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PBS NewsHour | The No Surprises Act left out ground ambulances. Here’s what’s happening now

 

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GAPBAC | Follow Up from Committee Meeting #2

Ground Ambulance and Patient Billing (GAPB) Advisory Committee Public Meeting #2 (August 16, 2023)

The Ground Ambulance and Patient Billing (GAPB) Advisory Committee Second Public Meeting was held on August 16, 2023. Materials for this meeting are available for download on the CMS.gov GAPB website.

As we continue this webinar series, we look to you as industry experts to provide feedback and recommend information that would be beneficial in future webinars. Written public comments for consideration by the Advisory Committee may be emailed to:  GAPBAdvisoryCommittee@cms.hhs.gov .

Public comments on the specific topics listed in the GAPB Advisory Committee Public Meeting #2 Agenda, should be submitted by September 5, 2023 for consideration by the GAPB Advisory Committee.

 

CMMI Notice of Termination of the Emergency Triage, Treat, and Transport Model

The Centers for Medicare & Medicaid Innovation (CMMI) has announced the agency will end the ET3 Model pilot program early, on December 31, 2023, which is two years prior to the ET3 Model Participation Agreement’s original Performance Period end date. CMS has been reaching out to ambulance services participating in the program notifying them of the early termination. Please find the notice being sent to participants linked below. 

Notice of Early Termination of the ET3 Model

 

Department of Veterans Affairs Issues Final Rule on Reimbursement for Ambulance Services and Other Special Modes of Transportation

On February 16, 2023, the Department of Veterans published in the Federal Register the final rule to revise the payment methodology for beneficiary travel by ambulance and other so-called “special modes of transportation. The changes contained within the final rule were first included in a November 5, 2020 proposed rule.

The final rule will become effective on February 16, 2024.

Relevant Background

The VA currently pays for beneficiary travel under certain circumstances.  To be eligible for reimbursement, the veteran must meet certain eligibility criteria.  Specifically, the veteran must be traveling either: (i) for care at a VA health facility or (ii) for care at a non-VA facility that has been previously approved by the VA.  The veteran must also meet one of the following additional criteria:

  1. The veteran must have a VA disability rating of 30% or higher;
  2. The veteran must be traveling for treatment of a service-related condition (if their VA disability rating is less than 30%);
  3. The veteran receives a VA pension;
  4. The veteran has an income below the maximum annual VA pension rate;
  5. The veteran cannot otherwise afford to pay for their travel; or
  6. The veteran is traveling for one of the following reasons: (i) to obtain a VA compensation and pension exam, (ii) to obtain a VA service dog, or (iii) to obtain VA-approved transplant care.

Beneficiary travel covers all modes of transportation, including transportation by private vehicle, common carriers (e.g., taxi, livery, and public transportation), mass transit, etc.  Beneficiary travel also covers so-called “special modes of transportation,” which includes air and ground ambulance services, wheelchair vans services, and stretcher vans services.

The rules governing the payment for beneficiary travel services at set forth in 38 C.F.R. § 70.30.

Subpart (a)(4) sets forth the payment methodology for the reimbursement of special modes of transport, and simply provides that payment is based on “[t]he actual cost of a special mode of transportation.  In the context of ambulance services, this has historically been interpreted to mean the ambulance provider’s full billed charges.

Provisions of Final Rule 

Under the final rule, the VA would revise its existing payment methodology for beneficiary travel by ambulance and other special modes of transportation to no longer reimburse providers for their actual costs, and to instead base reimbursement on:

  1. For ground and air ambulance services, the lesser of: (i) the actual charge for ambulance transportation (i.e., the provider’s billed charges) or (ii) the amount determined under the Medicare Ambulance Fee Schedule.
  2. For other special modes of transportation (i.e., ambulette, wheelchair van, or stretcher van), the lesserof: (i) the provider’s actual charge, (ii) the applicable Medicaid rate in the state where the provider is domiciled (using the lowest Medicaid rate where the provider is domiciled in multiple states), or (iii) the applicable Medicaid rate in the state where the transport occurred (or the lowest Medicaid rate if the transport occurred in more than one state). Note: the revised regulations provide that if none of the states involved has a “posted rate,” the VA would continue to pay the provider’s full billed charges

