Time to handle 911 call demands with Paramedics

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

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

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

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

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

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

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

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

Medicaid Replacement Plans

Medicaid billing in emergency medical services is unavoidable. From trauma trips to non-emergency transports, ambulance providers face a multitude of hurdles when trying to identify, verify and bill the correct payor for Medicaid patients. Guesswork is often used instead of real-time insurance verification.

This can be especially true when commercial payors such as United Healthcare and Blue Cross Blue Shield manage the Medicaid plan, commonly termed Medicaid Replacement Plans. This article provides four valuable tips for successfully processing EMS claims when a Medicaid Replacement Plan is involved.

The Challenge for EMS Billing: Benefits Verification

Just as commercial payers see growth opportunities in managing Medicare Advantage (MA) plans, they are also overseeing hundreds of Medicaid programs. According to the annual CMS-64 Medicaid expenditure report, in federal fiscal year (FFY) 2016, Medicaid expenditures across all 50 states and 6 territories exceeded $548 billion, with nearly half of all spending now flowing through Medicaid managed care programs. On average 54.67% of Medicaid dollars are spent on managed care, whether to manage the transition or fund plans. This ranged from 97.9% in Puerto Rico, down to 12.1% in Colorado.

A single trip may have Medicaid benefits, but also managed by United Healthcare or another third-party commercial payer. The result? Blended coverage for Medicaid patients and confusion for providers.

Four Tips to Expedite Medicaid Verification

 When checking benefits for Medicaid patients, carefully review the standard eligibility response. Payors usually note benefit management by a commercial payer in the response, but there is no consistency in format or location. The Medicaid Replacement Plan notification may be placed at the top, middle or very bottom of the file. Furthermore, unnecessary additional information may be provided by the payor causing more confusion and time delays for EMS billers. For example, Cigna often includes dental, pharmaceutical and other specialty coverage details even though this information is never required for ambulance trips.

To avoid reimbursement delays with Medicaid Replacement Plans, implement the following four tactics:

Ask the eligibility vendor to place replacement plan information at the top of the file. If notification is placed in the same location and in the same format for every eligibility response, billers save time searching for coverage.

  1. Request that only pertinent coverage for the claim be included in the eligibility notification. If this is not possible, ask the payer to prioritize eligibility information by placing only the relevant coverage at the top.
  2. Take time to check and verify eligibility up front. Ensuring a clean and correct claim saves EMS providers back-end expense and expedites reimbursement due to fewer payor rejections and denials.
  3. Ask your EMS software vendor to integrate eligibility checking directly in your system’s workflow for real-time access during the pre-bill and billing processes. Technology integration saves billing time by eliminating the need to access and enter data into an outside payor portal or insurance discovery application.

Numerous EMS providers struggle with insufficient billing staff to manage claims. Take every step possible to streamline efforts and reduce duplicate work due to denied or rejected claims. When checking eligibility, proper identification and billing of Medicaid Replacement Plans is an essential step.

About the Author:
Stacey Bickford is the Operations and Client Coordinator at Payor Logic. She has been involved with medical billing since a teenager with prior experience in data entry, billing and office management for physicians’ practices, hospitals and especially EMS agencies. Prior to joining Payor Logic in 2016, Stacey started with ZOLL in 2008 as a support technician moving to Product Manager of RescueNet Billing through 2016.

In her free time, Stacey enjoys travelling with her family, Michael and their dogs Benjamin and Poncho. They’ve visited 21 states in the last 15 months! She loves hiking, gardening and being outdoors as much as possible.

 

CBO Estimates Senate Bill Would Leave 22M More Uninsured

From Akin Gump:

The Congressional Budget Office (CBO) this afternoon released its cost estimate of the Senate’s health care bill, the Better Care Reconciliation Act (BCRA), projecting that the legislation would increase the number of uninsured by 22 million in 2026 relative to the number under current law. This is slightly fewer than the number of uninsured estimated for the House-passed American Health Care Act (AHCA). CBO also estimates that the BCRA would reduce federal deficits by $321 billion over 10 years, $202 billion more than estimated net savings for the House bill.

