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OIG Looking into SNF Consolidated Billing Claims

Written by Brian Werfel on . Posted in Medicare, Talking Medicare.

Over the past few weeks, we have been contacted by a number of ambulance suppliers that have received letters from the HHS Office of the Inspector General (OIG). These letters indicate that the OIG is conducting a national review of ambulance services that are subject to the consolidated billing provisions of the skilled nursing facility (SNF) prospective payment system. The review covers claims for ambulance services with dates of service from July 2014 through June 2016.

In each case, the ambulance supplier is being asked to provide documentation on a handful of round trip transports of an SNF patient. The letter indicates that these services were furnished to a Medicare beneficiary during the beneficiary’s Part A SNF stay, and therefore “may be subject to consolidated billing.” The letter asks the ambulance supplier to complete a short (3-page) questionnaire related to the identified transports, and to return the completed questionnaire to the OIG within seven business days.

The questionnaire asks some fairly basic questions related to the identified transports, including whether the ambulance supplier actually furnished the identified transports, whether it was paid by Medicare, the point of pickup and destination, and information on who called to request the transport. The questionnaire also asks for information on how the ambulance supplier determined whether the patient was in the Part A period, and what information the ambulance supplier obtained in order to make its determination that the claims were separately payable by Medicare Part B.

The OIG has conducted similar reviews in the past. For example, in August 2009, the OIG issued a report on payments for ambulance transportation provided to SNF beneficiaries during calendar year 2006. That report concluded that 61 of the 114 claims it reviewed (53%) were incorrectly billed to Medicare Part B, as opposed to the SNF. Based on its sample, the OIG estimated that Medicare made $12.7 million in incorrect payments to ambulance suppliers during calendar year 2006.

It is possible that the OIG is simply updating its previous report on SNF Consolidated Billing and ambulance transports. However, there is another possible explanation for the OIG’s renewed interest in these types of transports. Many of the claims the OIG has requested information on relate to transports to what appears to be a physician clinic located on a hospital’s campus. If correct, the SNF would have been responsible for payment for the physician’s services (in addition to the ambulance claims). If so, it is possible that the OIG’s interest was triggered by the lack of a corresponding hospital claim being submitted to Medicare on that date.

If this sounds familiar to you, it should.

In September 2015, the OIG issued a report in which it highlighted seven so-called “questionable billing practices” by ambulance suppliers. One of these billing practices was the existence of an ambulance claim for a particular date of service, but where there was no corresponding hospital claim (or any other claim from a Part A institution) for the beneficiary on that same date. The OIG identified $30.2 million in payments during the first half of 2012 that tested positive for this measure.

In an earlier blog post, we discussed the Supplemental Medical Review Contractor (SMRC), StrategicHealthSolutions, LLC. The SMRC is tasked with lowering the improper payment rate and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. The SMRC has recently started auditing ambulance suppliers, and it appears to be focusing, in large part, on claims where patients were evaluated at a physician’s clinic located on a hospital’s campus. It is possible that the OIG is conducting its own inquiry of this same issue.

This leaves us with a basic question: Is the OIG simply updating an earlier report, or is this sort of audit going to be become the new “normal” for ambulance suppliers? Ultimately, time will tell.

However, regardless of the OIG’s motives, this recent string of audits serves as a valuable reminder to the industry that many hospitals do sublease space to physician practices, and that these independent practices are licensed separately from the hospital. A transport to these independent physician practices would be bundled to the SNF under SNF Consolidated Billing. As an industry, we need to identify these transports when they occur, and be sure to bill the SNF, whenever appropriate. Otherwise, the OIG is likely to continue these sorts of audits.

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.

CMS – MLN Ambulance Transports Booklet

Written by David Werfel on . Posted in Medicaid, Medicare, News, Reimbursement.

CMS has issued an MLN Ambulance Transports Booklet. The booklet (36 pages) can be downloaded here.

Download MLN Ambulance Transports Booklet

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 transport from the freestanding ED to the hospital is not a separately payable service under Part B if the beneficiary is admitted as an inpatient prior to ambulance transport. For more information about criteria for coverage of ambulance transports separately payable under Part B or as a packaged hospital inpatient service under Part A, refer to Chapter 10, Section 10.3.3, of the Medicare Benefit Policy Manual.

This may be useful, along with the Manual section cited, when you have a free-standing ED that is part of a hospital and they call for transports to the main building for the patient to be admitted, but the hospital lists the time of admission as being prior to the time of your transport. When the hospital admits the patient prior to your transport, the hospital becomes responsible for the ambulance charges. It may be useful to show the hospital and ED the booklet and Manual section to prove to them that the hospital is responsible if the patient is admitted to the hospital prior to your transport.

UnitedHealthCare Denials for ALS-2 Claims

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member-Only, Private Insurance, Reimbursement, Talking Medicare.

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 the use of Current Procedural Terminology (CPT) Codes to support the ALS-2 level of service.

When these providers call UHC to question the denials, the customer service representative refers them to UHC’s online policies and procedures manual. The section of that manual devoted to the ALS-2 base rate largely mirrors Medicare’s definition. For example, it indicates that ALS-2 can be billed based on three separate administrations of one or more medications by IV push/bolus or continuous infusion, or upon provision of one or more of the designated ALS-2 procedures (e.g., an endotracheal intubation).

However, the manual section then goes on to indicate that “Ambulance Providers or Suppliers are required to report CPT or HCPCS codes… when reporting A0433.  Ambulance transport services that do not include the services described in criteria 1 or 2 above should be reported with a more appropriate ambulance transport code.”

The manual section concludes with links to two lists of CPT codes. The first list, designated as “ALS2 Criteria 1 Codes” relate to the intravenous administration of various medications. These codes fall within the range of: 96365 – 96376. The second list, designated as “ALS2 Criteria 2 Codes” correspond to the various ALS interventions:

CPT Code:                            Description:
31500                                    Endotracheal Intubation, Emergency
31603                                    Under Incision Procedures on Trachea and Bronchi
31605                                    Under Incision Procedures on Trachea and Bronchi
36000                                    Under Intravenous Vascular Introduction & Injection Procedure
36555                                    Central Venous Catheter Placement, Patient Under Five Years
36556                                    Central Venous Catheter Placement, Patient Over Five Years
36568                                    Insertion of Central Venous Access Device
36569                                    PICC Line Insertion
36680                                    Intraosseous Line Infusions
92950                                    Cardiopulmonary Resuscitation
92953                                    Other Therapeutic Cardiovascular Services
92960                                    External Electrical Cardioversion, Non-Emergency
92961                                    External Electrical Cardioversion, Emergency

The ambulance providers have indicated that they have questioned UHC on the necessity of including CPT codes on these claims. These providers argue, correctly, that CMS does not require the use of CPT codes on Medicare claims. Instead, Medicare requires the ambulance provider to document in the billing narrative the justification for billing ALS-2. For example, a provider might list multiple administrations of epinephrine, the use of an intraosseous line, etc.

The fact that UHC is asking for the CPT codes suggests that it does not currently review the billing narratives. Instead, UHC appears to be using the CPT codes to ensure that the ALS-2 criteria are met.

Is UHC correct to insist upon the use of CPT codes? Probably not, at least for its Medicare Advantage claims. However, I think the more appropriate question to ask ourselves is whether it is worth fighting UHC on this issue? If using CPT codes ensure that UHC correctly processes and pays these claims with minimal delay, my opinion is that it is probably easier just to comply with their policy.

