CMS To Phase-In Expansion of Medicare Prior Authorization Model
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orOn October 8, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a Fact Sheet setting forth the repayment terms for advances made under the Medicare Accelerated and Advance Payments Program (AAPP). These changes were mandated by the passage of the Continuing Appropriations Act, 2021 and Other Extensions Act, which was enacted on October 1, 2020.
Background
On March 28, 2020, CMS expanded the existing Accelerated and Advance Payments Program to provide relief to Medicare providers and suppliers that were experiencing cash flow disruptions as a result of the COVID-19 pandemic, and associated economic lockdowns. Under the AAPP, Medicare providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments. These advances are structured as “loans,” and are required to be repaid through the offset of future Medicare payments.
CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act. CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.
Under the pre-existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds. The program also called for a 100% offset until all advanced funds had been repaid.
Revised Payment Terms
Under the revised payment terms announced by CMS, providers and suppliers will not be subject to recoupment of their Medicare payments for a period of one year from the date they received their AAPP payment. Starting on the date that is one year from their receipt of the AAPP payment, repayment will be made out of the provider’s or supplier’s future Medicare payments. The schedule for such repayments will be as follows:
To the extent there remains an outstanding AAPP balance after that 17 month period (i.e., 29 months after the date the provider or supplier received its AAPP payment, the provider or supplier will receive a letter setting forth their remaining balance. The provider or supplier will have 30 days from the date of that letter to repay the AAPP balance in full. To the extent the AAPP balance is not repaid in full within that 30-day period, interest will begin to accrue on the unpaid balance at a rate of 4%, starting from the date of the letter.
Medicare providers and suppliers are also permitted to repay their accelerated or advance payments at any time by contacting their Medicare Administrative Contractor.
On August 25, 2020, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule with a comment period titled “Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments of 1988 (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.” The interim final rule sets forth a number of new requirements designed to limit the COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes.
Specifically, the interim final rule requires skilled nursing and other long-term care facilities to test residents and staff for COVID-19. The frequency of such testing is based on the positivity rate in which the facility is located, and can require COVID-19 testing as frequently as twice per week. Regardless of the frequency of required COVID-19 tests, facilities must also screen all staff, residents, and persons entering the facility for the signs and symptoms of COVID-19.
These requirements extend to individuals that provide services to nursing homes under arrangements, including health care personnel rendering care to residents within the facility. In subsequent guidance, CMS clarified that these testing and screening requirements apply to EMS personnel and other health care providers that render care to residents within the facility. However, in that same guidance, CMS indicated that EMS personnel must be permitted to enter the facility provided that: (1) they are not subject to a work exclusion as a result of to an exposure to COVID-19 or (2) showing signs or symptoms of COVID-19 after being screened.” CMS further indicated that “EMS personnel do not need to be screened so they can attend to an emergency without delay.”
In plain terms, CMS has created an affirmative obligation on nursing homes to ensure that any individual that provides services under a contractual arrangement with the nursing home comply with these testing and screening requirements. CMS has expressly waived the screening requirements for EMS personnel responding to medical emergencies at a nursing home. However, CMS has not specifically addressed the testing and screening requirements applicable to EMS personnel responding to nursing homes in non-emergency situations.
The A.A.A. is aware that a handful of State Health Agencies have issued their own guidance on this issue. The A.A.A. is also aware that individual nursing homes have started to require proof that EMS personnel have been tested for COVID-19 prior to allowing these individuals to enter the nursing home in a non-emergency situation.
EMS agencies may already be subject to state and local testing mandates. EMS agencies may also have their own internal policies that require employees to be periodically tested for COVID-19. As a result, there exists the potential for conflict where these existing testing policies conflict with the testing requirements of your local nursing homes.
The A.A.A. has been engaged in an ongoing conversation with CMS on these issues since the issuance of the interim final rule in August. As part of that conversation, the A.A.A. pushed for the exclusion of EMS personnel from the screening requirement when responding to medical emergencies, which was included in the recent CMS guidance document. The A.A.A. also continues to push for additional funding for COVID-19 testing for EMS agencies. CMS has recognized that the frequent testing of health care workers is essential to reducing the spread of the novel coronavirus. CMS has allocated funding for these purposes to other industries, including hospitals and nursing homes. As front-line health care workers, EMS agencies should have similar access to testing funds. The A.A.A. will continue to push for funding equity for the EMS industry.