According to the Senate Budget Committee, below is a brief summary of the changes that were made to the previous draft:

  • Conforming amendments to Sec. 106 – Changes made to better align the purposes of stability funding to the underlying CHIP statute.
  • Adds a new Sec. 206 – Starting in 2019, individuals who had a break in continuous insurance coverage for 63 days or more in the prior year will be subject to a six month waiting period before coverage begins.  Consumers will not have to pay premiums during the six month period.
  • Redesignates Secs. 206-208 to Secs. 207-209, to accommodate for the new Sec. 206 on continuous coverage.

Read the CBO report.

 

CMS – MLN Ambulance Transports Booklet

CMS has issued an MLN Ambulance Transports Booklet. The booklet (36 pages) can be downloaded here. One section of the Booklet that you might want to keep handy involves Free-Standing Emergency Departments. Specifically, on page 15, CMS states the following: Freestanding Emergency Department (ED) If a freestanding ED is provider based (a department of the hospital), the ambulance…

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UnitedHealthCare Denials for ALS-2 Claims

Talking Medicare with Brian S. Werfel, AAA Medicare Consultant Over the past few weeks, we have received emails from ambulance providers across the country reporting that UnitedHealthCare (UHC) has started to deny claims for the ALS-2 base rate. Affected claims include both commercial and Medicare Advantage claims. These providers are reporting that UHC is requiring…

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CMS Letter Regarding Merit-Based Incentive Payment System

Over the past week, multiple members have contacted the American Ambulance Association to report that they have received a letter from the Centers for Medicare and Medicaid Services (CMS) related to their participation in the Merit-Based Incentive Payment System (MIPS). The letter appears to have been sent to any entity with a taxpayer identification number…

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CMS Issues Final Market Stabilization Rule

On Thursday, April 13, the Centers for Medicare & Medicaid Services (CMS) released the final “Marketplace Stabilization Rule”. This is the final version of a rule that was first proposed on February 15, 2017. Last month, AAA consultant, Kathy Lester, published a blog post explaining the then proposed rule (“Administration’s Proposed Rule on Marketplace Stabilization”).

The final rule makes several policy changes to improve the market and promote stability, including:

    • 2018 Annual Open Enrollment Period: The final rule adjusts the annual open enrollment period for 2018 to more closely align with Medicare and the private market. The next open enrollment period will start on November 1, 2017, and run through December 15, 2017, encouraging individuals to enroll in coverage prior to the beginning of the year.
    • Reduce Fraud, Waste, and Abuse:  The final rule promotes program integrity by requiring individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll. It will encourage individuals to stay enrolled in coverage all year, reducing gaps in coverage and resulting in fewer individual mandate penalties and help to lower premiums.
    • Promote Continuous Coverage: The final rule promotes personal responsibility by allowing issuers to require individuals to pay back past due premiums before enrolling into a plan with the same issuer the following year. This is intended to address gaming and encourage individuals to maintain continuous coverage throughout the year, which will have a positive impact on the risk pool.
    • Ensure More Choices for Consumers:  For the 2018 plan year and beyond, the final rule allows issuers additional actuarial value flexibility to develop more choices with lower premium options for consumers, and to continue offering existing plans.
    • Empower States & Reduce Duplication:  The final rule reduces waste of taxpayer dollars by eliminating duplicative review of network adequacy by the federal government.  The rule returns oversight of network adequacy to states that are best positioned to evaluate network adequacy.

Read the Final Rule

HHS Letter to Governors on Medicaid Changes

On Monday evening, the Senate confirmed Seema Verma, MPH, as the new Administrator of the Centers for Medicare and Medicaid Services (CMS). She has a strong background in Medicaid, and prior to her appointment worked as a consultant to several States seeking Medicaid waivers. One of her first acts was to issue a letter to…

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Rep. Coffman Reintroduces VA Emergency Ambulance Service Bill

On March 9, 2017, Rep. Mike Coffman [R-CO-6] reintroduced the Veterans Reimbursement for Emergency Ambulance Services Act (H.R. 1445).