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.

Write to Your Senators! Support S.967

Written by Aidan Camas on . Posted in Advocacy Priorities, Government Affairs, Legislative, Member Advisories, News, Reimbursement.

Take Action for Permanent Medicare Ambulance Relief

Ask your Senators to Support S.967 – 2017 Medicare Ambulance Access, Fraud Prevention, and Reform Act

The current 33-month extension of the Medicare add-on payments is set to expire at the end of December 2017. Losing these add-on payments would be a devastating blow to ambulance services across the country. It is crucial that the payments be made permanent as we push for a long-term solution. More details about the Bill can be found below. Let your Senators know that you support S. 967 — Here are three quick and easy ways to get involved!

Writing to your members of Congress only takes 2 clicks, follow these simple steps:

1. Enter contact information below (required by Congressional offices) and click “Submit”
2. On the next page you’ll see the letter(s) to your Senators – click “Submit Messages”

Active on Social Media? Tweet at your Senators asking for their support of S. 967!

  • Authorize Your Account
  • Enter Contact Information
  • Tweet! (Tweet will be auto-generated with your Senators tagged)
Know your Senators’ Twitter accounts already? Tweet:
“#ambulance svs in your state need you, @[your Senators]! Please co-sponsor S. 967 to help us continue to provide quality #EMS!”


Post on Facebook why S. 967 is important! Be sure to tag your Senators and encourage others to share your post! Ask others to write letters of support as well! http://bit.ly/AAAbill

More About Our Bill S. 967, the 2017 Medicare Ambulance Access, Fraud Prevention, and Reform Act:
Permanent ambulance relief legislation has been introduced by Senators Stabenow, Roberts, Schumer, Collins, and Leahy (S. 967). This legislation will allow ambulance service providers to maintain high quality ambulance services and budget for the future.
Specifically, the bill:

  • Provides Medicare Ambulance Relief, by permanently incorporating the current temporary 2 percent urban, 3 percent rural, and super rural bonus payments into the Medicare ambulance fee schedule rates.
  • Requires the Centers for Medicare and Medicaid Services (CMS) to submit a report to Congress detailing the features of a reformed payment system for ambulance services under the Medicare program no later than July 1, 2019.
  • Modifies the process for the transport of dialysis patients by requiring the Department of Health and Human Services to establish a process for the prior authorization of coverage for such patients.
  • Treat ambulance services designated as “suppliers” as “providers” for certain purposes under Medicare.
  • Specifies CMS to work with stakeholders in the development of a data collection system for ambulance entities that defines the various types of ambulance entities as well as the relevant cost and data elements required for submission.

CMS Letter Regarding Merit-Based Incentive Payment System

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, News, Regulatory.

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 (TIN) that is enrolled in the Medicare Part B Program. The stated purpose of the letter is to inform the provider whether it is exempt from participation in the MIPS program.

This member advisory is being issued to advise ambulance suppliers that:

(1) they are not eligible to participate in the MIPS program
(2) no positive or negative adjustments will be made to the ambulance suppliers Medicare payments
(3) no further action is required on their part

Therefore, AAA members that received this letter can safely disregard it. 

 

Support AAA’s Medicare Relief Legislation, S. 967

Written by Mark Postma on . Posted in Government Affairs, Legislative, Medicare, Member Advisories.

Dear Fellow Members,

As you know, the Medicare ambulance add-on payments are set to expire on December 31, 2017. I’m proud to share with you that today, due to AAA advocacy efforts, permanent ambulance relief legislation was introduced by Senators Stabenow, Roberts, Schumer, Collins, and Leahy.

This bill, S.967, “Medicare Ambulance Access, Fraud Prevention, and Reform Act” would make permanent the vital urban and rural Medicare add-ons and super-rural bonus payments. Although some changes are likely during the committee markup process, we are cautiously optimistic that it will also carry through proposals to reclassify ambulance organizations as providers of health care (not suppliers of transportation), as well as a cost data collection system that does not place undue burden on ambulance services.

On behalf of the AAA, I’d like to extend my deepest thanks to Senators Stabenow, Roberts, Schumer, Collins, and Leahy for sponsoring the legislation, as well as the AAA Board, Government Affairs Committee, advocacy consultants, and staff who worked so diligently to build support on Capitol Hill.

Over the coming months, AAA will continue to connect with policymakers to build support for sustainable ambulance Medicare reimbursement. However, we need your help to ensure that this critical revenue remains in place. We ask that you please contact your Senators to voice your support for S. 967. AAA makes it easy to connect with your legislators through our online advocacy tool—please use it today to quickly send messages expressing the importance of the legislation to your ambulance service and the communities you serve.

If possible, we ask that you also work with fellow ambulance providers in your area to schedule in-person meetings with your legislators’ offices. If you arrange a meeting in your home state, please contact AAA staff at info@ambulance.org for talking points to support your conversation.

Now, more than ever, we need the active participation of each member organization to ensure our collective future! Thank you in advance for your assistance with advocacy outreach, as well as for your continued membership to the American Ambulance Association.

Mark Postma
President, American Ambulance Association
“Representing EMS in America”

Time to Automate

Written by Wendy Becofsky on . Posted in Finance, Medicare, Operations, Quality, Reimbursement.

Founded in 1964, now nationally recognized, Mohawk Ambulance Service is the largest privately owned ambulance service in upstate New York. Our organization services six emergency centers, makes 56,000 trips annually and employs a team of more than 250 staff members. Eighty percent of our trips are for emergency transports where patients are unknown, in critical condition or have no identifying information. Finding fast, efficient ways to verify demographics and discover insurance coverage for these patients is imperative for our revenue cycle and our bottom line.

We’ve always worked closely with our local hospitals and nursing homes to obtain information. Many standard processes have been refined over the years with checks and balances to verify coverage, screen deductibles and reduce eligibility-related rejections before claims are submitted to a payor. But our billing team knew we could do more to eliminate duplicate data entry and processing lag time.

This article describes our journey to a more streamlined billing process. It includes lessons learned and best-practice recommendations for other EMS providers looking to improve staff efficiency and reduce receivables.

First Stop: Real-Time Insurance Discovery

The first area we tackled was insurance discovery where we had three employees stationed. We focused on our self-pay patients and transports lacking complete demographic or insurance information. The goal was to eliminate manual steps and workflow lags—which we quickly achieved.

The original process involved building a list, submitting it to Payor Logic, waiting three days for feedback, and then re-entering information into our billing system. By bringing our vendors together to meet with our team, a real-time technology solution was developed and implemented.

Now our insurance verification team has immediate access to Payor Logic’s search capabilities. Insurance discovery is an online, real-time process. Lists, batches, searching websites and waiting for results have all been eliminated. Also, the two vendors built a crosswalk that integrates insurance coverage results back into our billing system to eliminate duplicate data entry and rekeying.

The productivity our verification team is now able to achieve is amazing. They now do the work of three staff with only two employees—a 30 percent boost in staff efficiency for insurance verification.

Billing also Gets Tech Boost

At Mohawk, we use a combination of technology solutions to support our revenue cycle. But each company worked independently—creating separate silos. Billers would have to search across several different systems, payor websites and the digital pages to collate all the various demographic and insurance data required to submit a claim. We had technology, but the process remained cumbersome and labor intensive.

By working with our vendors, we built points of integration to increase the number of claims processed without adding billing staff. For example, once a biller pulls up a trip, dozens of data elements from the billing system are uploaded into a single view to eliminate searching and save time.