The revised payment methodology for non-ambulance special modes of transport is intended to be temporary.  In its proposed rule, the VA indicated that it would use this payment methodology for a minimum of 90 calendar days after a final rule was posted in the Federal Register.  This period of time was intended to allow the VA to gather payment data.  If the VA believes that it gathered sufficient payment data during this initial 90-day period, it indicated that it would develop a new payment methodology “using the lowest possible rate.”  If the VA determined that it did not have sufficient payment data after the initial 90-day period, it would extend the proposed payment methodology for additional 90-day periods as needed until it believed it had sufficient data.  The VA indicated that it did not anticipate needing more than 18 months from the effective date of the final rule to gather sufficient payment data to implement a new payment method

Letter to VA Reimbursement of Ambulance Services

The AAA has sent a letter to VA Secretary Denis McDonough asking him to delay the implementation of a final rule that would allow the Department of Veterans Affairs (VA) to reimburse at the lower of billable charges or Medicare rates for certain non-contracted ambulance services. The proposed rule was issued back in 2020 but we understand that the VA could now issue the final rule in January 2023. GMR has been advocating on Capitol Hill for a delay in air and ground ambulance services. The AAA will be issuing later today a request for AAA members to reach out to the VA to also request the delay.

 

December 12, 2022

The Honorable Denis McDonough
Secretary of Veterans Affairs
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary McDonough,

The American Ambulance Association (AAA) respectfully requests that the Department delay release and implementation of the final rule on the “Change in Rates VA Pays for Special Modes of Transportation (RIN 2900-AP89).” Reimbursing for services to veterans at Medicare rates would have dire consequences for the ability of ground ambulance service organizations to provide lifesaving 9-1-1 emergency and also interfacility ambulance services not only to veterans but entire communities. We ask that the Department delay the rule until after Congress has had an opportunity to act on the results from the Medicare ambulance data collection system which is currently underway.

As documented by the Government Accountability Office (GAO) in 2007 and 2012, the Medicare program reimburses ground ambulance service organizations below the cost of providing their services when temporary add-ons are not considered. Since 2012, the disparity between the cost of providing ambulance services and reimbursement by Medicare has only increased through sequestration cuts, a reduction in inflation updates, and other Medicare payment policy changes. Ground ambulance service organizations are already facing difficult financial straits and cannot
sustain a reduction in reimbursement from another federal payor.

Ground ambulance service organizations serve as the foundation for emergency medical response for veterans and communities throughout the country. Our members are a vital component of our local and national health care and 9-1-1 emergency response systems and serve as lifelines of medical care for many rural and underserved communities. However, our ability to continue to serve communities is already at risk due to inadequate reimbursement and access to care for veterans would be further jeopardized if the Department were to reimburse at lower levels for ground ambulance services.

The AAA is the primary association for ground ambulance service organizations, including governmental entities, volunteer services, private for-profit, private not-for-profit, and hospital-based ambulance services. Our members provide emergency and non-emergency medical transportation services to more than 75 percent of the U.S. population. AAA members serve
patients in all 50 states and provide services in urban, rural, and super-rural areas.

Again, we request that you delay the release and implementation of the final rule on the “Change in Rates VA Pays for Special Modes of Transportation”.

If you have any questions regarding our request, please do not hesitate to have a member of your staff contact AAA Senior Vice President of Government Affairs Tristan North. Tristan can be reached by phone at (202) 802-9025 or email at tnorth@ambulance.org.

Thank you in advance for your consideration.

Sincerely,

/AAA - AmerAmbAssoc Team Folder/Signatures/Baird, Shawn Signature.png
Shawn Baird
President

AAA President Baird Named to Balance Billing Advisory Committee

The Centers for Medicare & Medicaid Services (CMS) today appointed American Ambulance Association President Shawn Baird to the Ground Ambulance and Patient Billing Advisory Committee (GAPBAC), established by the Congress under “The No Surprises Act.” Shawn will represent the ground ambulance service provider and field personnel community.

 “I am honored to have the opportunity to serve,” stated Baird. “I look forward to representing the interests of EMS providers and professionals as they care for our communities.

