CMS Publishes Two New Reports on GADCS Website
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Dear Ground Ambulance Providers and Suppliers,
We wanted you to be aware that we posted 2 reports on our Medicare Ground Ambulance Data Collection System website under Reports: |
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Dear Ground Ambulance Providers and Suppliers,
We wanted you to be aware that we posted 2 reports on our Medicare Ground Ambulance Data Collection System website under Reports: |
The letter to the editor below was submitted to The Guardian on July 23, following the July 21 publication of the article referenced.
To the Editor of The Guardian,
On July 21, The Guardian published Jessica Glenza’s “Plan to end exorbitant ‘surprise’ ambulance bills heads to Congress.” The inflammatory title and lack of context do no justice to the years of bipartisan collaborative effort leading to the forthcoming report to Congress. As a member of the Advisory Committee on Ground Ambulance and Patient Billing (GAPB) and Immediate Past President of the American Ambulance Association, I believe it is critical to set the record straight.
It is essential to understand that EMS directly bills patients instead of insurers only as a last resort. Sadly, as a frequent entry point to healthcare, EMS often faces the unenviable task of educating people about their limited insurance coverage or high deductibles, both of which are out of our control. As mobile healthcare is entirely decentralized in the United States, it is often unfeasible for small or volunteer-staffed ambulance services to negotiate sustainable in-network rates with dozens of insurance plans. The GAPB Advisory Committee’s recommendations seek to remedy this foundational disconnect between patients, EMS providers, and health plans.
The article notes that some EMS providers are owned by private equity, but overlooks that the vast majority of ambulance services in the United States are small, often conducting only a few dozen patient transports per day. These community-based services—some of which are the sole healthcare provider for miles—face skyrocketing costs for wages, fuel, and medical supplies that threaten their ability to keep their doors open. The collaborative work of the GAPB Advisory Committee sought to address these challenges by proposing recommendations that, if adopted by Congress, would help alleviate these financial pressures while also enhancing patient protection from surprise insurance denials.
The article implies that Patricia Kelmar was the only representative of the public interest on the panel. In fact, another Committee participant was explicitly appointed to represent patient advocacy groups, and as healthcare providers, EMS professionals and physicians consistently advocate for our patients’ well-being. The committee’s composition, as established by Congress within the No Surprises Act, was intentionally diverse and included stakeholders ranging from physicians to elected officials to insurance providers to ensure balance.
Additionally, it is important to clarify that the Health Affairs research cited in the article does not provide data on actual balance bills received by patients. Rather, it roughly estimates only potential balance bills as calculated based on a flawed estimation process. Even if we were to accept Health Affairs estimates as fact, the average balance bill calculated according to their methods would be just a few hundred dollars. This is far from the sole and extreme outlier bill cited in the piece. This distinction is critical as it underscores the need for data-driven policy decisions based on real-world evidence rather than projections and one-off examples.
Finally, the piece misses entirely the largest challenge with the Committee’s recommendations and their potential adoption by Congress. Based on longstanding legal precedent, ERISA plans, which cover about half of Americans through their employers, would not be bound by any legislation drafted based on our report. In Washington state and elsewhere, innovative “opt-in” clauses enable ERISA plans to voluntarily comply with state regulation. We encourage this and hope to see it replicated throughout the nation.
People become first responders because they have a passion for caring for others, and our communities trust them to do just that—24/7. Our Committee’s report to Congress includes 14 key recommendations designed to improve transparency, ensure fair reimbursement rates, and ultimately protect patients by strengthening state and local control. If these recommendations are adopted, they will help remove patients from the middle of billing disputes, allowing EMS providers to focus on our primary mission: delivering life-saving and life-sustaining healthcare around the clock.
For a detailed understanding of our recommendations and the Committee’s work, I encourage reading the full GAPB Advisory Committee report when it becomes available later this summer.