Everything the biller needs to complete a claim is displayed in a consolidated view, consistent across all Mohawk companies. Billers can easily see patient signature, facility signature, narrative, vital signs, advanced life support and more. This level of integration eliminates the need to look at every page of the system to build the claim—saving dozens of hours every week.

Lessons Learned

Like most EMS providers, our mission is to uphold the highest standard of services with consistent devotion to delivering superior emergency medical care. And through this automation project, we took service excellence one step further—delivering world-class service throughout our billing process. We find more insurance coverage, reduce eligibility-related rejections, convert self-pay accounts and collect more revenue from the right source. Results thus far include:

  1. 30% improvement in staff efficiency for insurance verification
  2. 67% less time needed per case to screen for Medicare deductibles
  3. 100% elimination of wait times to discover billable insurance for self-pay patients

EMS providers looking to streamline the billing process should revisit their existing technology applications and engage in serious discussions with current vendors. New capabilities are out there and should be explored. The automation efforts described above have resulted in an efficiency uptick for Mohawk, despite being short staffed. New workflows for verification are being maintained by our team and next steps for automation expansion are being discussed. By keeping open communications and an ongoing dialogue with all parties involved, this automation experience has been a win-win for our business, our staff and our patients.

Understanding CERT

Written by Brian Werfel on . Posted in Medicare, Member-Only, Talking Medicare.

Talking Medicare: Understanding CERT

Every year around this time, our firm receives a steady stream of questions from AAA members about the CERT Program. Typically, the provider has received a notice from what appears to be the Centers for Medicare and Medicaid Services (CMS), which asks for medical records for one or two patient transports. These providers naturally wonder whether they are being audited, and how they should respond. The intent of this post is to clear up any confusion.

What is the CERT program?

The Comprehensive Error Rate Testing (CERT) program is an attempt by CMS to measure the rate of improper payments in the Medicare Fee-for-Service Program. It does so by evaluating a statistically valid random sample of claims to determine whether these claims were properly paid under the applicable Medicare coverage, coding, and billing rules.

In August 2016, CMS awarded responsibility for conducting CERT reviews to AdvanceMed. Therefore, if you receive a letter from AdvanceMed, and that review is asking for only a single claim, it is likely that you are being asked to participate in the FY 2017 CERT review.

What is the National Error Rate for ambulance services?

In its report for Fiscal Year 2016, CMS indicated that the overall improper payment rate was 11.00% across all provider types. CMS estimated that this represented approximately $41.08 billion in improper payments. This is down slightly from the FY 2015 review, which estimated the improper payment rate at 12.09%, representing $43.33 billion in improper payments. The FY 2016 reporting period ran from July 1, 2014 through June 30, 2015.

The overall error rate for Part A Providers, i.e., hospitals, nursing homes, etc., was 13.98%. The overall error rate for Part B providers was 11.71%.  In contrast, the error rate for durable medical equipment, prosthetics, orthotics, and supplies (DME) was 46.26%.

The overall error rate for ambulance was 11.7%, or basically the same as the overall Part B error rate. The ambulance error rate was further broken down based on the basis for a payment error. The most common error, comprising more than three-fourths of all errors, was either no documentation or insufficient documentation. The lack of medical necessity for the ambulance comprised only 15.6% of all improperly paid ambulance claims.

Should I freak out if my service is selected for review?

In a word, “No.” The odds of your service being selected under the CERT program are quite low. If you are selected, it is helpful to keep in mind that the focus of this review is not on your billing practices. Rather, the focus is on whether your contractor processed your claim correctly. This is not to say that CMS will not attempt to recoup payment on the claim if it ultimately determines that the claim was paid in error; it will. However, from your perspective, that recoupment is the end of the matter.

In other words, the worst that can happen with a CERT review is that you would have to repay that single claim. It will not result in a large extrapolated overpayment. Nor is the denial of that claim likely to trigger a larger postpayment review. Therefore, other than being sure to respond to the record request in a timely fashion, there is little to fear from CERT.

I hope this helps put your mind at ease!

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.

Government Affairs Update: Protecting the Ambulance Add-ons

Written by Tristan North on . Posted in Advocacy Priorities, Government Affairs, Legislative, Member Advisories, Member-Only, Reimbursement.

Medicare Ambulance Relief and Reform

The top legislative priority this year for the American Ambulance Association is to extend, or hopefully make permanent, the temporary Medicare ambulance add-on payments. The temporary increases of 2% urban, 3% rural and the super rural bonus expire at the end of this year. The 2% urban and 3% rural increases have been in place since 2008 and the super rural bonus payment since 2004. While the AAA and our members have been successful in getting the payments extended numerous times, 2017 is not a typical year and we need everyone to be prepared to help push to make the increases permanent or extended for the longest possible duration.

The other top priorities for the AAA are for the Centers for Medicare and Medicaid Services (CMS) to recognize ambulance services more like providers of medical services instead of merely suppliers of transportation. In addition, it is critical that Congress direct CMS to collect cost data from ambulance service providers using a method, which will result in usable and meaningful data from everyone, but also not be overly burdensome on extremely low volume providers. Finally, Congress needs to target fraud and abuse with the transport of dialysis patients through a prior authorization program instead an arbitrary payment cut that impacts all providers.

The AAA is pushing its agenda again through a version of the Medicare Ambulance Access, Fraud Prevention and Reform Act which we hope to have introduced in the next few weeks. We are working with our champions on Capitol Hill on a different approach to being treated more like providers to mitigate issues raised about the provision last Congress. Instead of being listed in the Social Security Act as having provider status, we are looking to a hybrid model similar to dialysis facilities. This will clarify that we are not seeking to be treated like providers to achieve Medicare coverage because we are already reimbursed under the Medicare program. It will however still set the foundation for future legislative and regulatory changes to the Medicare fee schedule such as reimbursement for transporting to an alternate destination or treat and referral.

We are also making potential modifications to the House bill on our proposed data collection system. These changes would help with possible Committee consideration of the provision but still hopefully achieve or goal of obtaining useable data that is not overly burdensome to 73% of our industry which is composed of providers that do less than 1,000 Medicare transports a year of less. It is vital that we have meaningful data to make data-driven decisions as to changes to the Medicare ambulance fee schedule.

Ambulance Advocacy Webinar

We will let you know as soon as the revised legislation is introduced for the new Congress. In the meantime, we encourage you to register for the upcoming AAA webinar on the Ambulance Advocacy Action Plan with AAA Senior Vice President of Government Affairs Tristan North and AAA Government Affairs Coordinator Aidan Camas. Tristan and Aidan will provide you the latest information on our advocacy efforts and let you know how you can help. To register for the webinar which is free to AAA members, please go to: https://ambulance.org/product/ambulance-advocacy-action-plan/.

Also read Tristan and Kathy Lester’s recent Member Advisory on ACA Repeal & Reform:

ACA Repeal & Reform – What It Means for Ambulance Services (Pt. 1)
ACA Repeal & Reform – What It Means for Ambulance Services (Pt. 2)

HHS Letter to Governors on Medicaid Changes

Written by Mark Postma on . Posted in Government Affairs, Medicaid, Member Advisories, Regulatory, Reimbursement.