In the interim, we strongly encourage our members to work with their state associations and other stakeholders to advocate for reasonable rules related to testing on the state and local levels. To the extent the applicable state or local agency has determined the appropriate frequency for the testing of EMS personnel responding to medical emergencies, those rules should also apply to EMS personnel responding to scheduled transports and other non-emergencies that start or end at a nursing home. Requiring more frequent testing in these situations would impose an undue burden on EMS agencies that provide these services. More frequent testing may also prove counterproductive, as it may discourage EMS agencies that cannot meet these higher requirements from responding in these situations. We also encourage our members to continue to push for state and local funding for the testing of their employees.
CMS Clarify in Guidance that EMS Personnel Are Not Required To Be Tested under Skilled Nursing Facility Testing Interim Final Rule
The Centers for Medicare & Medicaid Services (CMS) have issued guidance clarifying the types of personnel who are subject to the testing requirements when entering a Skilled Nursing Facility (SNF) in the Interim Final Rule with Comment (IFC) on Additional Policy and Regulatory Revisions in Response to the COVID– 19 Public Health Emergency. The new guidance memo states:
Entry of Health Care Workers and Other Providers of Services
Health care workers who are not employees of the facility but provide direct care to the facility’s residents, such as hospice workers, Emergency Medical Services (EMS) personnel, dialysis technicians, laboratory technicians, radiology technicians, social workers, clergy etc., must be permitted to come into the facility as long as they are not subject to a work exclusion due to an exposure to COVID-19 or show signs or symptoms of COVID-19 after being screened. We note that EMS personnel do not need to be screened so they can attend to an emergency without delay. We remind facilities that all staff, including individuals providing services under arrangement as well as volunteers, should adhere to the core principles of COVID-19 infection prevention and must comply with COVID-19 testing requirements.
CMS issued this guidance at the request of the American Ambulance Association (AAA) to address concerns our members had raised about some SNFs misinterpreting the requirements. The guidance is also consistent with AAA’s interpretation of the IFC. As we indicated in an earlier Member Advisory, the IFC requires SNFs to test certain individuals for COVID-19 before they enter the facility. Specifically, it applies to employees, consultants, and contractors of a skilled nursing facility (SNF). It does not apply to vendors, suppliers, attending physicians, family, or visitors. Providers, such as medical directors and hospice, that are under a contract or consultants to a SNF are subject to the rule. EMS personnel do not come within the scope of the IFC.
Even though the testing requirements of the IFC do not extend to ground ambulance services that do not have a contractual relationship with a SNF, the AAA supports the efforts of all of our members to follow the World Health Organization and Centers for Disease Control and Prevention Guidelines to have EMT and paramedics use full Personal Protective Equipment (PPE) when they are engaging with any patient, not only those in SNFs. We also want to recognize the best practices of many members who have worked with SNFs to establish outdoor locations where the SNF personnel, when possible, can bring a patient out of the building to transfer the patient to the ambulance. These and other examples of safe practices can help control the spread of COVID-19, which is the paramount concern.
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orThe 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.
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:
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]
Examples of Data Collection and Reporting Periods for a Ground Ambulance Organization with Accounting Period not based on a Calendar Year:
The same principles apply to similar cases, for example when the other entity is a hospital, non-profit organization, or other type of entity.
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.
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.
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).
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.
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►
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.
The ACH deposit will come to you via Optum Bank. The payment description will read “HHSPayment.”
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.
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.
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.
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:
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.
Looking for highlights from the new CMS IFR? See below for an infographic! (Members, read Kathy Lester, Esq.’s comprehensive summary.)
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.
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.
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.
Members will receive updates via our Digest e-newsletter as we continue to make progress on these and other issues.
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
Kudos to the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) the development of this excellent COVID-19 data visualization.
The New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County WA ‘Patient 1’. This was the first reported case of COVID 19 in the US. This seminal document, which given the magnitude of the case and its initial findings is released in full here
The work by Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, et al for the Washington State 2019-nCoV Case Investigation Team was turned round in just over 5 weeks and below is an ‘Executive summary’ ( as extracted from the paper) but the full paper and range of results should be read in full.
On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.
On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.
Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24).
Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).
Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus
On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.
This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.
There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID 19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken
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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.
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.
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.
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:
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:
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.
The CDC recommends that while involved in the direct care of patients the following PPE should be worn:
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.
While not specific to COVID-19, agencies should:
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.
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:
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.
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?
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.
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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