The VREASA (Veterans Reimbursement for Emergency Ambulance Services Act) would provide veterans with reimbursement for emergency ambulance services when a Prudent Layperson would have a reasonable expectation that a delay in seeking immediate medical attention will jeopardize the life or health of the veteran.

Currently, prior to reimbursement, the Department of Veterans Affairs (VA) requires all medical records be provided, including the records of treatment after the emergency service has taken place. Should those records show that it was not a life threatening emergency or a false alarm, the claim for reimbursement is denied. The veteran is stuck with the bill.

Medicare, Medicaid, and other major payers adhere to the “prudent layperson” standard for the reimbursement of emergency ambulance services. The VA is the only major payer to not follow this standard. It is time we ensure our veterans are not stuck with the bill for their emergency ambulance service.

AAA Member, American Medical Response and their ‎VP Federal Reimbursement & Regulatory Affairs, Deb Gault, have been working with Rep. Coffman’s office to get this bill reintroduced.

Administration’s Proposed Rule on Marketplace Stabilization

The Centers for Medicare & Medicaid Services (CMS) has released the “Marketplace Stabilization Proposed Rule” (Proposed Rule). Overall, the rule proposes a series of modifications to the Marketplaces that align with requests made by issuers in an attempt to keep them in the Marketplaces. The background section of the Proposed Rule emphasizes the concerns of…

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CMS Proposes Rule to Increase Patients’ 2018 Insurance Choices

This morning, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for 2018. The AAA is currently drafting a member advisory on this proposed rule and it will be released soon. The text of the rule is below.

The rule proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.

“Americans participating in the individual health insurance markets deserve as many health insurance options as possible,” said Dr. Patrick Conway, Acting Administrator of the Centers for Medicare & Medicaid Services.  “This proposal will take steps to stabilize the Marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options. They will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated.”

The rule proposes a variety of policy and operational changes to stabilize the Marketplace, including:

  • Special Enrollment Period Pre-Enrollment Verification: The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.
  • Guaranteed Availability: The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.
  • Determining the Level of Coverage: The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.
  • Network Adequacy: The proposed rule takes an important step in reaffirming the traditional role of states to serve their populations. In the review of qualified health plans, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy. States are best positioned to ensure their residents have access to high quality care networks.
  • Qualified Health Plan (QHP) Certification Calendar: In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.
  • Open Enrollment Period: The rule also proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017.  This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.

Read the Proposed Rule

The Future of Prior Authorization

In May 2014, CMS announced the creation of a three-year demonstration project that calls for the prior authorization of repetitive scheduled non-emergency ambulance transports. The demonstration project was first implemented in the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on their higher-than-average utilization rates for repetitive ground ambulance transportation….

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Medicare Relief and Reform Letter by President Postma

This is a critical year for the legislative efforts of the American Ambulance Association and our members.  First and foremost, our temporary Medicare ambulance increases expire at the end of the year.  It is vital that we ensure the new 115th Congress makes these increases permanent, or at the very least approves another long-term extension. …

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EMS World: RAA’s Rob Lawrence on AAA President Postma

Rob Lawrence, Chief Operating Officer at the renowned Richmond Ambulance Authority, just shared his thoughts about AAA President Mark Postma over at EMS World. As always, we deeply appreciate the continued membership and support of RAAEMS.

[President Mark Postma] has a massive agenda and much business to do. This will require him to pursue current legislation to a successful conclusion, lead the development of AAA, foster the creation and maintenance of strategic partnerships and alliances for the betterment of the industry as a whole, and drive industry change, all while navigating Trump’s new world order.

Without a doubt a lot is about to change in 2017, but if ever there were a president up for the challenge—one who will knock down, not build, walls—Mark Postma seems that leader.