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 governors with Secretary Tom Price, MD, regarding the Medicaid program. The letter highlights several initiatives on which they are focusing with regard to Medicaid. Perhaps of most importance to the ambulance community is the section on “Aligning Medicaid and Private Insurance Policies for Non-Disabled Adults.” In this section, the Secretary and Administrator suggest that States:

may consider creating greater alignment between Medicaid’s design and benefit structure with common features of commercial health insurance, to help working age, non-pregnant, non-disabled adults prepare for private coverage. These state-led reforms could include, as allowed by law: …waivers of non-emergency transportation benefit requirements.

While it may be meaningful that the reference does not include “medical,” before transport, it is critically important that the AAA work to protect Medicaid beneficiary access to medically necessary non-emergency medical transports. Thus, the Medicare Regulatory Committee is developing a letter and considering additional engagement with CMS to clarify that the reference is to programs related to providing beneficiaries with the cost of taxis, buses, or other transportation options, but not to medically necessary non-emergency ambulance transports.

It is important that AAA members speak out on this issue with their governors and State Medicaid officials. The AAA has developed draft talking points to assist with these contacts as well.

Thank you for your attention to this critical issue.

Mark Postma
President, American Ambulance Association
Representing EMS in America

Thank you to AAA Consultant Kathy Lester, JD, of Lester Health Law for the analysis of this issue.

House Holds Hearing on Veterans Choice Program

Written by Todd Tuten on . Posted in Government Affairs, Legislative, News, Veterans Affairs.

The House VA Committee hearing started at 7:30 p.m., but it was well-attended and lasted until 10 p.m. The witnesses included Senator John McCain (R-AZ), VA Secretary David Shulkin, and representatives of the VA Office of Inspector General and the Government Accountability Office. Senator McCain and Secretary Shulkin were both warmly welcomed by Members of the Committee on a bipartisan basis.

Chairman Roe (R-TN) emphasized the need to act quickly to extend the authorization for the Veterans Choice Program, which expires on August 7. To that end, the House VA Committee is voting today on a bill to eliminate the sunset of the program’s authorization. In addition, the Committee will consider broader legislation later this year to make comprehensive reforms to the Choice Program. He noted that the VA has additional funds available but will not be able to spend them once the authorization expires. A copy of Chairman Roe’s opening statement is available here.

Secretary Shulkin testified in support of extending the Choice Program, and he clarified that the VA was not seeking additional funding – just the authority to spend funds already obligated. He noted that the VA already is being forced to deny Choice Program coverage to veterans whose episodes of care would extend beyond the August 7 expiration date (e.g., pregnancy).

Secretary Shulkin also urged Congress to support the VA’s efforts to bring appointment scheduling in-house for care coordination purposes. However, the VA OIG witness noted challenges in records going out to community-based providers and coming back to the VA. The GAO witness also underscored the need for the VA to have better systems in place in order to effectively coordinate care, which will take time to procure and implement. Rep. Brownley (D-CA) echoed that point, calling the VA’s information technology systems a “Model T in a Tesla world.” Rep. Esty (D-CT) also urged improvements in the VA’s information systems and expressed concern that veterans are being improperly billed.

Other Members, including Rep. Wenstrup (R-OH) and Rep. Poliquin (R-ME), raised concerns about continuing delays in the processing of claims and payments to providers. Secretary Shulkin agreed that providers deserve to be paid for their services, noting his own experience as a physician in the private sector. He acknowledged that the VA is not processing enough claims electronically today, and he advised that he plans to pursue options outside the VA for systems procurement going forward.

Many Members also raised serious concerns about treatment of PTSD and mental health conditions for veterans, including Rep. Wenstrup (R-OH), Rep. O’Rourke (D-TX), Rep. Sablan (D-MP), Rep. Banks (R-IN), Rep. Rutherford (R-FL) and Rep. Takano (D-CA). Rep. O’Rourke emphasized that suicide among veterans is the most serious crisis, and Secretary Shulkin agreed that it is his number one priority. The Secretary announced that the VA will begin providing urgent mental health care that also will include individuals other than those service members who were honorably discharged. He added that the VA needs 1,000 more mental health providers, as well as telemental health services, and is looking to expand community partnerships to address suicide.

Rep. Banks noted interest among Indiana veterans in greater access to alternative treatments for PTSD and traumatic brain injury. Secretary Shulkin underscored that he is “most concerned about areas like PTSD, where we do not have effective treatments.” He also advised that the VA has established an “Office of Compassionate Innovation” (separate from the VA’s Center for Innovation), which will focus on finding new approaches to health and physical wellness and explore alternative treatment options for veterans when traditional methods fall short.

Rep. Wenstrup inquired about the VA’s GME and residency programs, as well as its associations with academic institutions. Secretary Shulkin responded that the VA is “doubling down” on partnerships with academic medical institutions.

Chairman Roe concluded his remarks by emphasizing the need to extend the Choice Program authorization soon and to consolidate the VA’s community-based care programs. He also expressed support for the VA’s decision to stop developing its own information technology internally.

The Return of the Supplemental Medical Review Contractor

Written by Brian Werfel on . Posted in Medicare, Reimbursement.

In a November 2016 member advisory, we discussed StrategicHealthSolutions, LLC (Strategic), the CMS Supplemental Medical Review Contractor (SMRC). The SMRC is tasked by CMS to perform a variety of tasks aimed at lowering the improper payment rates and increasing the efficiencies of the medical review functions of the Medicare and Medicaid programs. In other words, the Strategic is yet another audit contractor.

In our earlier member advisory, we indicated that the Strategic had sent letters to a number of ambulance suppliers requesting medical records for certain ambulance transports. Those letters indicated that the Strategic was tasked with performing postpayment reviews of “Part B therapy claims for providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers.”

At this point, you are probably asking what the physical therapy cap threshold has to do with claims for ambulance services. If so, you are not alone.

On behalf of the AAA, our firm contacted Strategic to request further clarification. Specifically, we asked whether the intent was to limit its review to physical therapy providers, or whether the intent was to audit ambulance suppliers. Strategic responded by indicating that it intended to limit its review to physical therapy services, and that these letters were sent to ambulance suppliers in error. To its credit, Strategic did contact the affected ambulance suppliers by telephone to notify them of its error. Strategic also sent letters to the affected ambulance suppliers formally rescinding the record request.

Score one for the good guys, right? Think again.

Over the past few days, we have been notified by numerous AAA members that they have received a letter from Strategic requesting records for certain ambulance transports. These letters indicate that these postpayment reviews are being directed by CMS, and are based on an analysis of national claims data.

The audit notification letters cite the HHS Office of the Inspector General’s 2015 report on question billing practices as the establishing “good cause” for reopening the claims being audited. That report identified 7 billing practices that the OIG considered “questionable.”  Among the OIG findings being cited by Strategic are: (1) that CMS paid $17 million during the first half of 2012 for ambulance transports to and from a physician’s office and (2) that CMS paid $30 million over that same period for transports where there existed no record of the patient receiving covered Medicare services at either the pickup or drop-off locations on that date of service.

So, having cited two examples of improper payments from the industry as a whole as the basis to audit specific ambulance providers, one would naturally expect that the claims being audited would be limited to those instances, right? Unfortunately, when CMS and its contractors are involved, it is rarely that that simple.

Instead, Strategic appears to be consistently asking for samples of 40 or so claims. While it is difficult to discern a pattern from the handful of audit letters I have seen, one point of emphasis does appear to be ALS emergency claims, which typically represent more than half the sample being requested. However, in each case, the remaining claims come from each of the various base rates. In other words, it is possible that the claims being selected are truly random.

