment reduction as a result of not sufficiently submitting information under the data collection system, organizations should complete a request form that will be available at the end of the data reporting period on CMS’s Ambulances Services Center website at https://www.cms.gov/Center/Provider- Type/Ambulances-Services-Center.html. Organizations can request a hardship exemption within 90 calendar days of the date that CMS notified the organization that it would receive a 10 percent payment reduction as a result of not submitting sufficient information under the data collection system. Your organization will be asked to supply information such as reason for requesting a hardship exemption, evidence of the hardship (e.g., photographs, newspaper, other media articles, financial data, bankruptcy filing, etc.), and date when your organization would be able to begin reporting information. All hardship exemption requests will be evaluated based on the information submitted that clearly shows that they are unable to submit the required data.
  • Question: Where and how does my organization report information? [Updated 7/31/2020]
    • Answer: No information will be reported until 2022. As we stated in the CY 2020 Physician Fee Schedule Final Rule (84 FR 62867), a secure web-based data collection system will be available before the start of your data reporting period to allow time for users to register, receive their secure login information, and receive training from CMS on how to use the system. CMS will provide separate instructions on how to access the online Ground Ambulance Data Collection System. You can view a printable version of the ground ambulance data collection instrument at: https://www.cms.gov/Center/Provider- Type/Ambulances-Services-Center for the data collection requirements.
  • Question: My organization was selected in the first group to collect and report cost and other required data. When will we be able to register for the data collection system? [Updated 7/31/2020]
    • Answer: Registration for the system will begin in December 2021. Please check the Medicare Ambulance Services Center website at https://www.cms.gov/Center/Provider- Type/Ambulances-Services-Center.html for updates.
  • Question: Can my organization collect information using our current accounting practices? [Added 7/31/2020]
    • Answer: In general, you will be able to report information collected under your organization’s current accounting practices. CMS understands that some ground ambulance organizations use accrual-basis accounting while others use cash-basis accounting. Please follow the instructions in each instrument section.
  • Question: My ground ambulance organization is owned and/or operated by our local municipality. The municipality pays directly for some costs associated with our ground ambulance operations (e.g., facilities costs, utilities, fuel, benefits, etc.). Do we need to report on these costs? [Updated 7/31/2020]
    • Answer: Yes. You must work with your municipality to report the costs that are relevant to your ground ambulance service. Otherwise, the costs that you report will be incomplete and not reflect your organization’s total costs. This would also apply if your ground ambulance organization is part of a broader organization that pays directly for some of your organization’s costs (e.g., a hospital Medicare provider that also owns and provides ground ambulance services). The specific information that you will need to collect and report might include information on labor costs (Section 7); facilities costs (Section 8); Vehicle costs (Section 9); equipment, consumable, and supply costs (Section 10), and other costs (Section 11). If you are a fire, police, or other public safety-based ground ambulance organization, please report labor hours and compensation associated with both ground ambulance and other public safety roles per the data collection instrument instructions.
  • Question: How should we account for goods or services provided by another organization (e.g., hospital, local government)? [Added 7/31/2020]
    • Answer: Whether and how to account for costs realized by an entity other than your ground ambulance organization depends on the nature of the relationship with the other entity. CMS has heard that it is relatively common for some costs – for example dispatch, vehicle maintenance, or administrative costs – to be borne by an organization’s local municipality or a part of a local municipal government (such as a police department):
    • If your ground ambulance organization is part of or associated with a local municipality, you need to report these costs. For example, if dispatch services are provided by your municipality’s police department and your ground ambulance organization is part of or associated with the same municipality, then you must collect and report a share of dispatch costs associated with ground ambulance operations. See the related question “My ground ambulance organization is owned and/or operated by our local municipality. The municipality pays directly for some costs associated with our ground ambulance operations (e.g., facilities costs, utilities, ambulance fuel, benefits, etc.). Do we need to report on these costs?”
    • If your ground ambulance organization is NOT part of (i.e., owned or operated by) a local municipality, you do NOT need to report costs associated with services provided by your local municipality other than costs (if any) paid directly by your organizations for the service. If your municipality provides dispatch services for your community and your organization does not pay for this service, then no costs related to dispatch are reported. See the related question “My organization received donations during the data collection period (e.g., an ambulance donated by the community, medicines or medical consumables provided by hospitals, or cash donations). How should these donations be reported?” If your organization makes a payment in exchange for a service, report the payment as a cost under the appropriate section of the data collection instrument.

The same principles apply to similar cases, for example when the other entity is a hospital, non-profit organization, or other type of entity.

  • Question: Should hours on call be included in total hours worked? [Added 7/31/2020]
    • Answer: When reporting hours worked, whether for paid or volunteer staff, do not include hours on call toward hours worked.
  • Question: How should we report staff training in the data collection instrument? [Added 7/31/2020]
    • Answer: There are two ways that you can report training. If training is conducted by your organization’s staff, you would include hours worked and compensation for training staff in your calculations of total hours worked and total compensation. Employees would report hours spent and compensation (if any) for attending trainings. If the training is not just on ground ambulance topics, the reported total hours and compensation would reflect an estimate the percent of time related to ground ambulance. If you have other training expenses or pay money to an outside organization for training activities, these can be listed in Section 11, Question 3 under the category “Training and continuing education costs (e.g., costs for materials, travel, training fees, and labor).” Costs related to collecting and reporting data to the Medicare Ground Ambulance Data Collection System should not be reported.
  • Question: How should we report paid time off (PTO) in the data collection instrument? [Added 7/31/2020]
    • Answer: Paid time off (PTO) is not included in the hours worked section in the labor portion of the data collection instrument. However, PTO is a benefit that should be included in the total compensation questions of the labor section.
  • Service Area: Question: How should our organization define the primary and secondary service area for our particular circumstances? [Updated 7/31/2020]
    • Answer: For the purposes of this data collection effort, use your best judgement. In general, your primary service area is the area in which you are exclusively or primarily responsible for providing service at one or more levels and where it is highly likely that the majority of your transport pickups occur. A secondary service area is outside your primary service area, but one where you regularly provide services through mutual or auto-aid arrangements or at a different level of service compared to your primary service area. When reporting service areas using ZIP codes, it is possible that you will report the same ZIP code as belonging to both your primary and secondary service area, for example in a case where a town and a township share a ZIP code and your organization is primarily responsible for service within the town but has mutual or auto aid agreements with the surrounding township. Please list all ZIP codes in your service area, even if they cross over into another county or municipality. For the service volume section of the instrument, responses, transports, etc. to both primary and secondary service areas should be included in the totals reported.
  • Service Mix/Service Volume: Question: How should my organization count ground ambulance responses and/or transports if more than one vehicle is sent to the scene or if more than one patient is transported? [Added 7/31/2020]
    • Answer: If more than one vehicle is sent to the scene, count this as one response. Organizations should count the total number of patients transported. A single response may result in multiple transports in cases where multiple ambulances are deployed or when multiple patients are transported by the same ambulance.
  • Question: How should our organization report on situations where we respond to calls for service in conjunction with staff from another organization? [Added 7/31/2020]
    • Answer: In Section 5, Question 3, you can report that your organization responds to calls for service in conjunction with vehicles and/or staff from another organization. You must report payments that you make to the other organization (as “other costs” in Section 11) and payments received by your organization (as revenue in Section 13). You will not need to report specific labor or other costs from the other organization. Report the total revenue that your organization receives from payers and other sources, even if you later share the revenue with the other organization.
  • Facilities: Question: My organization does not record buildings as assets or calculate depreciation for buildings. Do we need to report depreciation for buildings? [Added 7/31/2020]
    • Answer: No.
  • Vehicles: Question: How should we calculate annual depreciation expenses for vehicles and capitalized equipment? [Updated 7/31/2020]
    • Answer: In general, you will be able to use your organization’s standard approach to calculating depreciation expenses. If your organization calculates depreciation expense for multiple purposes (e.g. depreciation for tax incentive purposes vs. Generally Accepted Accounting Principles (GAAP) for standard auditing purposes), please report the depreciation expense captured for standard auditing purposes. There are several presentations, such as the December 5, 2019 National Provider Call, that provide examples of reporting annual depreciation expenses in Section 8 (Facilities Costs), Section 9 (Vehicle Costs), and Section 10 (Equipment, Consumable, and Supply Costs) of the data collection instrument. These presentations are available on the Ambulances Services Center website at https://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.html.
  • Equipment: Question: My organization uses a cash basis for accounting and does not depreciate equipment or supplies. Do we need to start calculating annual depreciation? [Added 7/31/2020]
    • Answer: No. If your department is a cash basis entity and doesn’t calculate depreciation, you do not have to report depreciation. Please report the entire purchase costs in the relevant sections.
  • Revenue: Question: How is revenue defined for the purposes of collecting and reporting data? [Added 7/31/2020]
    • Answer: Report gross/total revenue received from all sources during the data collection period. You may need to collect information from a billing company or your municipality in order to report this information. Do not report charges, billed amounts, or bad debt. Depending on your organization’s accounting practices, CMS understands that the revenue received during the data collection period may not perfectly align with the services provided during the data collection period.
  • Question: My organization is unable to separate revenue from payers related to transports and non-transport services. How should we report revenue for non-transport services? [Added 7/31/2020]
    • Answer: If possible, report only revenue from transports in Section 13, Questions 2-4. Report revenue from non-transport EMS and ground ambulance services in Section 13, Question 5.
  • Question: My organization shares revenue from billed service with another organization. Should we report the revenue we receive from payers or the share we retain? [Added 7/31/2020]
    • Answer: Report the revenue that you initially receive from payers. Do not subtract the amount that you share with another organization. Report the amount you do share in Section 11 (“Other Costs”) as a cost.