Read the full article►

 

GAO Report on Revised Provider Enrollment Screening Process

In March 2011, the Centers for Medicare and Medicaid Services (CMS) implemented a revised process for processing the enrollment of new Medicare providers and suppliers. This revised process also applied to existing Medicare providers and suppliers that were revalidating their enrollment information. This new process included assigning all providers and suppliers to one of three…

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EMS Today: Payment Reform Town Hall

EMS Today Conference & Exposition
Maximize your time at EMS TODAY by adding half-day or full day pre & post-conference workshops to your Gold (3-day) or Silver (2-day) full conference registration.
These unique, CE certified workshops are designed to provide in-depth clinical and hands-on instruction to students and will take place on Wednesday, February 22, 2017. These workshops are taught by recognized experts in the world of EMS.
ADD 1 or 2 today! Don’t forget that complimentary lunch is provided for all attendees registered for two onsite 4-hour workshops or one 8-hour workshop!
FEATURED WORKSHOP
American Ambulance Association’s Town Hall Meeting on Payment Reform (#16200)
Wednesday, February 22, 2017: 1:00 PM – 5:00 PM
Workshop Description
The AAA has been leading efforts on Capitol Hill to take the initial steps necessary to reform the Medicare ambulance fee schedule. It began with the successful securement and multiple extensions of the 2% urban, 3% rural and super rural increases in Medicare payments for ambulance services. Through the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 377/H.R. 745), those increases would be made permanent and set the foundation for future reform by changing the status of ambulance service suppliers to that of providers, collecting data on the cost of providing ambulance services and addressing fraud and abuse with dialysis transports. EMS needs to be considered providers and have cost data if we are to make data driven changes to the fee schedule beyond ambulance services just being a transportation benefit. The AAA Payment Reform Committee is looking at what Medicare reimbursement policy would look like as providers of health care services with the data to support changes in ambulance policy. The Committee, comprised of representatives of the AAA, NAEMSP, NAEMT and NASEMSO, has developed a policy payment outlining the future of reimbursement for EMS including treat and refer, mobile integrated health and alternate destinations. Come to this special Town Hall Meeting on Payment Reform to hear about the activities of the Committee in detail and provide valuable input for the future of ambulance reimbursement policies.

Speakers:
Jimmy Johnson
Owner & President, LifeEMS, Past President, American Ambulance Association, United States

Kathleen Lester
Principal, Lester Health Law PLLC, United States

Asbel Montes
V.P. of Governmental Relations and Reimbursement, Acadian Ambulance Service, United States

Tristan North
S.V.P. of Govt. Affairs, American Ambulance Association, United States

Cost:
Open to all registered EMS Today attendees. There is no charge to attend this workshop, but registration is required.

Register Today CLICK HERE to learn more about the
Pre & Post-Conference Workshops
EMS Today Conference & Exposition

 

December CMS Ambulance Open Door Forum & Follow Up Q&A

The next CMS Ambulance Open Door Forum is scheduled for Thursday, December 1 at 2:00 PM Eastern. Please dial in at least 15 minutes before the call. View Agenda CMS Ambulance Open Door Forum December 1 | 2:00 PM ET 1-800-837-1935 Conference ID: 44947739 Questions? Have questions after the CMS Open Door Forum? The AAA is here to…

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2015 Medicare Data Shows Evident of Crackdown on Non-Emergency Transport

2015 Medicare Payment Data Offers Evidence of Nationwide Crackdown on Non-Emergency Ground Ambulance Transportation; Impact Varies Dramatically by Medicare Administrative Contractor Every year, CMS releases data on aggregate Medicare payments for the preceding year. This file is referred to as the Physician/Supplier Procedure Master File (PSP Master File). This past month, CMS released the 2016…

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Payment Reform Chairs Pen Op-Ed in JEMS

Ambulance payment reform is critical to the future of emergency medical services across our country. Don’t miss the op-ed in JEMS by Asbel Montes and Jimmy Johnson, chair and vice chair of AAA’s Payment Reform Committee.

Before the industry as a whole can embrace mobile integrated health, community paramedicine, and value-based purchasing, the industry must contend with standardizing cost data and submitting it to the federal government. We must also fight to ensure that payment is linked to the health care services provided and less to the act of transporting patients.

Read the full op-ed►

Ready to add your voice to the conversation? Join fellow members at AAA’s Payment Reform Town Hall at EMS Today in Salt Lake City. Learn more►