It is premature to speculate on how these audits turn out. However, the initial misstep by Strategic does not inspire confidence.

If you receive a letter from Strategic, it is important that you respond within the time frames set forth in your letter. If you are unable to meet that deadline, I would strongly recommend that you contact Strategic to ask for an extension. Typically, the contractor will grant an extension of 30 days as a courtesy. I would also use that time to obtain supporting documentation from the hospitals and SNFs. Given the scrutiny currently being paid to the patient signature requirement, I would review each claim to ensure that the requirement has been met. To the extent you are relying upon a facility signature, I would verify that the signature is legible (or accompanied by the signer’s printed name). If it is not, I would suggest obtaining a signature attestation from the individual that signed.

Please keep in mind that the best way to avoid a potential recoupment is to convince the contractor that the claim was properly paid in the first place. Maximum effort prior to your initial response is likely to pay big dividends down the road.

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.

Administration’s Proposed Rule on Marketplace Stabilization

Written by Kathy Lester on . Posted in Government Affairs, Medicaid, Medicare, Member Advisories, Member-Only, Private Insurance, Regulatory.

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 issuers and the Agency’s interest in making sure that consumers have more plan options for 2018. Comments are due March 7.

While ambulance services are not directly mentioned, the Proposed Rule could affect the ability of individuals in the marketplace to enroll and remain enrolled in plans. Another provision that could impact the ambulance industry is the proposal to rely more upon the States to enforce the network adequacy requirements of the ACA.  

Changes to Open Enrollment/Special Enrollment Periods

CMS proposes to tighten the enrollment rules in several ways. First, the Proposed Rule would change the open enrollment period to November 1 – December 15 to “increase the incentives for individuals to maintain enrollment in health coverage and decrease the incentives for individuals to enroll only after they discover they require services.”[1]  Individuals may still be eligible for a special enrollment period that would allow them to enroll outside of these dates.

CMS would increase the States’ pre-enrollment verification from 50 percent to 100 percent beginning June 1, 2017, and require consumers’ enrollment requests to be “pended” until verification is complete. CMS encourages State-based Exchanges to adopt a similar policy. The Proposed Rule would also limit the ability of existing Exchange enrollees to change plan metal levels during the coverage year.  It would allow Exchanges to require enrollees that qualify for a special enrollment period because of a dependent to be add only to the current Qualified Health Plan (QHP) or allow the enrollee and the new dependent to enroll in another QHP within the same level of coverage.[2]

The Proposed Rule would also require that if an enrollee or the dependent is not enrolled in a silver level QHP and becomes newly eligible for cost-sharing reductions and qualifies for the special enrollment periods, the Exchange may allow the enrollee and dependent to enroll in only a QHP at the silver level.[3] CMS also proposes a new restriction that would allow the Exchange only to allow an enrollee and dependents who qualify for remaining special enrollment periods to make changes to their enrollment in the same QHP or to change to another QHP within the same level of coverage, if other QHPs at that metal level are available.[4]

CMS would allow consumers to start their coverage one month later than their effective date would ordinarily have been, if the special enrollment period verification process results in a delay in their enrollment such that they would be required to pay two or more months of retroactive premium to effectuate coverage or avoid termination for non- payment. [5]

Additionally, CMS would permit the issuer to reject an enrollment for which the issuer has a record of termination due to non-payment of premiums unless the individual fulfills obligations for premiums due for previous coverage.

The Proposed Rule also expresses concern that some consumers not seeking coverage until they are married. CMS proposes that if consumers are newly enrolling in QHP coverage through the Exchange through the special enrollment period for marriage, at least one spouse must demonstrate having had minimum essential coverage for 1 or more days during the 60 days preceding the date of marriage. There is a special rule for individuals who may not have been living in the United States prior to their marriage.[6]

The Proposed Rule would also significantly limit the use of the exceptional circumstances special enrollment period. In previous years, this special enrollment period has been used to address eligibility or enrollment issues that affect large cohorts of individuals where they had made reasonable efforts to enroll, but were hindered by outside events. If the proposal were adopted, CMS would apply a more rigorous test for future uses of the exceptional circumstances special enrollment period, including requiring supporting documentation where practicable. It would grant this special enrollment period only if provided with sufficient evidence to conclude that the consumer’s situation was truly exceptional and in instances where it is verifiable that consumers were directly impacted by the circumstance, as practicable.[7]

CMS is also exploring ways to incentivize consumers to maintain continuous coverage.

These proposed special enrollment changes would not apply to special enrollment periods under the Small Business Health Options Program (SHOP).[8]

Network Adequacy

CMS proposes changes to the oversight of network adequacy requirements to “affirm the traditional role of States in overseeing their health insurance markets while reducing the regulatory burden of participating in Exchanges for issuers.”[9]

CMS proposes to rely on State reviews for network adequacy in States in which an FFE is operating, provided the State has a sufficient network adequacy review process, rather than performing a time and distance evaluation. Beginning in plan year 2018, it would defer to the States’ reviews in States with the authority that is at least equal to the “reasonable access standard” and means to assess issuer network adequacy, regardless of whether the Exchange is a State-based Exchange or federally facilitated, and regardless of whether the State performs plan management functions.

In States without the authority or means to conduct sufficient network adequacy reviews, CMS would rely on an issuer’s accreditation (commercial or Medicaid) from an HHS-recognized accrediting entity. HHS has previously recognized 3 accrediting entities for the accreditation of QHPs: the National Committee for Quality Assurance, URAC, and Accreditation Association for Ambulatory Health Care. An unaccredited issuer would have to submit an access plan.

Interpretation of the Guaranteed Availability Requirement

CMS proposes revising the interpretation of the guaranteed availability requirement to allow issuers to apply a premium payment to an individual’s past debt owed for coverage from the same issuer enrolled in within the prior 12 month. CMS argues this change is necessary to “remov[e] economic incentives individuals may have had to pay premiums only when they were in need of health care services and to encourag[e] individuals to maintain continuous coverage throughout the year and prevent gaming.”[10]

De Minimis Variation in the Actuarial Values

CMS proposes increasing the de minimis variation in the actuarial values (AVs) used to determine metal levels of coverage for the 2018 plan year to “allow issuers greater flexibility in designing new plans and to provide additional options for issuers to keep cost sharing the same from year to year.”[11]

Essential Community Providers

CMS proposes allowing issuers to use a write-in process to identify essential community providers (ECPs) who are not on the HHS list of available ECPs for the 2018 plan year; and lower the ECP standard to 20 percent (rather than 30 percent).[12] 

[1] CMS Patient Protection and Affordable Care Act; Market Stabilization Proposed Rule.

[2]Id.

[3]Id.

[4]Id.

[5]Id.

[6]Id.

[7]Id.

[8]Id.

[9]Id.

[10]Id.

[11]Id.

[12]Id.

The Future of Prior Authorization

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, Reimbursement.

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. For example, in a June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC) cited these states as having particular high utilization rates for dialysis transports. Prior authorization went live in these states on December 15, 2014.

Congress Acts to Expand the Prior Authorization Regime

On April 16, 2015, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015. Section 515 of that law required CMS to expand the demonstration program into five additional states (Delaware, Maryland, North Carolina, Virginia, and West Virginia) and the District of Columbia on or before January 1, 2016. The law further instructed CMS to expand the prior authorization regime to the rest of the country beginning no earlier than January 1, 2017. However, the national expansion was conditioned on CMS determining that the demonstration project has been effective in reducing Medicare expenditures without jeopardizing patient’s access to necessary medical care.