EMS1: National associations join forces to tell the story of the front line

AAA Communications Chair Rob Lawrence shared his insights about recent  EMS and fire association joint advocacy efforts in EMS1. Don’t miss the full article!

Last week, the AAA were approached, via EMS1, by U.S. News, a national publication represented by journalist Gaby Galvin, asking about COVID-19 as it affects the front lines, rates of infection and quarantine, and generally life on the street. This opportunity provided the chance to bring together three national organizations who are all working hard to represent their members, lobby Congress and highlight the challenges at the tip of the spear.

Keep reading on EMS1►

HHS Announces Release of Initial Tranche of CARES Act Provider Relief Funding

On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.  These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.  These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19.  Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”

On April 9, 2020, the Department of Health and Human Services (HHS) indicated that it would be disbursing the first $30 billion of relief funding to eligible providers and suppliers starting on April 10, 2020.  This money will be disbursed via direct deposit into eligible providers and supplier bank accounts.  Please note that these are outright payments, i.e., these are not loans that will need to be repaid. 

Who is Eligible to Receive Relief Fund Payments?

HHS indicated that any healthcare provider or supplier that received Medicare Fee-For-Service reimbursements in 2019 will be eligible for the initial allocation.  Payments to practices that are part of larger medical groups will be sent to the group’s central billing office (based on Medicare enrollment information).  HHS indicated that billing organizations will be identified by their Taxpayer Identification Numbers (TINs).

Are There Any Conditions to Receipt of this Funding?

Yes.  As a condition to receiving relief funding, a healthcare provider or supplier must agree not to seek to collection out-of-pocket payments from COVID-19 patients that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.

How is the Amount of Relief Funding an Entity will Receive Determined?

HHS indicated that the amounts healthcare providers and suppliers will receive will be based on their pro-rata share of total Medicare FFS expenditures in 2019.  HHS indicated that Medicare FFS payments totaled $484 billion in 2019.

Providers and suppliers can estimate their initial relief payment amount by dividing their 2019 Medicare FFS reimbursement by $484 billion, and then multiplying that “ratio” by $30 billion.  Note: payments from Medicare Advantage plans are not included in the calculation of a provider’s/supplier’s total 2019 Medicare payments.

As an example, HHS cited a community hospital that received $121 million in Medicare payments in 2019.  HHS indicated that this hospital’s ratio would be 0.00025.  That amount is then multiplied by $30 billion to come up with its initial relief fund payment of $7.5 million.

The AAA has created a CARES Act Provider Relief Calculator
that you can use to estimate your initial relief payment.  |
USE DOWNLOADABLE EXCEL CALCULATOR►

Do I Need to do Anything to Receive Relief Funds?

No.  You do not need to do anything to receive your relief funding.  HHS has partnered with UnitedHealth Group (UHG) to disburse these monies using the Automated Clearing House (ACH) system.  Payments will be made automatically to the ACH account information on file with UHG or CMS.

Providers and suppliers that are normally paid by CMS through paper checks will receive a check from CMS within the next few weeks.

How Will I Know if I Received My Relief Funds?

The ACH deposit will come to you via Optum Bank.  The payment description will read “HHSPayment.”

Do I Need to do Anything Once I Receive My Relief Funds?

Yes.  You will need to sign an attestation statement confirming relief of the funds within 30 days.  These attestations will be made through a webportal that HHS anticipates opening the week of April 13, 2020.  The portal will need to be accessed through the CARES Act Provider Relief Fund webpage, which can be accessed by clicking here.

You will also be required to accept the Terms and Conditions within 30 days.  Providers and suppliers that do not wish to accept these terms and conditions are required to notify HHS within 30 days, and then remit full repayment of the relief funds.  The Terms and Conditions can be reviewed by clicking here.

How will HHS Distribute the Remaining $70 Billion in Relief Funds?

HHS has indicated that it intends to use the remaining relief funds to make targeted distributions to providers in areas particularly impacted by the COVID-19 outbreak, rural providers, providers of services with lower shares of Medicare reimbursement or who predominantly serve Medicaid populations, and providers requesting reimbursement for the treatment of uninsured Americans.

CMS Announces Delay to ET3 Start Date

On April 8, 2020, the Centers for Medicare and Medicaid Services (CMS) announced that it will be delaying the start of the Emergency Triage, Treat and Transport (ET3) Model until Fall 2020.  The ET3 Model was previously set to start on May 1, 2020.  CMS cited the national response to the COVID-19 pandemic as the reason for this delay.

In its delay notice, CMS also reminded the EMS industry that it has issued a number of temporary regulatory waivers and new rules that are designed to give health care providers and suppliers maximum flexibility to respond to the current national emergency.  This includes a number of flexibilities offered specifically to the ambulance industry.

Paycheck Protection Program Loans Summary

Summary of Loans Under Paycheck Protection Program (Section 1102)

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Overview

Section 1102 provides $349 billion for expedited individual loans up to $10 million through approved lenders that are guaranteed 100% by the U.S. government. The loan proceeds can be used to cover payroll support (such as employee salaries, paid sick or medical leave, insurance premiums) and mortgage, rent and utility payments incurred from February 15, 2020 through June 30, 2020.1 The maximum amount of a loan equals 2.5 months of average historical monthly payroll expenses, subject to certain exclusions.

On March 31, 2020, the Department of Treasury issued preliminary guidance regarding the imminent implementation of the Paycheck Protection Program (PPP). On April 2, 2020, the Small Business Administration (SBA) issued an interim final rule providing additional implementation guidelines and requirements for the PPP.

Small businesses and sole proprietorships started to apply for and receive PPP loans on April 3, 2020. Independent contractors and self-employed individuals can begin applying on April 10, 2020. The loans are first come, first served.

Benefits for Borrowers: Borrowers are eligible for loan forgiveness equal to the amount spent by the borrower during an 8-week period after the origination date of the loan on payroll costs, interest payment on any mortgage incurred prior to February 15, 2020, payment of rent on any lease in force prior to February 15, 2020, and payment on any utility for which service began before February 15, 2020. All borrower and lender fees, collateral and personal guarantee requirements are waived. The fixed interest rate is 1 percent and loan maturity is two years. No prepayment fees will be charged. Loan repayments can be deferred for six months.

Benefits for Lenders: Allows loans to be sold on the secondary market. Provides the regulatory capital risk weight of loans made under this program, and temporary relief from troubled debt restructuring (TDR) disclosures for loans that are deferred under this program. Lender compensation for servicing the loan is 5 percent for loans of not more than $350,000;
3 percent for loans of more than $350,000 and less than $2,000,000; and 1 percent for loans of not less than $2,000,000. Interim SBA regulations provide some protection for banks in the underwriting process.

The SBA lender list can be found at https://www.sba.gov/paycheckprotection/find.

Eligible businesses include:
  • 1. Businesses with 500 or fewer employees (calculated as discussed below);
  • 2. Small businesses as defined in the Small Business Administration Size Standards at 13 C.F.R. § 121.201;
  • 3. 501(c)(3) nonprofits, 501(c)(19) veteran’s organizations and Tribal business concerns described in section 31(b)(2)(C) of the Small Business Act with not more than 500 employees;
  • 4. Hotels, motels and restaurants with either 500 or fewer employees at each physical location or in the aggregate, without regard to affiliation under
    13 C.F.R. §§ 121.103 and 121.301;
  • 5. Franchises listed in the SBA Franchise Directory without regard to affiliation under 13 C.F.R. §§ 121.103 and 121.301; and
  • 6. Sole proprietors, independent contractors, gig economy workers and self-employed individuals are all eligible.
Ineligible Businesses include but are not limited to:
  • 1. Employers who elect to take advantage of “Delay of payment of employer payroll taxes” in CARES Act Section 2302 or the “Employee retention credit for employers subject to closure due to COVID-19” in Section 2301 are not eligible to take advantage of these loans (unless, in the case of the Section 2302 payroll tax deferral, the loan proceeds were not forgiven under either Section 1106 or Section 1109).
  • 2. Financial businesses primarily engaged in the business of lending, such as banks, finance companies and factoring companies (pawn shops, although engaged in lending, may qualify in some circumstances); SBA’s Standard Operating Procedure 50 10 (SOP) provides this includes:
    • i. Banks;
    • ii. Life Insurance Companies (but not independent agents);
    • iii. Finance Companies;
    • iv. Factoring companies;
    • v. Investment Companies;
    • vi. Bail Bond Companies; and
    • vii. Other businesses whose stock in trade is money.
  • 3. Passive businesses owned by developers and landlords that do not actively use or occupy the assets acquired or improved with the loan proceeds (except Eligible Passive Companies under 13 C.F.R. § 120.111);
  • 4. Businesses located in a foreign country (businesses in the United States owned by aliens may qualify);
  • 5. Pyramid sale distribution plans;
  • 6. Businesses deriving more than one-third of gross annual revenue from legal gambling activities;
  • 7. Loan packagers earning more than one third of their gross annual revenue from packaging SBA loans;
  • 8. Businesses primarily engaged in political or lobbying activities; and
  • 9. Other businesses listed at 13 C.F.R. § 120.110.2

Counting Employees and Affiliation Rules:

SBA counts all individuals employed on a full-time, part-time or other basis, so this includes employees obtained from a temporary employee agency, professional employee organization or leasing arrangement. Contractors receiving IRS Form 1099 and volunteers are not considered employees.