Shawn Baird
Immediate Past President, American Ambulance Association
Member, Advisory Committee on Ground Ambulance and Patient Billing
Portland, Oregon
The Centers for Medicare & Medicaid Services (CMS) has released the Calendar Year (CY) 2025 proposed rule that proposes changes to the CY 2025 definitions of ALS-2 services to include one type of whole blood product. The rule does not propose any other changes to the Medicare ambulance fee schedule for 2025.
CMS proposes expanding the list ALS-2 to include low-tier O+ whole blood transfusions. However, there is no new money added to support the provision of the additional services. Specifically, CMS states that most transports involving whole blood are already reimbursed as ALS-2 and no additional payment will be added. For the few instances when whole blood is used and not in connection with another ALS-2 service, the transport would now be reimbursed under ALS-2. If a ground ambulance uses a blood product other than low-tier O+ whole blood, there would be no opportunity for reimbursement unless the transport qualified for ALS-2 through another service.
CMS states:
“We believe that many ground ambulance transports providing WBT already qualify for ALS2 payment, since patients requiring such transfusions are generally critically injured or ill and often suffering from cardio-respiratory failure and/or shock, and therefore are likely to receive one or more procedures currently listed as ALS procedures in the definition of ALS2, with endotracheal intubation, chest decompression, and/or placement of a central venous line or an intraosseous line the most probable to be seen in these circumstances. Patients requiring WBT are typically suffering from hemorrhagic shock, for which the usual course of treatment includes airway stabilization, control of the hemorrhagic source, and stabilization of blood pressure using crystalloid infusion and the provision of WBT or other blood product treatments when available, but not necessarily the administration of advanced cardiac life support medications. Consequently, we do not believe it is likely that most patients who may require WBT would trigger the other pathway to qualify as ALS2, the administration of at least three medications by intravenous push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer’s Lactate).”
“However, not all ground ambulance transports providing WBT may already qualify for ALS2 payment. An ambulance transport would not qualify for ALS2 payment where a patient received only WBT during a ground ambulance transport, and not one or more other services that, either by themselves or in combination, presently qualify as ALS2. We believe WBT should independently qualify as an ALS2 procedure because the administration of WBT and handling of low titer O+ whole blood require a complex level of care beyond ALS1 for which EMS providers and suppliers at the EMT-Intermediate or paramedic level require additional training. In addition, WBT requires specialized equipment such as a blood warmer and rapid infuser. While there is no established national training protocol, many systems follow the guidelines of the Association for the Advancement of Blood and Biotherapies (AABB), which requires additional training that is 4 hours in length for paramedics and 6 hours in length for EMS supervisory staff. Medicare’s requirements for ambulance staffing at 42 CFR 410.41(b) include compliance with state and local laws, which here would establish appropriate training requirements with respect to WBT administration.”
“Therefore, we believe it is appropriate to modify the definition of ALS2 to account for the instances where patients are administered WBT but do not otherwise qualify for ALS2 payment. Of note, we do not have the authority to provide an additional payment, such as an add-on payment for the administration of WBT under the AFS.”[1]
CMS proposes this changed based on data showing that about 1.2 percent of ground ambulance providers/suppliers use some time of blood product, with the majority (60 percent of those carrying the low-tier O+ whole blood). CMS does not discuss the ongoing discussions of the blood community and medical profession about the appropriateness of this treatment versus other types of whole blood or blood components. Nor does it discuss the cost of providing these services. Moreover, it does not address how this proposal may affect the current blood shortage in the United States.
The AAA is working with our members, other EMS organizations, and the blood community to assess the clinical aspects of this proposal, but has identified the failure to address the cost of providing blood and blood products to ground ambulance services that are already woefully underfunded.
The AAA will prepare a comment letter to submit before the September 9 deadline. We also plan to work with members who would also like to provide comments on the proposed rule.
[1]CMS. “CY 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; and Medicare Overpayments.” Display Copy pages 1165-66.