Short Term Prospects for Expansion

As of the end of January 2017, CMS has yet to issue its report on the effectiveness of the prior authorization program in the original 8 states and the District of Columbia. Therefore, there it is highly unlikely that CMS will be expanding the program nationally in the foreseeable future. However, CMS has not officially ruled out the possibility of expanding the program at some point during 2017.

While CMS has not officially ruled out a national expansion in 2017, I rate the prospect as unlikely. I base this statement simply on the calendar. Even if CMS were to issue the required certifications tomorrow, it would still need to give its contractors instructions on how to implement the program. It would also need to give some advance notice to the provider community. If you assume it would want to give everyone involved at least a month to prepare, it would be April at the earliest before it could expand the program. Personally, I have a hard time believing that CMS would go through all that trouble—not to mention allocating the necessary funding—for 8 months.

Long Term Prospects for Prior Authorization

While I rate the short term prospects for prior authorization to be unlikely, I think that our industry should expect prior authorization for repetitive patients to be part of our long term future.

The data thus far suggests that prior authorization is highly effective at reducing Medicare expenditures. In 2014, the last year before prior authorization went into effect, Medicare paid more than $106 million for dialysis transports in New Jersey alone. In 2015, total spending on dialysis decreased to slightly more than $15 million, a decrease of more than 85%. While there has been anecdotal reports of patients in the state being unable to obtain transportation to their dialysis appointments, there is little empirical evidence to suggest that these are anything other than isolated occurrences, or that prior authorization is contributing to a systematic lack of access. The data from Pennsylvania and South Carolina shows similar dramatic decreases in spending on dialysis.

Collectively, total spending on dialysis in these three states was approximately $140 million less in 2015 than 2014. This corresponds to nearly 20% of total dialysis spending in 2014. To put these reductions in their proper perspective, it may be helpful to remember that the Congressional Budget Office scores the cost of our existing temporary adjustments (i.e., the 2% urban, 3% rural and super rural adjustments) at approximately $100 million a year.

Some will argue that the 2015 reductions in these states were magnified by what can be charitably described as “friction” in the implementation of the program. (We recognize that affected providers in these states are likely to use far less charitable descriptions.) These people would argue that the reductions in subsequent years is likely to be less dramatic. CMS will be releasing 2016 payment data in a few months; at which point we will know whether this prediction proves true. Regardless of whether the data shows an uptick in payments in these states, that same data is almost guaranteed to show a dramatic decrease in total spending on dialysis in these states over the 2014 base year.

In sum, the data makes clear that prior authorization offers substantial cost savings to the federal government. Moreover, the overwhelming majority of these cost savings come from dialysis transports, an area that CMS has long-identified with fraud, abuse, and overutilization. This represents a tempting target for both CMS and Congress when looking for future cost-savings.

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.

Medicare Relief and Reform Letter by President Postma

Written by Mark Postma on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, Reimbursement.

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.  To be successful, we will need all of your help in reaching out to your members of Congress in support of the increases.

The AAA and our partners have been also working to further the reform of the Medicare ambulance fee schedule.  To accomplish the first steps in this process, ambulance services need to be treated as providers of health care services rather than only suppliers of medical transportation.  In addition, we will need the cost data necessary for Congress, Centers for Medicare and Medicaid Services and the AAA to make data-driven decisions regarding the reform.

To achieve these goals, we are working with our champions in Congress to reintroduce a version of the Medicare Ambulance Access, Fraud Prevention and Reform Act (HR 745, S. 332 – 114th Congress).  We hope to have a bill reintroduced in the House and Senate in the coming weeks.  Only with your help in sustained outreach to your legislators will we be able to get the provisions of this bill passed.

Our absolute top priority this year is preventing the expiration of the Medicare add-on payments.  Building the increases into the base rates is also vital to the future of reform, as is provider standing and cost data collection.  These changes will lead, we hope, to the demonstration of the need for additional reimbursement as well as recognition of the role ambulance services can play in the larger health care picture.  The subsequent goal is coverage for services such as mobile integrated health and alternate destinations.

The AAA will also be closely following the debate and implications for our industry around repeal and replacement of the Affordable Care Act, potential Medicare and Medicaid reform, and other health care and broader initiatives of interest to us.  We will keep you posted of new developments as the process unfolds.

Since this is such a vital year for us in Congress, I ask that each of you respond to our Calls to Action for help with your members of Congress on the Medicare increases and other legislative priorities.  We will only be successful if we all push as one.

CMS Extends Temporary Moratorium (NJ, PA, TX)

Written by Brian Werfel on . Posted in Medicare, Member Advisories, Member-Only, Reimbursement.

On January 9, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a notice in the Federal Register extending the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey, Pennsylvania, and Texas. The extended moratoria will run through July 29, 2017.

Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse. On July 31, 2013, CMS used this new authority to impose a moratorium on the enrollment of new ambulance providers in Houston, Texas and the surrounding counties. On February 4, 2014, CMS imposed a second moratorium on newly enrolling ambulance providers in the Philadelphia metropolitan areas. These moratoria have been extended every six months thereafter.

However, on August 3, 2016, CMS announced changes to its existing moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that the moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier, but that it would expand the enrollment moratorium on non-emergency ambulance services to cover the entire states of New Jersey, Pennsylvania, and Texas. At the same time, CMS announced the creation of a new “waiver” program that would permit the enrollment of new non-emergency ambulance providers in these states under certain circumstances.

On or before July 29, 2017, CMS will need to make a determination on whether to extend or lift the enrollment moratorium.

Have a Medicare question? AAA members, send your inquiry to Brian Werfel, Esq. using our simple form!

President’s Perspective January 2017

Written by Mark Postma on . Posted in AAA HQ, Government Affairs, Reimbursement.

Happy New Year from the American Ambulance Association. 2017 promises to bring many changes to the health care landscape, and AAA will be there with you and your ambulance service the whole way. As we launch our 2017 initiatives, I wanted to share the updates below from AAA’s board and headquarters.

Advocacy Priorities

In 2017, we will continue to work tirelessly toward our primary advocacy goal: making the CMS temporary ambulance add-on payments permanent.

This effort fits seamlessly into our longer-term payment reform plan, which includes seeking a change in our CMS status from “Supplier” of services to “Provider” of health care. We plan to back this effort with cost data obtained through a rotating, statistically valid survey of ambulance providers, rather than burdensome universal annual reporting. This Provider status would open the door for future innovations in our field, including mobile integrated health (MIH).

Our Government Affairs, Medicare Regulatory, and Payment Reform Committees, along with our paid staff and consultants, have been extremely engaged and active on these issues. To add your voice to AAA’s, please visit our advocacy page to quickly and easily contact your elected officials.

Capital Campaign

I am proud to share that the $1 million capital campaign we kicked off at the 2016 Annual Conference & Trade Show is progressing nicely, with $150,000 raised to date. These funds will be restricted, and only used after a full board vote. I ask that you consider donating as we are in uncharted waters on Capitol Hill.

Committees and Task Forces

AAA thrives on the dedication of its committee chairs, vice-chairs, and members. We have seen a recent surge in volunteerism from our active members. One of my campaign goals was to get more participation from members, what a great thing to see this happening! If you would like to be considered for committee membership, please complete AAA’s short online form.