The method for determining size includes the following principles:

  1. The average number of employees (including the employees of its domestic and foreign affiliates) for each of the pay periods for the preceding completed 12 calendar months.
  2. Part-time and temporary employees are counted the same as full-time employees.
  3. If a new company/venture, the average number of employees is used for each of the pay periods during which it has been in business.
  4. The average number of employees of a business with affiliates is calculated by adding the average number of employees of the business with the average number of employees of each affiliate. If the business has acquired an affiliate or been acquired as an affiliate during the applicable period of measurement or before the date on which it self-certified as small, the employees counted in determining size status include the employees of the acquired or acquiring concern. Furthermore, this aggregation applies for the entire period of measurement, not just the period after the affiliation arose.
  5. The employees of a former affiliate are not counted if affiliation ceased before the date used for determining size. This exclusion of employees of a former affiliate applies during the entire period of measurement, rather than only for the period after which affiliation ceased. However, if a business has sold a segregable division to another business concern during the applicable period of measurement or before the date on which it self-certified as small, the employees used in determining size status will continue to include the employees of the division that was sold.

The SBA’s affiliation rules substantially impact the ability of many entities to qualify for small business loans. On April 3, 2020, SBA issued an interim final rule (Affiliation IFR) about the applicability of affiliation rules at 13 C.F.R. §§ 121.103 and 121.301 to PPP loans. This supplements the SBA’s April 2 interim final rule.

The Affiliation IFR clarifies that SBA’s affiliation rules apply to all PPP applicants unless an exemption provided in the CARES Act applies. It also adds a new exemption, providing that affiliation rules do not apply to relationships of any church, faith-based organization, or entity that is based on religious teaching or belief. Affiliation rules a waived for:

  1. any business concern with not more than 500 employees that, as of the date on which the loan is disbursed, is a hotel, motel, or restaurant;
  2. Franchises listed in the SBA Franchise Directory;
  3. business concern that receives financial assistance from a company licensed under section 301 of the Small Business Investment Act of 1958 (15 U.S.C. 681); and
  4. the relationship of a faith-based organization to another organization if the relationship is based on a religious teaching or belief or otherwise constitutes a part of the exercise of religion.

Concerns and entities are affiliates of each other when one controls or has the power to control the other, or a third party or parties controls or has the power to control both. It does not matter whether control is exercised. SBA’s affiliation rules applicable to financial assistance programs, found at 13 C.F.R. §§ 121.103, provide that any of the following circumstances is sufficient to establish affiliation.

Ownership:
  • a. A concern is an affiliate of an individual, concern, or entity that owns or has the power to control more than 50 percent of the concern’s voting equity.
  • b. If no individual, concern, or entity is found to control, SBA will deem the Board of Directors or President or Chief Executive Officer (CEO) (or other officers, managing members, or partners who control the management of the concern) to be in control of the concern.
  • c. SBA will deem a minority shareholder to be in control, if that individual or entity has the ability, under the concern’s charter, by-laws, or shareholder’s agreement, to prevent a quorum or otherwise block action by the board of directors or shareholders.
Stock options, convertible securities, and agreements to merge:
  • a. Stock options, convertible securities, and agreements to merge are treated as though the rights granted have been exercised for purposes of determining control.
  • b. However the following are not given such present effect:
    • i. Agreements in negotiations;
    • ii. options, securities, and agreements subject to conditions precedent which are incapable of fulfillment or where the probability of the transaction occurring is extremely remote; and
    • iii. options, securities, and agreements that give entities in control of the operative business concern the ability to divest all or part of their ownership interest in order to avoid a finding of affiliation.
Common management:
  • a. Affiliation arises where the CEO or President of the applicant concern (or other officers, managing members, or partners who control the management of the concern) also controls the management of one or more other concerns.
  • b. Affiliation also arises where a single individual, concern, or entity that controls the Board of Directors or management of one concern also controls the Board of Directors or management of one of more other concerns.
  • c. Affiliation also arises where a single individual, concern or entity controls the management of the applicant concern through a management agreement.
Identity of interest
  • a. Affiliation may arise among two or more individuals or firms with an identity of interest. Individuals or firms that have identical or substantially identical business or economic interests (such as close relatives, individuals or firms with common investments, or firms that are economically dependent through contractual or other relationships) may be treated as one party with such interests aggregated.
  • b. Where SBA determines that such interests should be aggregated, an individual or firm may rebut that determination with evidence showing that the interests deemed to be one are in fact separate.
Totality of the circumstances:
  • a. SBA may consider all connections between the concern and a possible affiliate. Even though no single factor is sufficient to constitute affiliation, SBA may find affiliation on a case-by-case basis where there is clear and convincing evidence based on the totality of the circumstances.
  • b. However, where an SBA Lender has made a determination of no affiliation, SBA will not overturn that determination as long as it was reasonable when made given the information available to the SBA Lender at the time.

Loan Amount

Eligible borrowers can seek a total loan amount equal to monthly average of payroll over the past 12 months, multiplied by 2.5. “Payroll costs” include salary, wages, commissions, cash tips, paid vacation or leave, insurance premiums and other group health care payments, allowance for separation or dismissal, paid retirement benefits and state or local taxes. The statute also allows a business to include the “sum of any compensation to or income of a sole proprietor that is a wage, commission, or income, net earnings from self-employment, or similar compensation” in payroll costs to the extent these amounts are in an amount that is not more than $100,000 in one year.

“Payroll costs” do not include individual compensation in excess of $100,000, certain taxes (including the employer’s share of the social security portion (6.2% of employee wages) and the Medicare portion (1.45% of employee wages) of payroll taxes known as Federal Insurance Contributions Act (FICA)) and ordinary income tax withholding, compensation paid to an employee if their place of residence is outside the United States and paid leave under the Families First Coronavirus Relief Act.

Example: An employer with total payroll costs of $12 million over the past 12 months is eligible for a PPP loan of $2.5 million ($1 million average monthly payroll cost x 2.5).

If you received an Economic Injury Disaster Loan (EIDL) between January 21, 2020 and April 3, 2020, you can add the outstanding amount of that loan (less the amount of any “advance” under a COVD-19 EIDL) to your calculated total (average monthly payroll cost x 2.5) for purposes of calculating your maximum loan amount.

Example: An employer calculated the $2.5 million amount in the above example, and also has an outstanding COVID-19 EIDL of $600,000, $100,000 of which was an advance. The employer is eligible for a PPP loan of $3 million ($2.5 million plus
$600,000, minus $100,000 advance).

Borrowers that were not in business between February 15, 2019 and June 30, 2019 can receive a loan amount equal to 2.5 times their average payroll costs between January 1, 2020 and February 29, 2020. Borrowers that have existing loans under certain SBA programs may be subject to different limits.

Certifications, Fees and Allowable Uses

Lenders must consider whether the borrower was in operation before February 15, 2020 and had employees for whom the borrower paid salaries and payroll taxes, (or paid independent contractors under Form 1099-MISC). Borrowers also must make a good faith certification on the PPP application form that:

  1. Current economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant;
  2. The Applicant is eligible to receive a loan under the rules in effect at the time this application is submitted that have been issued by the Small Business Administration (SBA) implementing the Paycheck Protection Program under Division A, Title I of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) (the Paycheck Protection Program Rule).
  3. The funds will be used to retain workers and maintain payroll, or make mortgage payments, lease payments and utility payments;
  4. Any loan received by the Applicant under Section 7(b)(2) of the Small Business Act between January 31, 2020 and April 3, 2020 was for a purpose other than paying payroll costs and other allowable uses loans under the Paycheck Protection Program Rule;
  5. The recipient has not received loan amounts under the same subsection for the same purpose between February 15, 2020 and December 31, 2020;
  6. The Applicant will provide to the Lender documentation verifying the number of full- time equivalent employees on the Applicant’s payroll as well as the dollar amounts of payroll costs, covered mortgage interest payments, covered rent payments and covered utilities for the eight-week period following this loan; and
  7. All information provided in the application and all supporting documents and forms is true and accurate in all material respects, acknowledging that knowingly making false statements is punishable by imprisonment of not more than 5 years and/or a fine of up to $250,000.

The PPP waives certain fees typically required for SBA loans, including those under Sections 18(A) and 23(A) of the statute. Applicants also do not need to certify that they are unable to obtain credit elsewhere, or provide a personal guarantee or collateral for a covered loan. However, loan proceeds received under PPP cannot be used for the same costs for which proceeds from a loan received through the Economic Disaster Loan Assistance Program are used.

Use of Loan Proceeds, Forgiveness and Reduction in Forgiveness Amount

Loan proceeds may only be used to pay: (1) payroll costs; (2) costs related to the continuation of group health care benefits during periods of paid sick, medical or family leave, and insurance premiums; (3) mortgage interest payments; (4) rent payments; (5) utility payments; (6) interest on any debt obligation incurred before the covered period; or (7) refinancing EIDL made between January 31, 2020 and April 3, 2020.

Loan amounts expended during the eight-week period following the loan origination will be forgiven, up to the total amount of the loan, if used for payroll costs (up to an annualized rate of
$100,000 per employee). In addition, up to 25 percent of the loan forgiveness amount may be attributable to qualifying non-payroll costs including: (1) interest on a mortgage obligation; (2) rent; or (3) covered utilities. The CARES Act provides an exception from the general rule that debt forgiveness is taxable, so that that amount of loan forgiveness will not be included in the borrower’s taxable income.

The forgiveness amount will be reduced if the employer reduces the number of full-time equivalent employees, or reduces employees’ salary and wages beyond a certain amount during the eight-week period.

First, the forgiven amount will be reduced by multiplying the amount of forgivable costs by:

  1. the average number of full-time equivalent employees (FTEs) employed during the eight weeks following the loan origination, divided by
  2. the average number of FTEs employed between either February 15, 2019 and June 30, 2019, OR January 1, 2020 and February 29, 2020 (the employer may elect the period used).