Health Insurance Coverage Projections For The US Population And Sources Of Coverage, By Age, 2024–34
In the Congressional Budget Office’s projections of health insurance coverage, 92.3 percent of the US population, or 316 million people, have coverage in 2024, and 7.7 percent, or 26 million, are uninsured. The uninsured share of the population will rise over the course of the next decade, before settling at 8.9 percent in 2034, largely as a result of the end of COVID-19 pandemic–related Medicaid policies, the expiration of enhanced subsidies available through the Affordable Care Act health insurance Marketplaces, and a surge in immigration that began in 2022. The largest increase in the uninsured population will be among adults ages 19–44. Employment-based coverage will be the predominant source of health insurance, and as the population ages, Medicare enrollment will grow significantly. After greater-than-expected enrollment in 2023, Marketplace enrollment is projected to reach an all-time high of twenty-three million people in 2025.
CMS recently posted an updated Medicare Ground Ambulance Data Collection System (GADCS) webinar on Public Safety Organizations on their Ambulance Events webpage.
CMS recently posted an updated Medicare Ground Ambulance Data Collection System (GADCS) webinar on Labor Costs on their Ambulance Events webpage.
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orThe growing EMS economic crisis is a combination of expense increases for service delivery AND the reimbursement for services provided.
One of the major factors in the revenue gap for EMS as a safety-net healthcare provider is the percentage of patients who cannot pay for their EMS care due to lack of insurance, meaning the patient is responsible for reimbursing the cost of EMS care.
To help NAEMT, AIMHI, and other associations develop communication strategies regarding public policy to address rising levels of uncompensated care, we are asking EMS agencies to help quantify the level of uncompensated care in their agency.
You can participate in the FLASH POLL through the on-line link here:
For your planning purposes, we’re including the questions on the poll below, so you know in advance what the questions are…
The Centers for Medicare and Medicaid Services (CMS) defines uncompensated care as “Health care or services provided by hospitals or health care providers that don’t get reimbursed. Often uncompensated care arises when people don’t have insurance and cannot afford to pay the cost of care.”
https://www.healthcare.gov/glossary/uncompensated-care/
Using this definition, we’d like to seek your input on the following six data points related to your level of uncompensated care.
2019 | 2021 | 2023 | |
% of your billable services that were billed to patients as the primary payer.
(Often referred to as “Self-Pay”, or “Private-Pay”, or “Uninsured”) |
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Average dollar amount reimbursed per service for this payer classification. | |||
Your Average Patient Charge. |
Agency Name:
Name and E-Mail Address of Respondent:
Service Type:
Agency Type:
Primary Service Area State:
Annual Response Volume:
On March 9, 2024, the Centers for Medicare and Medicaid Services (CMS) announced the creation of the Change Healthcare/Optum Payment Disruption (CHOPD) Program. Under the CHOPD Program, CMS will make accelerated payments to Part A providers and advance payments to Part B suppliers that have experienced claims disruptions as a result of the Change Healthcare cyberattack.
Under the CHOPD Program, qualifying providers and suppliers will be eligible to apply for and receive Medicare advances of up to 30 days of their average Medicare payments. Applications for payment advances must be made to the provider’s or supplier’s Medicare Administrative Contractor (MAC). The 30-day payment advance will be based on the average Medicare payments to the provider or supplier between August 1, 2023 and October 31, 2023. Specifically, CMS will compute the total amounts paid to the provider during this period, and then divide by 3 to arrive at the 30-day average amount.
Advance payments received through the CHOPD Program are considered a loan. Therefore, these amounts must be repaid through offsets against future Medicare payments. Recoupments will commence on the date the advance payments are received by the provider or supplier. These recoupments will be equal to 100% of future payments, and will continue until the earlier to occur of: (1) the full repayment of the advance payment or (2) 90 days. In the event a balance remains after 90 days, the MAC will generate a demand notice for the outstanding balance, which must be repaid within 30 days. If the provider does not repay the outstanding balance within that period, interest will start to accrue on the outstanding balance.