 The Congress recognizes that the one-size-fits all approach to addressing surprise medical bills would not work for EMS. State and local governments regulate EMS agencies services and rates, as both first responders and medical care providers, which adds another level of complexity. As a result, the Congress established GAPBAC so the unique characteristics of ground ambulance services could be taken into consideration when evaluating private insurer billing policies to protect access to EMS, respect state and local government regulation, and protect patients.

 Patients with private insurance should not be caught in the middle when their insurers do not adequately reimburse for vital ground ambulance services,” said Baird. “EMS must receive fair reimbursement by insurance companies for providing critical medical services to patients.”

 Baird will bring to the Committee his years of firsthand experience and expertise as a paramedic and operator of an ambulance service in both urban and rural areas. He will also share knowledge gained from his years of volunteer leadership at the American Ambulance Association and the Oregon State Ambulance Association, as well as his term as an appointee to the National EMS Advisory Committee.

 The GAPBAC is charged with “reviewing options to improve the disclosure of charges and fees for ground ambulance services, better inform consumers of insurance options for such services, and protect consumers from balance billing.” The Committee will submit a report that includes recommendations with respect to disclosure of charges and fees for ground ambulance services and insurance coverage, consumer protection and enforcement authorities of the Departments of Labor, Health and Human Services, and the Treasury and State authorities, and the prevention of balance billing to consumers. The report must be received no later than 180 days after the date of its first meeting.

About the American Ambulance Association

The American Ambulance Association safeguards the future of mobile healthcare through advocacy, thought leadership, and education. AAA advances sustainable EMS policy, empowering our members to serve their communities with high-quality on-demand healthcare. For more than 40 years, we have proudly represented those who care for people first.

CMS Posts 2023 Public Use File

On November 23, 2022, CMS posted the 2023 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in the calendar year 2023 for the various levels of ambulance service and mileage. These allowable reflect an 8.7% inflation adjustment over the calendar 2022 rates. The 2023 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.

Please note that these files reflect the Medicare allowable based on current federal law.  Accordingly, the 2023 Public Use Files do not include the current add-ons (i.e., 2% for urban, 3% for rural, and the super-rural bonus), as these add-ons are currently scheduled to expire on December 31, 2022.

The AAA is actively working with congressional offices to not only extend but hopefully increase, the Medicare ambulance add-ons by the end of the year. If you have not already written to your members of Congress about extending the add-ons at increased levels, please do so today by using the AAA online advocacy tool by clicking here.

Unfortunately, in recent years, CMS has elected to release its Public Use Files without state and payment locality headings. As a result, in order to look up the rates in your service area, you would need to know the CMS contract number assigned to your state. This is not something the typical ambulance service would necessarily have on hand. For this reason, the AAA will be publishing a reformatted version of the CMS Medicare Ambulance Fee Schedule that includes the state and payment locality headings. The reformatted fee schedule will be available on the AAA website in the coming days.

The AAA will also be publishing an updated version of its Medicare Rate Calculator, which we expect to have available on our website once we have a better sense of the timing of the extension of the add-ons.

CMS Update-CY 2023 Final Ambulance Fee Schedule

Member Advisory:  CMS Issues CY 2023 Final Ambulance Fee Schedule Rule Updated Data Ground Ambulance Data Collection System

by Kathy Lester, JD, MPH

CMS has released the “CY 2023 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicare and Medicaid Provider Enrollment Policies, Including for Skilled Nursing Facilities; Conditions of Payment for Suppliers of Durable Medicaid Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); and Implementing Requirements for Manufacturers of Certain Single-dose Container or Single-use Package Drugs to Provide Refunds with Respect to Discarded Amounts” (Final Rule).  The Final Rule includes proposals affecting ground ambulance services in terms of medical necessity requirements and documentation requirements, as well as to the ground ambulance cost collecting tool.