*Seasonal employers must measure the average number of FTE employees for the period from February 15, 2019 to June 30, 2019.

Example: Borrower had average FTEs of 300 employees per month from February 15- June 30, 2019, and average FTEs of 250 employees per month from January 1- February 29, 2020. The borrower obtains a $2.5 million loan and uses all of the loan proceeds to pay for forgivable expenses. During the eight-week period following the loan, the borrower employ an average of 150 FTEs per month. Employer elects January 1-February 29, 2020 baseline period. Forgiveness on the loan is reduced as follows:
150 Covered Period FTEs / 250 Baseline Period FTEs = 0.6
$2.5 million x 0.6 = $1.5 million forgiven
*Remaining $1 million principal must be repaid at applicable interest rate over remaining term of loan

Second, the forgiven amount will be reduced by the amount of any reduction in total salary or wages during the eight weeks after origination that exceeds 25 percent of an employee’s total salary or wages during most recent full quarter during with the employee was employed.
Employees that earned annualized pay in excess of $100,000 in 2019 are not counted for these purposes.

Example: Borrower obtains a $2.5 million loan and uses all of the loan proceeds to pay for forgivable expenses. During the eight-week period following the loan, the borrower reduces pay of hourly employees by 50 percent, resulting in a total reduction in compensation of $1,500,000. The borrower also reduces the pay of its five officers, all of whom earn more than $100,000, by 50 percent. The reduction in officer pay produces a savings of $250,000. No reduction in FTEs occurs. Forgiveness on the loan is reduced as follows:

$2.5 million – $750,000 (comp. reduction in excess of 25 percent to employees earning less than $100,000) = $1.75 million forgiven

(Remaining $750,000 principal must be repaid at applicable interest rate over remaining term of loan)

Borrowers may “cure” reductions in FTEs or compensation for purposes of forgiveness in certain circumstances. Specifically, these reductions will not reduce the forgiveness amount if:

  1. The borrower reduces the number of FTEs between February 15, 2020 and the date 30 days after the enactment of the Act and eliminates that reduction no later than June 30, 2020.
    Example: Same as above. Borrower has a baseline of 250 FTEs and lays off 100 FTEs on March 1, 2020. Average FTEs over the eight-week period is 150, but the borrower rehires 75 FTEs on June 15, 2020.
    225 Covered Period FTEs / 250 Baseline Period FTEs = 0.9
    $2.5 million x 0.9 = $2.25 million forgiven
  2. The borrower reduces the salary and wages of employees between February 15, 2020 and the date 30 days after enactment of the Act and eliminates the reduction no later than June 30, 2020.
    Example: On March 15, 2020, the borrower reduces the pay of hourly employees by 50 percent, resulting in a total reduction in compensation of $1,500,000. On June 15, 2020, the borrower restores all hourly employees to full pay.
    No reduction in forgiveness amount.

Borrowers must provide sufficient documentation to demonstrate compliance with these requirements, including: (1) payroll tax filings reported to the Internal Revenue Service; (2) state income, payroll and unemployment insurance filings; and (3) other documentation, including cancelled checks, receipts or account transcripts, to verify mortgage interest, rent and utility payments.

Borrowers also must certify that the amounts for which forgiveness is requested were used to retain employees and make covered mortgage interest, rent or utility payments.

SBA intends to issue additional guidance on the loan forgiveness provisions of the PPP loan.

Application Process

Beginning on April 3, 2020, you can apply at any lending institution that is approved to participate in the Small Business Administration’s 7(a) lending program. Additionally, upon completion of the CARES Act Section 1102 Lender Agreement (SBA Form 3506), the following types of lenders will be “automatically qualified” to issue PPP loans provided they are not currently designated in Troubled Condition:

  1. Federally insured depository institutions or federally insured credit unions;
  2. Farm Credit System institutions (other than Federal Agricultural Mortgage Corporations); and
  3. Certain depository or non-depository financing providers.

However, the $349 billion in funds may not still be available by the time additional qualified lenders submit the requisite Lender Agreement. You will not have to visit any government institution to apply for the loan. Applicants are eligible to apply for the PPP loan until June 30, 2020.

For eligibility purposes, lenders will not be determining eligibility-based repayment ability, but rather whether the business was operational on February 15, 2020 and had employees for whom it paid salaries and payroll taxes (or paid independent contractors).

Notes

  • Section 7(a)(36)(A)(iii) of the Small Business Act (15 U.S.C. § 636(a)(36)(A)(iii)), as added by the CARES Act, defines the covered period for the PPP loan program as the period beginning on February 15, 2020 and ending on June 30, 2020. However, this covered period is not further addressed in the interim final rule SBA issued on April 2, 2020.
  • Although this list of ineligible businesses also includes: “[b]usinesses principally engaged in teaching, instructing, counseling or indoctrinating religion or religious beliefs, whether in a religious or secular setting,” SBA issued guidance on April 3, 2020, following the issuance of its interim final rule on affiliation earlier that day, stating that this provision “impermissibly exclude[s] some religious entities” and therefore it will decline to enforce this provision with regard to PPP and EIDL. See https://www.sba.gov/sites/default/files/2020-04/SBA%20Faith- Based%20FAQ%20Final.pdf.
  • The Department of Treasury issued guidance on affiliation in conjunction with the Affiliation IFR, which largely mirrors the affiliation rules found at 121.301.
  • Section 7(a)(36) of the Small Business Act (15 U.S.C. § 636(a)(36)), as added by the CARES Act, does not place any requirement on the amount of PPP loan proceeds that must be applied to any particular eligible expense. However, the interim final rule SBA issued on April 2, 2020, requires that at least 75% of the PPP loan proceeds be used for payroll costs.

5 Steps to an Emergency Small Business Coronavirus Loan

Download PDF from Akin Gump – Five Steps to an SBA PPP Loan

Step 1. Does my business qualify?

  • Were you in business on February 15, 2020?
  • Does your business have at least one but no more than 500 employees or do you meet the applicable SBA size standards for your industry?
  • Have you faced economic uncertainty as a result of the COVID-19 pandemic? Will you use the loan to maintain payroll and other business obligations?
  • Will you decline to take the “Employees Retention Tax Credit for Employers?”

If the answer to all of the questions above is “yes,” keep reading.

Step 2. How much of a loan can I get?

First, check your payroll records to see how much you paid in total over the past 12 months:

  • Salary, wages, tips, and commissions (no more than $100,000 per employee)
  • Payments for group health insurance and retirement programs like 401(k) plans
  • Payments to the state unemployment insurance fund

Second, take that total number, divide by 12, and multiply this result by 2.5. This is your loan amount. The loan cannot be more than $10 million.

Step 3. For what can I use the loan money?

You can use the loan proceeds to pay your employees, pay health insurance premiums, pay rent, pay utilities, and pay interest on any debts your business had before February 15, 2020.

Step 4. Do I have to pay the loan back?

If in the eight weeks after the loan is issued, the following is true, the loan will be entirely forgiven:

  1. All loan proceeds have been spent on allowable expenses, and no more than 25 percent of the money has been spent on non-payroll allowable expenses (like rent), AND
  2. You have maintained the same number of employees you had previously, and none of your employees have received a pay cut of more than 25 percent compared to their historical compensation.

*If you are required to layoff employees or reduce payroll during the eight week period, only a portion of your loan may be forgiven. Any portion of the loan that must be paid back will be at an interest rate of 1.0 percent over a two year term with the first payment being deferred six months after such determination is made.

Step 5. How do I apply?

Any bank or credit union will be able to offer these loans, and most will. All you need to do to apply is go to them with proof you were in business on February 15, 2020 and provide evidence of your payroll expenses (as defined in Step 2) for the 12 months leading up to the application. You should be able to get a loan disbursed to you the same day. Deadline is June 30, 2020. Application can be found here: Paycheck Protection Program Application Form.

© 2020 Akin Gump Strauss Hauer & Feld LLP

EMS Granted Access to the Amazon COVID-19 Store!

Thank you to the thousands of EMS and fire professionals who joined our social media campaign to encourage Amazon Business to admit mobile healthcare providers into their new COVID-19 Store. In response to the collective voices of our profession, Amazon has updated their policy! Effective April 6, EMS and Fire will begin to be onboarded into the limited-access marketplace. To participate:

  1. Ensure your agency has established an Amazon Business account. 
  2. Request access to the COVID-19 Store. When you complete the form, select “OTHER” as organization type until/unless EMS becomes available as an option. When entering your company name, please make it clear that you are an ambulance service or fire department (no abbreviations).
  3. Wait patiently for up to 10 days to receive confirmation of access as each enrollment request is individually reviewed by Amazon staff.
  4. If you have questions, experience excessive delay, or need assistance, please contact Amazon support.

The store is a new venture, and the virtual shelves are in the process of being stocked. However, Amazon has assured us that they have tens of millions of units of PPE and supplies on rush order. We encourage you to set up your agency account and check back frequently for new item availability. 

We hope that access to the COVID-19 supplies and Amazon’s legendary logistics and delivery expertise will assist ambulance services in meeting the needs of their communities during this challenging and stressful time.

CMS Waives Restrictions on Ground Ambulances During COVID-19 Pandemic

The Centers for Medicare and Medicaid Services (CMS) promulgated an interim final rule with comment period (IFC) entitled “Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.”  Consistent with the recommendations the AAA made to CMS, for the duration of the public health emergency (PHE), the IFC allows ground ambulance service providers and suppliers to transport patients both on an emergency or non-emergency basis to any destination that is equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished.  In related guidance, CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic, waived patient signature requirements, and is pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model. The policies of the IFC are effective retroactively to March 1, 2020.