Providers and suppliers with multiple National Provider Identifiers (NPIs) may be eligible for multiple advance payments.
To qualify for advance payments, a provider or supplier must meet the following requirements:
To the extent a provider or supplier is approved for an advance payment, they must then execute a Terms and Conditions document acknowledging the following:
From the Centers for Medicare & Medicaid Services on March 9
The Centers for Medicare & Medicaid Services (CMS) is continuing to monitor and assess the impact that the cyberattack on UnitedHealth Group’s subsidiary Change Healthcare has had on all provider and supplier types. Today, CMS is announcing that, in addition to considering applications for accelerated payments for Medicare Part A providers, we will also be considering applications for advance payments for Part B suppliers.
Over the last few days, we have continued to meet with health plans, providers and suppliers to hear about their most pressing concerns. As announced previously, we have directed our Medicare Administrative Contractors (MACs) to expedite actions needed for providers and suppliers to change the clearinghouse they use and to accept paper claims if providers need to use that method. We will continue to respond to provider and supplier inquiries regarding MAC processes.
CMS also recognizes that many Medicaid providers are deeply affected by the impact of the cyberattack. We are continuing to work closely with States and are urging Medicaid managed care plans to make prospective payments to impacted providers, as well.
All MACs will provide public information on how to submit a request for a Medicare accelerated or advance payment on their websites as early as today, Saturday, March 9.
CMS looks forward to continuing to support the provider community during this difficult situation. All affected providers should reach out to health plans and other payers for assistance with the disruption. CMS has encouraged Medicare Advantage (MA) organizations to offer advance funding to providers affected by this cyberattack. The rules governing CMS’s payments to MA organizations and Part D sponsors remain unchanged. Please note that nothing in this statement speaks to the arrangements between MA organizations or Part D sponsors and their contracted providers or facilities.
For more information view the Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/change-healthcare/optum-payment-disruption-chopd-accelerated-payments-part-providers-and-advance
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The Ambulance Open Door Forum has been rescheduled from March 14th to NEW DATE date, April 11th at the same time of 2:00pm-3:00pm ET. Thank you.
Overview:
The Ambulance Open Door Forum (ODF) addresses issues related to the Medicare payment, billing, and coverage for air and ground ambulance services. The Ambulance Fee Schedule (AFS) proposed and final rules, rural and other additional payments under the AFS, and Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) are just some of the many types of issues addressed within the forum. In addition, discussions differentiating the rules related to ambulance providers and independent ambulance suppliers are facilitated. Timely announcements and clarifications regarding important rulemaking, agency program initiatives and other related areas are also included in the forum.
The Centers for Medicare & Medicaid Services (CMS) released a new “Reporting for Rural and Super-Rural Organizations Tip Sheet” on February 16, 2024. This guide assists ground ambulance organizations in rural and super-rural areas to meet the Medicare Ground Ambulance Data Collection System (GADCS) requirements.
You can find all of their tip sheets, including those focused on allocation, governmental, and public safety organizations, on the CMS GADCS website.
Services selected as part of the Year 3 and Year 4 list are due to submit their 2023 data to CMS by May 31, 2024, or 5 months after the close of their fiscal year. The AAA offers various resources to help services collect, verify, and submit data on time and avoid penalties. For more information about our resources, including Amber, email hello@ambulance.org.
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Dear ground ambulance providers and suppliers,
Starting January 1, 2024, selected ground ambulance organizations in Year 3 and Year 4 are required to report cost, utilization, revenue, and other information to CMS. Organizations that fail to report may be subject to a 10 percent payment reduction.
Thursday, January 18 from 2– 3:30 pm ET
Register for this webinar. While everyone is welcome to participate, this session will be most relevant to selected ground ambulance organizations in Years 3 and 4 as they start reporting Medicare Ground Ambulance Data Collection System (GADCS) data to CMS in 2024.
This 60-minute presentation will cover all aspects of the GADCS, including:
A Q&A session will follow the presentation.
More Information:
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