In addition to our standing committees, we have launched three mission-critical task forces: BLS Non-Emergency, Social Media/Communications, and Small Providers. A large group of ambulance services participated in a recent Chicago meeting for the Non-Emergency task force, with another meeting planned in the Northeast in the near future.

2017 Membership Renewal

Membership is the lifeblood of AAA. Dues are the fuel that powers our advocacy engine, and enables us to offer the innovative benefits your service has come to rely on. If you have already renewed, please accept our most sincere thanks for your continued support. If you have not yet submitted payment for this year’s membership, I encourage you to renew online or reach out to staff at info@ambulance.org for assistance. Again, AAA needs your support through membership to continue our industry-advancing work.

It continues to be my pleasure to serve so many talented, dedicated healthcare professionals. Thank you for your service to your communities, and we wish you a successful and productive 2017!

Mark Postma—President
AAA
Representing EMS in America

Federal Judge Offers Hope for Reduction in ALJ Appeal Backlog

Written by Brian Werfel on . Posted in Medicare, Reimbursement.

As our industry prepares to close the book on 2016 and turns its eye to 2017, I want to focus your attention on a recent federal court ruling that has the potential to significantly reduce the current backlog of appeals pending Administrative Law Judge (ALJ) hearings.

The Medicare regulations require ALJs to conduct a hearing and issue a written decision within 90 days of the filing of an appeal. However, the average time to process decisions has skyrocketed in recent years, from 94.9 days in FY 2009 to nearly 2.5 years in FY 2016. Those statistics come from the CMS Office of Medicare Hearings and Appeals (OMHA). On their face, those numbers may seem discouraging; however, the reality is far worse. Those numbers reflect the average time to render a decision on appeals filed by both beneficiaries and health care providers. However, the law requires the ALJs to give priority to appeals filed by beneficiaries. OMHA has indicated that it continues to decide these cases within approximately 90 days.

Of course, if the appeals filed by beneficiaries continue to be decided within 90 days, the pending appeals filed by health care providers must be delayed even further. In July 2016, OMHA indicated that there were approximately 750,000 claims currently awaiting ALJ hearings. This statement was made in the context of OMHA taking credit for increasing its capacity for processing appeals to approximately 77,000 claims a year. In other words, it is possible that the expected time for a hearing on an appeal filed today could be close to 10 years.

Enter the American Hospital Association. In May 2014, the AHA filed a lawsuit in the federal District Court for the District of Columbia seeking a writ of mandamus (lawyer-speak for “I would really appreciate it if you forced this government official to do his or her job”) to compel the Secretary of Health and Human Services to comply with statutorily imposed deadlines for ALJ decisions. In other words, the AHA was asking the court to force CMS to eliminate the ALJ backlog.

District Court Judge James E. Boasberg initially dismissed the case for lack of jurisdiction. The AHA then appealed to the Court of Appeals for the D.C. Circuit, which, in 2016, reversed the dismissal, and remanded the case back to the lower court for further proceedings. The Circuit Court specifically instructed the judge to determine whether “compelling equitable grounds” existed to justify the issuance of the writ.

CMS then moved to stay further proceedings until September 30, 2017. This is the close of the next full appropriations cycle, and CMS argued that this would give it time to pursue various administrative and legislative efforts to reduce the ALJ backlog. The court denied that request, finding that sufficient grounds existed to justify the writ of mandamus. The court then asked the parties to submit written suggestions on the form such mandamus relief should take. Both CMS and the AHA then submitted suggestions for how to deal with the issue.

The AHA proposed two possible avenues to reduce the backlog:

  1. CMS should: (i) offer reasonable settlements to broad groups of Medicare providers and suppliers (similar to its periodic settlement offers to hospitals over the past few years), (ii) defer the obligation for providers and suppliers to repay outstanding overpayments, and toll the accumulation of interest, while their ALJ appeal was pending, and (iii) impose financial penalties on RACs that have high reversal rates; or
  2. Set specific numeric targets for reducing the backlog over a four year period. These targets would be: (i) a 30% reduction in the backlog by December 31, 2017, (ii) a 60% reduction by December 31, 2018, (iii) a 90% reduction by December 31, 2019, and (iv) the elimination of the backlog by December 31, 2020. The AHA also recommended that, to the extent a backlog still existed on January 1, 2021, that any provider or supplier with an ALJ appeal pending for more than 1 year be granted summary judgment.

CMS objected to each of these requirements. Instead, CMS continued to argue that time should be allowed for its recent initiatives to have the desired impact. However, CMS indicated that the ultimate elimination of this backlog would require legislative action.

On December 6, 2016, Judge Boasberg issued his ruling. In his decision, he stated that, while he was sympathetic to the challenges faced by CMS, he found CMS’ argument somewhat less than persuasive. Moreover, he indicated that CMS’ plan was largely contingent on Congressional intervention, which was by no means a sure thing. However, the Judge indicated that he was hesitant to intrude upon CMS’ specific decision-making process. For that reason, he rejected the specific proposals offered by the AHA. Instead, he elected to adopt the AHA’s proposed timetable for reducing the backlog. The Judge did refuse to grant the AHA’s request that providers automatically be granted summary judgment if the backlog was not eliminated by 2021, agreeing with CMS that this might create some perverse incentives for providers and suppliers to file non-meritorious appeals. Instead, he indicated that, to the extent the backlog is not eliminated by that date, individual providers or suppliers would have the option of moving for default judgment or to seek their own writ of mandamus to compel an immediate hearing. Finally, the Judge ordered CMS to provide status reports every 90 days on its efforts to reduce the backlog.

In sum, a federal court has now ordered CMS to eliminate the current ALJ backlog over the next four years. It is likely that CMS will appeal this decision, and, therefore, this is unlikely to be the last time the courts weigh in on this issue. Moreover, even if the court order stands, it is unclear how CMS could significantly reduce the backlog without securing additional financial resources from Congress. One option might be to expand its settlement offers to additional provider groups. Another might be slow-down the pre- and postpayment audits that feed the appeals pipeline. However, these are purely speculative at this time.

Thus, the court’s decision is unlikely to have a meaningful impact on appeals in the near future. However, it is almost 2017, and I for one am choosing to be optimistic.

Best Wishes for a Happy and Healthy New Year!

 

Have an issue you would like to see discussed in a future Talking Medicare blog? Submit your question!

GAO Report on Revised Provider Enrollment Screening Process

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only.

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 risk categories—limited, moderate, and high—based on the perceived risk of fraud and abuse. The risk category then determines the applicable screening process used for providers within that risk category.

Please note that ambulance providers and suppliers were placed in the moderate risk category. This risk category includes a verification of the information provided by the provider on its enrollment application, a check of the provider’s state licensure, a check of any adverse legal actions against the provider, and a site visit of the provider.

On December 15, 2016, the Government Accountability Office (GAO) released a report on the initial results of this revised provider enrollment screening process.