On March 11, the AAA sent CMS a letter specifically requesting for the agency to waive during the COVID-19 pandemic the regulatory restrictions that prevent coverage for transport to alternative destinations.  Separately, the AAA has been pressing CMS to provide relief from signature requirements. The AAA had also been working with CMS to lifting of these restrictions and others to eliminate barriers the current Medicare regulations in responding to the COVID-19 crisis.

Paying for Transports to Alternative Destinations.  During the duration of the crisis, CMS has expanded the list of destinations for which Medicare covers ambulance transportation to include all destinations, from any point of origin, that are equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished.

These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH) or skilled nursing facility (SNF), community mental health centers, federal qualified health clinic (FQHCs), rural health clinics (RHCs), physicians’ offices, urgent care facilities, ambulatory surgery centers (ASCs), any location furnishing dialysis services outside of an ESRD facility when an ESRD facility is not available, and the beneficiary’s home.

This expanded list of destinations applies to medically necessary emergency and non-emergency ground ambulance transports of beneficiaries during the PHE for the COVID-19 pandemic.  The IFC does not waive the medically necessary requirements for ground ambulance transport of a patient in order for an ambulance service to be covered.

The AAA is working closely with CMS to confirm that patients who require isolation meet the medical necessity requirements.

Suspension of Audits and Relief on Patient Signatures.  In guidance released separately, CMS indicates that it is suspending nearly all audits of providers and suppliers for the duration of the PHE.

CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.

CMS also indicates in this guidance that a beneficiary’s signature will not be required for proof of delivery, as it relates to durable medical equipment services, during the PHE.  In a follow-up exchange with CMS, the AAA has confirmed that this policy of not requiring a beneficiary’s signature also applies to ground ambulance providers and suppliers. The AAA has requested that this clarification for ground ambulances also be provided in a written FAQ.

Pause in the Non-Emergency Prior Authorization Model.  CMS has paused the claims processing requirements for the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model, effective March 29 until the end of the PHE.  During this pause, claims for repetitive, scheduled non-emergent ground ambulance transports for the COVID-19 pandemic in States in which the model operates will not be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period. During the pause, the MAC will continue to review any prior authorization requests that have already been submitted, and ambulance suppliers may continue to submit new prior authorization requests for review during the pause. Claims that have received a provisional affirmative prior authorization decision and are submitted with an affirmed unique tracking number (UTN) will continue to be excluded from future medical review. Following the end of the PHE for the COVID-19 pandemic, the MACs will conduct postpayment review on claims otherwise subject to the model that were submitted and paid during the pause.

Telehealth Services.  While CMS does not provide authority for ambulance organizations to bill directly for telehealth services, it does modify for the duration of the PHE the “direct supervision” requirements to allow physicians enter into a contractual arrangement with an entity that provides ambulance services to allow the physician to use the ambulance organization’s personnel as auxiliary personnel under a leased agreement.  Under such circumstances, the provider or supplier would seek payment for any services it provided from the billing physician and would not submit claims to Medicare for such services directly.

Ongoing work of the AAA.  The rule does not address two critical issues:  (1) reimbursement for treatment in place and (2) direct reimbursement for telehealth services.  The AAA will continue to work with CMS and the Congress to address these issues that are critical to meeting the needs of patients and your community during the epidemic.

AAA Social Media Campaign During COVID-19

Demonstrate the value of EMS in the COVID-19 crisis!
#EMS is on the very front lines of the #COVID19 epidemic. We provide on-demand #mobilehealthcare for the most vulnerable patient populations, 24/7. Help AAA showcase the incredible importance of #Paramedics#EMTs, and #Dispatchers in the response to this pandemic. Would you please capture a photo of yourselves in action, holding a simple sign? It is essential that we communicate visually with legislators, regulators, and the general public to help them understand the critically important role we play in saving and sustaining lives. #AlwaysOpen #StayHomeForUs

If practical, please consider showing your medics standing apart from one another (social distancing) if they are not in PPE.

Instructions on Facebook►

COVID-19 Message from President Aarron Reinert

Aarron Reinert
President
American Ambulance Association

Dear Fellow AAA Members,

I write to you today during what we all recognize as an extraordinary time for EMS. As we collectively serve on the very front lines of the COVID-19 epidemic, we know that the most challenging times are still ahead. However, I am heartened by the collective resolve of the members of the American Ambulance Association to provide 24/7 on-demand mobile healthcare, no matter the circumstances.

As President of the Association, I am sharing below a brief summary of the AAA’s activities to support its members in the face of this devastating disease.

COVID-19 Content & Approach

  • Coronavirus Working Group—AAA Region III Director Tom Tornstrom, Executive Director of Gundersen Tri-State Ambulance, has been appointed to lead the AAA Coronavirus Working Group. The team includes AAA’s lobbyists, leadership, staff, and members from across the nation. We meet frequently and collaborate constantly to track challenges and find solutions to EMS issues relating to COVID-19 response. Sample topics include:
    • First responder safety and wellness
    • Reimbursement for alternative destinations, treatment in place, and mobile testing
    • Paperwork reduction / waivers
    • Advocating for policies in federal legislation that support mobile healthcare and redacting those that can negatively impact the industry

Members will receive updates via our Digest e-newsletter as we continue to make progress on these and other issues.

  • Representation in Stakeholder Groups—From CMS to Congress to local mayors, AAA has representatives and members working with legislators, regulators, and officials at every level of government to advocate for EMS. Simultaneously, AAA leaders are working to showcase mobile healthcare’s unique strengths and capabilities for addressing the viral threat.
  • Member Newsletter—The frequency of our member Digest e-newsletter has been increased from weekly to near-daily to ensure that we are curating and communicating the most relevant and important information.
  • COVID-19 Archive—All AAA posts related to the virus can be found on our website. A COVID-19 resource link has been added to the top navigation of the AAA website for easy access by providers.

Association Events & Operations

  • Stars of Life—Out of an abundance of caution, the Stars of Life event in Washington has been canceled. All blocked rooms will be canceled and refunded by the hotel, and all attendee registration fees will be refunded by diflucan. Staff is working on the development of meaningful ways to celebrate 2020 Stars outside of the context of an in-person event.
  • Ambulance Cost Education (Cost Collection)—A plan is in place to move ACE Gold cost collection education from face-to-face to an interactive online learning environment. Subscribers can expect additional updates in early April.
  • Headquarters—Association staff is all working remotely whenever possible. Staff is adhering to strict health, hygiene, and social distancing. All order fulfillment, mail processing, and other functions have been moved offsite.

Please don’t hesitate to reach out to staff at info@ambulance.org or 202-802-9020 if we can be of any assistance. Thank you again for your service to your communities during this very difficult time.

Aarron Reinert
President, American Ambulance Association

COVID-19 Coronavirus EMS Advisory 1

This guidance is written to offer American Ambulance Association members the situational background and a list of resources and websites with which to draw guidance and further updates on the latest situation with COVID-19, colloquially referred to as “Coronavirus.” Key information for this update has been drawn from the NHTSA EMS Focus series webinar What EMS, 911 and Other Public Safety Personnel Need to Know About COVID-19, which took place on February 24, 2020. The on-demand recording is available below.

General Information

Background

The COVID-19 Coronavirus Disease was first reported in Wuhan China in December 2019. CDC identifies that it was caused by the virus SARS – CoV-2. Early on, many patients were reported to have a link to a large seafood and live animal market. Later, patients did not have exposure to animal markets which indicates person-to-person transmission. Travel-related exportation of cases into the US was first reported January 21, 2020. For reference the first North American EMS experience of  COVID-19 patient transport, including key lessons learned, can be found in the EMS 1 article Transporting Patient 1.

Spread and Identification

Global investigations are now ongoing to better understand the spread. Based on what is known about other coronaviruses, it is presumed to spread primarily through person-to-person contact and may occur when respiratory droplets are produced when an infected person costs or sneezes. Spread could also occur when touching a surface or object that has the virus on it and when touching the mouth, nose, or eyes. Again, research is still ongoing, and advice and guidance will inevitably follow.

For the cases that have been identified so far, those patients with COVID19 have reportedly had mild to severe respiratory illness with symptoms including fever and shortness of breath. Symptoms have typically appeared 2 to 14 days after exposure. Both the WHO and CDC advise that patients that have been to China and develop the symptoms should call their doctors.

COVID-19 Prevention and Treatment

To date, 30 international locations, in addition to the US, have reported confirmed cases of   COVID-19 infection. Inside the US, two instances of person-to-person spread of the virus have been detected. In both cases, these occurred after close and prolonged contact with a traveler who had recently returned from Wuhan, China.

The CDC activated its Emergency Operations Center (EOC) on January 21 and is coordinating closely with state and local partners to assist with identifying cases early; conducting case investigations; and learning about the virology, transmission, and clinical spectrum for this disease. The CDC is continuing to develop and refine guidance for multiple audiences, including the first responder and public safety communities.

As at the date of publication there is still no specific antiviral treatment licensed for   COVID-19, although the WHO and its affiliates are working to develop this.

The following are recommended preventative measures for  COVID-19 and many other respiratory illnesses:

  • Wash your hands often with soap and water for at least 20 seconds.
  • Use an alcohol-based hand sanitizer with at least 60% if soap and water are not readily available.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.
  • Avoid contact with people who are sick.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue, then throw it away.
  • Clean and disinfect frequently touched objects and surfaces.

Interim Guidance for EMS and 911

The Centers for Disease Control (CDC) has issued its Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.