I.           Medical Necessity and Documentation Requirements for Nonemergency, Scheduled, Repetitive Ambulance Services

              CMS finalizes the modifications to the documentation requirements codified in regulation pertaining to the medical necessity and documentation requirements for nonemergency, scheduled, repetitive ambulance services, such as those to/from dialysis facilities.  The Final Rule clarifies that the Physician Certification Statement (PCS), and additional documentation from the beneficiary’s medical record, may be used to support a claim that transportation by ground ambulance is medically necessary.  It also notes that the PCS and additional documentation must provide detailed explanations that: (1) are consistent with the beneficiary’s current medical condition; and (2) explain the beneficiary’s need for transport by an ambulance.  Coverage includes observation or other services rendered by qualified ambulance personnel.  It maintains the following requirements:

  • In all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to CMS;
  • The ambulance service must meet all program coverage criteria including vehicle and staffing requirements; and
  • A signed PCS does not alone demonstrate that transportation by ground ambulance was medically necessary.

             CMS declines to “confine this regulatory clarification to the RSNAT prior authorization program, as there may be non-emergent, scheduled, repetitive ambulance transport services outside of that program that would be affected.” (Display Copy 1756)  CMS also does not provide further clarification about what it means by the term “additional documentation” because it believes that “the data elements needed will vary depending upon the beneficiary’s specific conditions and needs.” (Id.)  CMS also states that “[t]his proposal does not establish new obligations for documentation; rather, it merely clarifies existing requirements.” (Id. at 1757).  In response to a comment, CMS also writes, “In addition, our pre-proposal language and proposed regulatory language both reflect that the presence of a PCS alone is not sufficient to demonstrate medical necessity, and, therefore, must be supported by medical documentation.” (Id.)  CMS also declined to extend authorization to nurse practitioners and physicians’ assistants, stating that to do so would be outside of the scope of the rule.

II.         Ground Ambulance Data Collection Instrument

            CMS finalizes the proposed changes to the ground ambulance data collection instrument and instructions with a few additional modifications in response to comments.  They fall within four areas:  (1) editorial changes for clarity and consistency; (2) updates to reflect the web-based system; (3)  clarifications responding to feedback from questions from interested parties and testing; and (4) typos and technical corrections.  The updated instrument that includes all of the CY 2023 proposed changes to review and provide comments on is posted on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/Downloads/Medicare-Ground-Ambulance-Data-Collection-System-Instrument.pdf.

            One of these modification is to Section 5, Question 3c, which now reads: Does your organization respond to calls with another non- transporting agency such as a local fire department that is not part of your organization? After the question, the following instructions will be provided: This includes joint responses with other ground ambulance organizations as well as cases where a fire, police, or other public safety department responses to calls for service with your organization. Only consider cases where your ground ambulance does or would have transported the patient, if necessary.

            The Final Rule notes that the system already includes an “autosave” feature that saves responses as they are entered. The system also allows the same user to enter information at different times, and/or multiple users to enter information at different times. The system also already includes many validation and error checking steps that are automatically applied as respondents enter information. CMS also noted that it has no plans to adopt additional import functionality prior to the launch of the system, but that it will continue to explore the option of an API.  CMS also indicates that the final written tool and web-based platform will align before the system goes live.  A print function will also be available for the online submissions.

            CMS indicates that the data from the collection system will be made available to the public through posting on the CMS website at least every 2 years.  Summary results will be posted by the last quarter.  The data collected under the ground ambulance data collection system will be publicly available beginning in 2024.

            CMS also indicates that it will not require a ground ambulance organization to fill the data entry submitter and data certifier roles with different individuals.

            CMS has also provided additional guidance, including FAQs available at:  https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/AmbulanceFeeSchedule/Downloads/Medicare-Ground-Ambulance-FAQs.pdf.

            CMS also finalizes its proposal for an automated process for submitting a hardship exemption request and informal review request.

III.        Origin and Destination Requirements Under the Ambulance Fee Schedule

            In the Final Rule, CMS also responds to comments it received on the Interim Final Rule that expanded the origin and destination requirements.  It finalizes the interim final policy that the expanded list of covered destinations for ground ambulance transports including, but are not limited to, any location that is an alternative site determined to be part of a hospital, CAH or SNF, community mental health centers, FQHCs, RHCs, physician offices, urgent care facilities, ASCs, any location furnishing dialysis services outside of an ESRD facility when an ESRD facility is not available, and the beneficiary’s home.  The policy will be In effect for the duration of the PHE for the COVID-19 only.

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