In its report, the GAO indicated that CMS applied its revised enrollment screening process to over 2.4 million newly enrolling and revalidating Medicare providers and suppliers from March 25, 2011 through December 31, 2015. Other relevant findings include:

  • The total number of enrolled Medicare providers and suppliers increased from 1.4 million in March 2011 to 1.9 million in December 2015, an increase of more than 30%.
  • CMS denied more than 6,000 applications for ineligible providers and suppliers. The most commonly cited reason for a denial was the failure of applicant to meet the provider/supplier type requirements. This included situations where the provider/supplier did not hold the required certification for that provider/supplier type.
  • CMS rejected 17,000 applications as incomplete. The GAO found that approximately 25% of the rejected applications were the result of the application being filed in error, either by the provider/supplier or the MAC. 21% of applications were rejected as being duplicates. Another 16% of rejections were the result of the provider/supplier failing to timely respond to the MAC’s request for additional information.
  • CMS screening of existing providers/suppliers resulted in more than 660,000 provider numbers being deactivated. This was typically (47%) the result of the provider failing to respond to the MAC’s request that they revalidate. Another 29% were the result of the provider/supplier voluntarily withdrawing from the Medicare program. Another 5% of deactivations were the result of the provider/supplier not submitting a claim to Medicare within the previous 12 months. The majority of these were likely individual practitioners (e.g., physicians) that either died, or who retired from professional practice, and who failed to inform the MAC at the time of retirement to request that their provider number be deactivated. This could also include organizational providers that were sold or otherwise no longer operational.
  • These were frequently the result of an individual practitioner (e.g., a physician) failing to deactivate his or her Medicare number upon their retirement, and their either not responding to a request to revalidate, or notifying the MAC of their retirement and agreeing to voluntarily withdraw
  • CMS revoked the billing privileges of 43,000 provider/suppliers. The most common reason cited (61%) was the failure of the provider/supplier to be professionally licensed. However, within the moderate risk category, which includes ambulance, 26% of all revocations were the result of a “CMS-approved revocation,” e.g., the result of some adverse legal action against the provider/supplier which was not properly disclosed to the MAC within 30 days.

 

CMS estimated that its revised screening procedures avoided $2.4 billion in Medicare payments to ineligible providers and suppliers over this period.

CMS also reported that it made several changes to its screening process over this period. This includes the implementation of a continuous license monitoring report in November 2013, and a continuous criminal monitoring report in July 2015. This also includes fingerprint-based criminal background checks for the owners and certain key employees of categorically high-risk providers and suppliers. In December 2015, CMS also began conducting site-visits for certain limited-risk providers and suppliers.

Despite the progress made by CMS, the GAO did find that certain program vulnerabilities still exist. For example, the GAO found that CMS had not established performance measures to monitor its ability to place providers and suppliers in the proper risk categories. The GAO recommended that CMS establish objectives and performance measures for assessing its progress in establishing better screening procedures for new enrollments and revalidations. CMS ultimately agreed with this recommendation.

Have a Medicare question? AAA members, send your inquiry to Brian Werfel, Esq. using our simple form!

 

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

Written by Brian Werfel on . Posted in Medicaid, Medicare, Reimbursement, Talking Medicare.

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 PSP Master File, which contains information on all Part B and DME claims processed through the Medicare Common Working File with 2015 dates of service.

In September’s blog post, I discussed the results of the first year of the prior authorization demonstration project for repetitive, scheduled non-emergency ground ambulance transports. During this first year, the project was limited to three states: New Jersey, Pennsylvania, and South Carolina. The data confirms that these three states saw a dramatic reduction in Medicare’s approved payments for dialysis transports.

This month, I will be discussing the national payment trends for non-emergency ground ambulance transports, and, in particular, Basic Life Support non-emergencies.

In 2015, Medicare paid approximately $990 million for BLS non-emergency transports. This is 13% less than what it paid for BLS non-emergency transports in 2014 ($1.14 billion). Please note that these figures only reflect payments for the base rate; when the payments for the associated mileage are included, the reduction is even more dramatic.

In actual terms, this means Medicare Administrative Contractors (MACs) approved nearly 1 million fewer BLS non-emergency transports in 2015 (5.86 million) than they approved in 2014 (6.81 million). Roughly 75% of this reduction can be directly attributed to the prior authorization program in the three states listed above. Note: the reduction in approved dialysis transports in New Jersey accounts for nearly half of the national decline). However, that leaves nearly 250,000 fewer approved transports in the remaining 47 states. This reduction was not the result of fewer claims being submitted in 2015; the number of submitted claims was actually higher in 2015 than 2014. Rather, the data shows that this reduction is the result of the MACs actively denying many more claims than in year’s past.

I believe these reductions are the direct result of a step-up in the enforcement activities of the MACs, which I also believe has the tacit, if not outright, approval of CMS.

To test this thesis, I looked at the state-by-state data to see if any trends could be found. What I found was that 28 states saw increases in the total number of approved BLS non-emergency transports in 2015, with 19 states seeing decreases. However, on its face, that number is somewhat deceiving. The states that saw increases tended: (1) to see either relatively small increases or (2) had relatively low utilization rates to begin with. The states that saw decreases tended to be larger states with higher utilization rates, and those decreases tended to be larger in percentage terms. For instance, California saw a 21.5% decrease in the number of approved BLS non-emergency transports. Ohio saw an 11.7% decrease.

Digging deeper, it becomes clear that a state’s overall change in payments for BLS non-emergencies is almost perfectly correlated with its change in payments for dialysis transports. In other words, to the extent the state saw an overall reduction in payments for BLS non-emergencies, that reduction – – in nearly all cases – – was the result of the total payments for dialysis decreasing by more than any offsetting increase in the total payments for non-dialysis transports.

These relative changes in dialysis were also highly correlated with the MAC that administers Medicare claims in that state. To the extent your state saw a reduction in dialysis payments, it is highly likely that neighboring states administered by the same MAC saw similar reductions in payments. The following charts will help illustrate this point:

2016-11-29-werfel-non-emergency-crackdown-chart-1As you can see, all three states within Cahaba’s jurisdiction saw a net increase in the total payments for dialysis. While the increases themselves were quite minor in Alabama and Tennessee, Georgia saw an 11.8% increase in total payments for dialysis. Similarly, both Florida and Puerto Rico saw significant increases in the approved payments for dialysis.

By contrast, every state in National Government Services’ (NGS’) jurisdiction with more than 1,000 paid dialysis transports in 2015 saw a net reduction in the total payments for dialysis. These reductions ranged from a relatively minor reduction of 1.17% in New York to a nearly two-thirds (64.58%) reduction in Minnesota.

2016-11-29-werfel-non-emergency-crackdown-chart-2This trend was present in all remaining jurisdictions, although the results were more mixed. For example, with the exception of South Carolina, the three remaining states administered by Palmetto all saw increases. Likewise, the majority of states administered by WPS saw decreases. This included Indiana, which has a sizeable dialysis population. Among WPS states, only Missouri saw a small (3.90%) increase.

California saw a 31.76% decrease in its payments for dialysis. The only other Noridian states with more than 1,000 paid dialysis trips were Hawaii and Washington, which both saw increases.

Novitas presents a more complicated picture, with several large states, such as Texas, seeing double-digit increases in payments for dialysis, while other large states saw sizeable decreases.

All in all, the data suggests that CMS and its contractors continue to pay close attention to the non-emergency side of our business, particularly BLS non-emergency transports. These transports have been under scrutiny for many years, as reports from the Office of Inspector General, the Government Accountability Office and other federal agencies have flagged this portion of our industry as being particularly prone to overutilization (and, in some cases, outright fraud).  However, this heightened scrutiny is not being uniformly applied across-the-board. The data suggests that certain MACs have been far more aggressive in targeting these sorts of trips across their entire jurisdictions, while others seem content to target specific (typically large) states within their jurisdictions. This could serve as a template for how MACs will approach prior authorization in their jurisdictions.

‘Praemonitus, Praemunitus’     

Latin Proverb, loosely translated to “forewarned is forearmed.”

 

 

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