The guidance identifies EMS as vital in responding to and providing emergency treatment for the ill. The nature of our mobile healthcare service delivery presents unique challenges in the working environment. It also identifies that coordination between PSAPs and EMS is critical.

Key points are summarized below:

Recommendations for 911 PSAP Locations

The link between PSAPs and EMS is essential. With the advent of COVID19 there is a need to modify caller queries to question callers and determine the possibility that the call concerns a person who may have signs or symptoms and risk factors for COVID19.

The International Academy of Emergency Dispatch (IAED) recommends that agencies using its Medical Priority Dispatch System (MPDS) should use its Emerging Infectious Disease Surveillance (EIDS) Tool within the Sick Person and Breathing Problem protocols. For those that are not MPDS users, IAED is offering its EIDS surveillance Tool for Coronavirus, SRI, MERS and Ebola-free of charge under a limited use agreement.

Recommended Personal Protective Equipment (PPE)

The CDC recommends that while involved in the direct care of patients the following PPE should be worn:

  • Single pair of disposable examination gloves
  • Disposable isolation gown
  • Respiratory protection (N95 or higher)
  • Eye Protection (goggles or disposable face shield)

EMS Transport of a Patient Under Investigation (PUI) or Patient with Confirmed COVID19

  • Notify receiving healthcare facility so appropriate precautions can be put in place
  • Discourage family and contacts from riding in transport vehicle
  • Isolate the vehicle driver from the patient compartment by closing the windows between compartments and ensuring that the vehicle ventilation system is set to the non-recirculated mode
  • Document patient care

Cleaning EMS Transport Vehicles After Transporting PUI or Patient

  • Don PPE for cleaning with disposable gown and gloves, facemask, and goggles or face shield if splashes are anticipated
  • Routine cleaning and infection procedures should follow organizational standard operating procedures
  • Use protect use products with EPA-approved emergent viral pathogens claims

Once transport is complete, organizations should notify state or local public health authorities for follow up. Additionally agencies should (if not done already) develop policies for assessing exposure risk and management of EMS personnel, report any potential exposure to the chain of command, and watch for fever or respiratory symptoms amongst staff.

Employers Responsibilities

While not specific to COVID-19, agencies should:

  • Assess current practices and policies for infection control
  • Job- or task-specific education and training
  • PPE training and supply
  • Decontamination processes and supplies

Local EMS Considerations

  • PPE supplies
  • 911 and EMD call taking activities
  • Appropriate approach to potential patients
  • Educational resources for EMS personnel
  • Interaction with local public health/healthcare systems/emergency management
  • Interaction with local fire and law enforcement
  • Considerations for local jails

Further Reading

Conclusion

The COVID19 situation constantly evolving. Agencies should defer to their local EMS authorities, Public Health departments, and the CDC for definitive guidance. Going forward, the AAA will continue to both monitor the disease and alert issues to the membership.

Non-Emergency Transport: Avoiding the Fraud Trap [Sponsored]

By Eric van Doesburg, MP Cloud Technologies
This sponsored post is not endorsed by the American Ambulance Association. It reflects the views of the author.

Did you know that one of the most common practices in our industry could put your company at financial risk? Transporting patients not qualified for ambulance transportation is a hot topic these days as it has heavily contributed to the rise of Medicare fraud cases. This issue has grown even more relevant recently with a case in Florida, where not only was the EMS company found liable of fraud, but it was the first time several hospitals were held culpable as well.¹


While the burden of proof falls on the government to satisfy the statutes in the Federal False Claims Act, the fact is investigators are becoming more aggressive in fighting these types of billing schemes.

“The fact is investigators are becoming more aggressive in fighting these types of billing schemes.”

Yes, there are some bad actors in our industry like any other, but more times than not employees simply may be unaware of the qualifications needed when dispatching non-emergency transport.

Thankfully, a company can protect its financial future simply by having the necessary protocols in place.


For ambulance transportation to be covered by Medicare for a patient, the answer must be “yes” to at least one of the three criteria listed below:

  • “Is the patient bed-confined?”
  • “Does the patient require assistance to get out of bed?”
  • “Is the patient unable to safely sit in a wheelchair for the duration of the transport?”

Dispatchers must ask these specific questions in order to understand the scope of the situation – a step that should be incorporated into your business’ procedures immediately. If it is determined that the patient meets none of the above criteria, then an alternative transportation source must be sought and you have a couple of options.


Non-EMS Transport Options

Rideshare Partnership

Uber™ and Lyft™ have not only affected how we approach transportation as a society but have left a prominent mark on the EMS industry as well. According to a University of Kansas study, the use of ambulance transportation dropped 7% in cities that adopted ride-sharing platforms.² Consider the formation of a partnership with these companies as a low-cost alternative for non-emergency transport that could reduce your liability and develop a sustainable revenue stream for the future without a lot of overhead. Of course, just because the patient may not meet the Medicare criteria for non-emergency transport doesn’t mean that they are in a condition to be able to ride in a car by themselves. This is where the situation can become a little tricky. Is Uber™ or Lyft™ really the bestoption for an elderly person who may have some mild form of dementia and is being released after having a medical episode?

Add Non-Emergency Fleet

As an alternative, another option would be setting up your own fleet of non-emergency transport to cater to your clients’ specific needs. These non-emergency shuttles can ensure a consistent and legal discharge process to keep you in compliance and managing dispatch on your terms. It also allows for a higher level of patient care during the transport than a ride-sharing service can provide.

____________________________________________________________________

With the stakes for fraudulent claims getting higher, you’ll want to make sure you have a protocol in place that protects your business, employees, and clients from any hint of impropriety. However, with the right planning and core systems/partnerships, it will make the process for handling non-emergency transport that much easier… and possibly lead to new revenue channels not available in the past. That’s something we can all get excited about.

¹https://www.modernhealthcare.com/article/20150511/NEWS/150519994

HHS OIG Issues Advisory Opinion on Community Paramedicine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Recovering Loss of Revenue from “not at fault” Accidents

When your units get hit by a third party and the vehicle is out of service, are you getting Loss of Revenue for the downtime while the unit is being repaired? Whether you answered yes or no to that question, reading this article will be the one of the most lucrative uses of your time this year.

A call comes in and your dispatcher does a perfect job of answering and scheduling the run. The EMT’s jump into the clean, fueled, and well stocked ambulance responding to the call. Then from out of nowhere, a car turns directly into the ambulance’s path rolling through a stop sign. Now what? You have two paramedics stranded on the side of the road who will be spending the next few hours on paperwork and drug testing. In addition, all the drugs and small equipment need to be removed or secured. Hopefully you have another unit to dispatch or your competitor may have already been called.

What happens next is key to getting maximum recovery for your losses caused by the accident.

Key items that help maximize your recovery from accidents:

  1. Educate and equip fleet drivers with the tools necessary to collect key accident information at the scene and relay it. This includes a description of the accident, clear color pictures of the accident scene, the damaged vehicles, and third-party driver’s license and insurance information.
  2. Gather as many witnesses as possible and statements from both drivers.
  3. On board videos are great, but if not, having a smart phone video of the damage and intersection can be very helpful if the liability is in question.
  4. Get an accurate and thorough estimate. Be aware that, for the most part, insurance companies are motivated to pay out the least amount possible to get the claim settled. Their adjusters are typically not trained accurately determine the damage to specialty vehicles or the equipment they may contain. Using a TPA with strong experience with commercial fleets is critical.

We are surprised how many firms don’t realize or understand what they are entitled to recover because of an accident where their driver was not at fault. Essentially, the law supports that the owner is entitled to the use of their “chattel” and compensation pursuant to the same. Here is an interesting titbit. Chattel is originally a Latin and old French term referring to moveable personal property. A good term to throw out at the next risk managers meeting to impress everyone. With that said, what you are entitled to and what shows up in your mailbox are two drastically different things. Insurance companies are motivated to pay the least amount possible and delay that payment as long as possible.

Most people assume that insurance companies make money when they generate more in premiums than they pay out in losses and expenses, but for the most part that’s not true. Most insurers are happy to break even on their underwriting and make their money by investing the premiums and keeping the investment returns.

What am I entitled to from a “not at fault” accident? There are a lot of factors influencing this, but essentially you are entitled to your physical damage, diminution of value, and loss of use/revenue. How much you are entitled to are the subjective negotiations that firms like ours engage in hundreds of times each day. Driver liability, statute of limitations and minimum policy limits vary from state to state. Typically, the state where the accident happens will be the applicable laws and regulations.

If I have a spare unit to take the place of the damaged vehicle, am I still entitled to Loss of Revenue? The short answer is yes, but getting the carrier to ink the check is another matter. There are real costs of having a spare unit which is why the law supports the loss of the use as a recoverable item. Acquisition cost, maintenance, licensing, certification, insurance, and storage are all costs incurred by having a spare unit.

Pursuing Loss Recovery

The following are steps fleets can take to help maximize recovery:

  1. Pursue all possible recoveries. There is often potential recovery from the third-party drivers in the form of an umbrella policy, company policy, or personal assets. Driver liability, statute of limitations and minimum policy limits vary from state to state. The key is to know which accidents offer what potential in which states, and then to pursue recovery using the latest industry tools as quickly as possible.
  2. Follow insurance industry documentation standards. The required forms need to be properly completed and submitted to the third-party driver’s insurance carrier. Knowing insurance industry regulations, standards, and the law are key to move the carriers to action. Technically, a carrier can wait 30 days after receiving a demand before taking action on the claim.
  3. A key component to Loss of Revenue is accurate records showing the income the unit generated prior to the accident. This is the hardest to recover and gets the most pushback from the insurance companies. Putting the data in a format that meets the insurance company’s needs varies by company.
  4. Even after the carrier has agreed to pay, be prepared to make a lot of follow-up calls and emails to get your claim paid. A common tactic used by carriers is to drag out the claim hoping you will either give up or accept less. Essentially wearing you down.

The second key recovery component is Diminution of Value (DV), or Loss of Market Value the vehicle suffers even after it is repaired. Age of the vehicle, miles, condition, and other factors determine this amount. Without a strong recovery plan or Third Party Administrator (TPA), we see significant diminution of value left on the table. The key here is strong data which supports your valuation utilizing use multiple sources and have extensive experience and a successful track record for recovering DV.

Getting accurate value when a vehicle is a total loss. The term “Total Loss” is an insurance term lacking legal definition. Carriers have often used title branding laws to determine if a vehicle is a “Total Loss”. While each state has different criteria for “branding” titles, vehicles can, and have been, paid as total losses with damage percentages well below the title branding statutes. Carriers often tout statements such as “Federal Guidelines” or “State Statutes” when attempting to settle claims. More accurately, legal entitlements are based upon what is called the Restatement of Torts, and defined by case law in each state. Typically, property and casualty insurance adjusters don’t understand these laws and again are motived to pay out the minimum possible. Engaging a firm that specializes in commercial fleet claims can provide an arm’s length transaction necessary to be pro-active on the front side in setting the claim up properly, which usually results in a higher recovery.

So how do you win at the recovery game? Well unfortunately you are in a game where the opponent is highly motivated to not pay or pay the least possible, has their own set of rules on how much you should get, and make most of their profit on dragging out a payment when they finally do decide to pay.

There are essentially three routes you can pursue.

  1. Handle the claims yourself. Unless you have extensive knowledge in the law and insurance industry, plus have ample time to talk to the voicemails of insurance carriers, this option may not be ideal.
  2. Let your insurance company handle the claim. They will pay your Physical Damage, but rarely does the policy have coverage for Loss of Revenue and Diminution of Value.
  3. Hire a TPA (Third Party Administer) to handle the claims for you. Select a firm with a long track record, experience with specialty vehicles, adequate technology, a strong legal department, and specializes in Loss of Revenue recovery. Make sure their fees are performance based and they only win if you do. They can recover Loss of Revenue, Diminution of Value (inherent and repair related) and other costs typically not recovered.

Few fleets have the number of trained personnel in each of these areas to adopt these best practices. If the fleet’s resources are already stretched to capacity, consider outsourcing to a TPA. The chances are the partnership will yield state-of-the-art best practices and more than pay for itself.

I hope you found this article helpful, don’t hesitate to contact me with any questions or to learn more.

Brian J. Ludlow is Executive Vice President for Alternative Claims Management. He is an entrepreneur and consultant to the insurance, financial, and transportation industries. Brian specializes in disruptive technologies. His firm has transformed the accident claims recovery process.

bludlow@AltClaim.com | 231-330-0515

Family Liaisons Following EMS Line of Duty Deaths

I was just a kid when I started in EMS. 23 years old, hungry for adventure, and ready for everything the world of EMS was prepared to give me. Car accidents, gunshot wounds, stabbings, intoxicated shenanigans, elderly falls, fist fights, medical emergencies, strokes, and cardiac arrest were all on my list of expected possibilities. One of the scenarios I had not thought of, and nobody presented to me throughout school and orientation, was the possibility of clocking in for shift and not going home. I do not recall line of duty deaths being a discussion point in the paramedic curriculum, job interview, or orientation process. I had experienced the unexpected loss of a younger sibling due to a motor vehicle crash before I started my journey in EMS, but the fact that life is short and unpredictable did not connect with the fact that I was knowingly and willingly walking myself into unknown and potentially dangerous situations with each response. Even after the UW Med Flight crash happened early in my career, and in my service area, we simply did not talk about our own potential for death as a direct result of our profession.

Years later, after many more line of duty deaths and even more reports of violence against EMS and healthcare workers, this topic weighs heavy on my mind. In my time as Staff Development Manager for a service, I pushed for the DT4EMS courses to train our medics on how to recognize potential dangers, escape those situations, and defend themselves if they are unable to escape.  We all know the ‘scene safe/BSI’ tagline and list of what things might make a scene unsafe is not enough. As the Rescue Task Force (RTF) formed, I watched as some were excited for the opportunity to be involved and others started to question their willingness to respond to so many unknown situations as their young families were beginning to grow. I started asking myself if EMS agencies are doing enough in terms of preparing themselves and their employees for the possibility of a line of duty death.

The Line of Duty Death Handbook, published in part by the AAA, is a great tool to start building policies, protocols and personnel records. The handbook guides you through the importance of having employees fill out emergency contact and next of kin forms, and keeping them updated, as well as assigning family liaisons and how to manage coverage for funeral services. As I reviewed this, I started thinking about the assignment of a family liaison—a member of your agency who knew the individual well and will be the primary contact for everything the family needs once the notification has been made. What type of person should be assigned this role, and what kind of training should they have? I sat down with KC Schuler, MDiv and board member for the Fox Valley Critical Incident Stress Management group to discuss.

What are some considerations services should make when putting together their line of duty death policy/procedure?

I think the first significant consideration should be conducting pre-incident training. I mean, are you starting the conversation about critical incident stress exposure all the way up to, and including, the possibility that they may never go home to their family, at orientation? During onboarding? So many of the EMTs and Paramedics coming in are young, and this may be their first job. In my experience, they can be somewhat blind to the possibilities. Early education and creating a culture of support—including letting them know you have their back (and their family’s back) in every potential scenario is important. The second consideration, I think, is to determine what scope you define as a line of duty death. The on-shift motor vehicle crash or incident resulting in death while on the clock is apparent, but what about suicide? If someone is having significant job-related stress and commits suicide, will that be looked at as a line of duty death, or not? This is something all organizations need to consider before such an event happens.

S: What type of actions would you recommend take place, or are discussed, as part of the orientation process?

KC: This is a great time for employees to fill out the emergency contact and next of kin form—this also provides an opening to discuss the possibility of death and the importance of filling out the form accurately and keeping it up to date. They are the best ones to tell you who you should notify in such a situation; guessing in the event of a death is not ideal. A portion of orientation and annual training should also be spent on mental health, including awareness, recognition of post-traumatic stress symptoms in themselves and their peers, and available support resources. Trained peer support and EAP can be very valuable in the management of work and home related stressors. Again, being intentional to build and sustain an organizational culture of support prior to an unfortunate tragedy like a line of duty death will help all those involved.

S: The Line of Duty Death Handbook talks about assigning a family liaison—a person who becomes the 24/7 primary contact for the family once notification has been made. This person should be available, in person and via phone, and dedicated to the family whether it is household chores such as mowing the lawn and grocery shopping, to communicating with out of town family members and arranging hotels. Who should be considered for such an assignment, and what might the service do to prepare these individuals?

KC: This is a high-intensity assignment, and this role should not be assigned to shifts in the beginning either. Being a family liaison is a big responsibility, and it is not a responsibility that should shift from person to person; ideally, the family will have one liaison for the duration. Trust is a significant factor—the family must trust the individual they are assigned, so that individual must be able to build that trust or recognize early if it is not a good match. Services should consider the following in their selection of a family liaison:

  1. Someone who is specially trained in being a family liaison. The nature of this position is demanding and can significantly interfere with the liaison’s personal life and responsibilities of emotionally supporting another. They need to be able to have clear boundaries, open lines of communication to leadership, and have a stellar support system in place as well. The International Critical Incident Stress Foundation does offer a 2-day LODD course.
  2. Preferably, the family liaison would not have any other roles (such as being an honor guard member) as they will likely have other duties and responsibilities throughout the process and at the funeral itself. The liaison duties need to be 100% dedicated to the family.
  3. Gender sensitivity—If the deceased is a male, you may want to assign a female liaison to the spouse as there can be a lot of strong emotions during this time and unhealthy attachments can form. You should consider gender identity and sexual preference in assigning a liaison as well.

Training and preparation of individuals for family liaison assignment should happen before an event like this ever occurs.

S: If I am a service director looking to send a few people to train for this, what type of people should I look for?

KC: If I had to provide a list of characteristics for liaison selection, it would probably include someone who:

  1. Does not gossip and respects confidentiality.
  2. Can make things happen—someone who is comfortable making, and either has the authority to make decisions on behalf of the service, or has direct contact with someone who can.
  3. Has a great support system of their own.
  4. Understands and respects boundaries—can set limits where appropriate and necessary.
  5. Is comfortable speaking, but also understands and can recognize the importance of silence, or when not to respond.

S: When it comes to families, there are a lot of dynamics a liaison might have to contend with such as divided families or family members that do not get along. If more than one individual is involved in a LODD, such as two members killed in a car accident, there may also be dynamics between those two families that need to be considered. What are your recommendations for addressing those type situations, where either a single family or multiple families may be at odds?

KC: If there is more than one family involved (i.e., two employees) you will want to assign each family a liaison, and those liaisons will need to be in close communication with each other and the organization leadership. One thing agencies may wish to consider is holding family support or family networking events throughout the year, before an event like this happens. I mean, beyond the Christmas parties and summer picnics where all families are invited—events that allow family members of your employees to get together, build relationships, and form a support system between families who understand the dynamic of supporting someone in EMS. If families are meeting for the first time as the result of a fatal accident, the dynamic will likely be much different (and more difficult) than if they are afforded a place to get to know each other and form bonds before such an event would happen. It is a lot easier to blame a stranger than a friend; it is easier to share pain and experience with someone you share a bond.

If there is pre-incident conflict within a family, such as animosity between divorced parents or an ex-spouse, these situations become more difficult to manage. Training will help the liaison better navigate and handle these situations.

S: You mentioned before, the importance of knowing the resources in your area—what would you say to those services who might plan to reach out to their local CISM or hospital for a family liaison or other support in this situation?

KC: As I mentioned before, EAP is a valuable resource but likely not the best as a stand-alone support in the event of LODD, and it certainly would not be able to function as a family liaison. Many hospitals may have pastoral care staff, such as myself; however, many would not have the capacity to operate as a family liaison or the awareness, authority, and connections to make decisions on behalf of your service. So, neither of these options would not be the best plan in my opinion. CISM teams can help in debriefings, but again, that is different than functioning as a family liaison. Some of your staff members that are trained as CISM peer counselors, however, may be excellent candidates for continued training in LODD and more specifically, as family liaisons.

S: You also mentioned how the family liaison should be taken off shift responsibility and assignments while they are functioning as the family liaison. What time frame should a service expect, and could the director or administrative staff function as the liaison to reduce scheduling disruptions?

KC: The time frame will be variable and unique to each situation; this is part of the importance of a service’s selection and training of these individuals. They need to determine when the family needs the high-intensity liaison, when to move to periodic support, and when to transition out to periodic or then eventual annual check-ins. They need to do this without creating a co-dependence.

A director or administrative staff would not be the ideal candidate for the family liaison assignment. The director will be busy dealing with many other operational details and would not be able to devote the time or attention to the family during the high-intensity phase. Ideally, the liaison will be someone the fallen individual knew, worked alongside, and had a good relationship with; someone who can share some stories with the family. The liaison’s ability to do this goes back to the importance of fostering the family/spousal support network as well.

There are many ways in which services can prepare for a line of duty death. Option one is to bury your head in the sand and pretend it will never happen to you. This, we know, is a lie; a lie to ourselves, our employees and their families. Option two is to address the potential with eyes wide open and full support starting in orientation and stretching through the selection of qualified employees for advanced training. Even if I am lucky enough never to experience a LODD personally, I would rather work for an organization adopting option two every time.

“It is a curious thing, the death of a loved one. We all know that our time in this world is limited and that eventually all of us will end up underneath some sheet, never to wake up. And yet it is always a surprise when it happens to someone we know. It is like walking up the stairs to your bedroom in the dark, and thinking there is one more stair than there is. Your foot falls down, through the air, and there is a sickly moment of dark surprise as you try and readjust the way you thought of things.”

― Lemony Snicket, Horseradish

HIPAA and Mobile Devices: What Your Service Needs to Know

For ambulance services, HIPAA compliance is a particularly sensitive issue. Because of the sensitive nature of the health data that EMS and EMT professionals deal with on a daily basis, HIPAA Privacy and Security standards must be carefully adhered to.

This issue becomes even more sensitive when you consider that most of the data collected during pre-hospital care will likely be collected, tracked, and documented on a mobile device. Laptops, smartphones, and tablets are indispensable tools for ambulance care. Most of these devices will have access to electronic health records (EHR) platforms, which will in turn be connected to the rest of a hospital’s EHR data.

While mobile devices can provide convenience in life-or-death situations, they are also particularly vulnerable to the risk of a data breach. A data breach of unsecured health information can lead to serious HIPAA violations and put patient privacy at risk.

The kind of health information that these devices have access to is called protected health information, or PHI. PHI is any demographic information that can be used to identify a patient. Common examples of PHI include names, dates of birth, medical information, insurance ID numbers, addresses, full facial photos, and telephone numbers, to name a few.

The HIPAA Rules set specific standards for maintaining the privacy, security, and integrity of PHI. Though the regulation can seem complex, the standards are in place to safeguard PHI. As per HIPAA, ambulance services necessarily fall under the category of Covered Entities, meaning that they are responsible for maintaining compliance with both the HIPAA Privacy Rule and the HIPAA Security Rule.

These two rules set limits for how and when PHI must be stored and accessed. Below, we list a few of the major components of the HIPAA Rules that all ambulance services can implement in order to keep PHI safe and secure on the go.

  • All mobile devices that can access PHI must have full-disc encryption. Additionally, all devices should be routinely backed-up on encrypted servers. In the event that a device is lost or stolen, full-disc encryption will keep hackers or thieves from accessing sensitive health data.
  • Your organization should have HIPAA policies and procedures in place pertaining to mobile devices taken “off-site.” This would necessarily include all laptops, tablets, and smartphones with access to PHI that are used in pre-hospital care in an ambulance. By outlining when devices are permitted to be used, who is permitted to use them, and how they are to be handled in off-site settings, your organization will mitigate the risk to PHI stored on these devices.
  • Keep a full inventory of all devices within your organization that can access or handle PHI in any way. Routine check-ups on the condition and location of devices listed in your inventory will help ensure that devices are not misplaced. And in the event that a device is misplaced or stolen, organization officials will notice as soon as the inventory is reviewed so that action can be taken to remedy the breach.
  • Access to PHI on mobile devices and in pre-hospital settings should be limited only to essential members of the organization’s workforce. This is known as the Minimum Necessary Standard. It’s a part of the HIPAA Privacy Rule that states that access to PHI must be limited based on employees’ roles, and that when access is granted, it should be limited to the minimum access necessary for each employee to perform their role.

These are just a few of the ways that ambulance services can protect PHI and comply with HIPAA mobile device standards.

In addition to the actions listed above, a total compliance program that addresses the full extent of the law must be in place in order to prevent HIPAA violations and data breaches.

Addressing HIPAA compliance can help ambulance services confidently treat their patients without worrying about the risk of data breaches or government fines.

What I Wish I Had Known

Congratulations! You were selected for the Paramedic Supervisor position, if you accept, we’ll start the transition immediately.

I remember the excitement I had when I heard those words so many years ago. The excitement that carried strongly through 2 days of celebrating with my husband, anticipating the new world I was about to be part of; making a mental list of all the mountains I couldn’t wait to move! This excitement was quickly drowned by a sinking feeling deep in my gut. It felt like running out of gas on a country highway at one in the morning and your cell phone is dead; it’s dark, there is nobody around, and you cannot phone a friend.

Whether it comes right away, or later—because of the reaction of people we thought were friends or feeling overwhelmed in a new situation you were expected to handle with precision, we’ve all felt that feeling as a new leader. By sharing our stories with one another, the success and the failures, we all grow.

I remember getting so much advice from those who walked the road before me, some solicited some not. The stories were sometimes shocking, often comical and always gave me perspective and insight into my own blunders – most importantly the stories many shared with me taught me the importance of humility and the ability to laugh at myself, admit my mistakes, learn and move on. At some point, the tide started turning, and friends and colleagues began asking me for my stories and advice. Although I often felt like I wasn’t experienced (i.e. old enough) to be offering any advice I realized it’s not necessarily the age or years of experience behind the story that makes it meaningful. The power is in the ability to share an experience through storytelling—finding common ground amongst the hierarchy of titles and job descriptions.

I think it is easy to lose sight of how our words and actions can affect others as we are wrapped up in our day to day and moving down the checklist of tasks. The influence of a leader in an organization, even an informal leader, is long lasting and not to be taken for granted. Over the past year, I’ve been talking to many EMS leaders of the past and present. I’ve been asking them what they wish they would have known when they first started their leadership journey, and what advice they might give to others just starting out. Here are 10 of the most common answers I received.

Top 10 Things I Wish I Had Known

  1. I wish I would have known I could be myself. Being myself earned me the role, but suddenly it didn’t seem like enough. At first, I thought others were putting all this pressure on me to be an amazing supervisor immediately – in hindsight, I realize I was putting the pressure on myself and it was totally unnecessary. Being myself allowed me to be a more effective supervisor for my team and I wish it hadn’t taken me so long to figure it out.
  2. I wish I would have learned earlier how important listening is. Listening to understand your people, listening to learn and listening to understand the politics that are happening beyond the surface.
  3. I wish I would have known that I didn’t have to be right all the time; I wasn’t expected to be right all the time. I was only expected to be an honest and reliable resource for my team.
  4. Change is slow. PAINFULLY slow. In EMS there is constant instant gratification – you see a problem with a patient, you fix it, you drop them off. Transitioning to an administrative role and learning that change is slow and takes time (SO MUCH TIME!) is more difficult than I ever would have imagined. I had to really learn to see the long game.
  5. It’s not a “day job”. As a leader, you’re never off duty. Whether you’re on a regular rotation as a shift supervisor, or in the office as a manager or director, EMS is a 24/7 world which means you work nights, weekends and holidays right along with your team. You may not be on a truck or at a station—but you’re still available to them all the time.
  6. I wish I would have understood how important mission, vision, and values really are to a company, and how important it is to talk about them with staff.
  7. We’re all learning, and it is OK to ask for help.
  8. Just because a staff member is asking me a question, it does not mean they are challenging my authority. As a leader, it took me a long time to realize that I should embrace a staff member challenging a decision so long as they are doing it in a constructive manner.
  9. I wish I would have known how much of an impact I have on people. I don’t mean that in an arrogant way. I’ve had staff bring up conversations we had years ago, and I had forgotten all about it—but they were still carrying that encounter with them.
  10. That it wasn’t for me. I thought I wanted to be a supervisor – a leader. I was wrong. I was unhappy with the role and everyone knew it but me, and I was becoming destructive.
    When I came to the realization that I wasn’t the right person for the role, my boss allowed me a front row seat to the best example of leadership I have personally witnessed. He allowed me to step back from the role but didn’t forget about me; he continued to invest in me as an employee and as an individual despite the certain protest of others. To this day, he continues to provide guidance on my professional endeavors and is someone I truly look to for honest advice.

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