President Biden’s Budget Seeks to Bypass Ground Ambulance Patient Billing Advisory Committee
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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:
- The veteran must have a VA disability rating of 30% or higher;
- The veteran must be traveling for treatment of a service-related condition (if their VA disability rating is less than 30%);
- The veteran receives a VA pension;
- The veteran has an income below the maximum annual VA pension rate;
- The veteran cannot otherwise afford to pay for their travel; or
- 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:
- 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.
- 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
2023 Ambulance Fee-for-Service Medicaid Rate Survey
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Revised CY 2023 Ambulance Fee Schedule Public Use Files
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Ambulance Medicare Add-Ons Extended to 2024
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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,
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.
AAA Posts Reformatted 2023 Public Use File
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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.
CMS Announces Providers Selected for Year 3 & 4 Cost Data Collection
Centers for Medicare & Medicaid Services Announces Year 3 and Year 4 Medicare Ground Ambulance Data Collection System Selected Providers and Suppliers
The Centers for Medicare & Medicaid Services (CMS) has released the ground ambulance suppliers and providers selected for Years 3 and 4 of the Medicare ground ambulance data collection system. The list of the selected providers and suppliers is available on the CMS website. These providers and suppliers will be asked to collect data during their budget year starting in 2023 and to report the data within five months of the close of that year.
Providers and suppliers who are selected should respond to the notification letter sent by Medicare Administrative Contractors (MAC). Organizations may select a calendar year or fiscal year start date for the data collection period. Data will be submitted for a continuous 12-month period using the Medicare Ground Ambulance Data Collection Instrument: English (PDF).
The AAA continues to provide educational support for ground ambulance services to help them collect and report these data. In addition to in-person sessions, the AAA offers webinars on demand.
It is important that all ground ambulance providers and suppliers collect and report data through this program. The Congress intends to use the information to help reform Medicare ambulance fee schedule.
CMS Announces 2023 Ambulance Inflation Factor
On October 14, 2022, CMS issued Transmittal 11642 (Change Request 12948), which announced the Medicare Ambulance Inflation Factor (AIF) for the calendar year 2023.
The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Starting in the calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi-factor productivity index (MFP). The MFP reduction may result in a negative AIF for any calendar year. The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.
For the 12-month period ending in June 2022, the Federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U increased by 9.1%. CMS further indicated that the CY 2023 MFP would be 0.4%. Accordingly, CMS indicated that the Ambulance Inflation Factor for the calendar year 2023 will be 8.7%.
This is the largest inflation update since the implementation of the current Medicare Ambulance Fee Schedule in April 2002. The increase from last year’s 5.1% increase is also the single largest year-over-year increase on record.
Administration Includes Ambulance Add-Ons Extension on CR List
The Biden Administration has issued a list of expiring programs and items that they would like to see or have no objection to being, extended as part of the FY2023 Continuing Resolution. The list includes “Medicare add-on payments for ground ambulance services”. The list also includes a “Suspension of Medicare Sequestration” on which the AAA has been advocating. Congress will need to pass a CR by September 30 to avoid a partial government shutdown.
No determination has been made by congressional decision-makers as to when Congress will address Medicare extenders that expire at the end of the year but most key congressional staff believe extenders will be addressed after the election. Even if extenders are not included in the CR, the list demonstrates the overall support and/or recognition of the Administration for the listed programs and items including the Medicare ambulance add-on payments and suspension of sequestration.
Authorization Issues
Note: The following list is provided for your information. In the event that authorizing
legislation is not enacted in a timely manner, these items will allow either for the
continuation of programs that will be funded in the continuing resolution (CR) or for other
legislative fixes.
Agriculture/Rural Development:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Agriculture, Livestock Mandatory Reporting
No Objection to Inclusion in a CR if Not Enacted First in Other Legislation
HHS, FDA User Fees
HHS, Exclusivity of Certain Drugs Containing Single Enantiomers
HHS, Medical device programs expiration: 1) Authority to accredit 3rd parties to review certain medical device applications; 2) Conformity Assessment Pilot Program for Devices; 3) Device Postmarket Pilot Projects; 4) Inspections by Accredited Persons; 5) Modification to Humanitarian Device Exemption
Commerce/Justice/Science:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Justice, Additional Special Assessment (Expires 9/11/22)
Justice, U.S. Parole Commission (NOTE: Extension for two years is recommended)
Justice, Protection of certain facilities and assets from unmanned aircraft (Also DHS)
Justice, Extending Temporary Emergency Scheduling of Fentanyl Analogues Act (Expires 12/31/22)
Defense:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Defense, North Atlantic Treaty Organization Security Investment Program (NSIP)
Defense, Authority to Provide Temporary Adjust in Rates of Basic Allowance for Housing (BAH) if the Actual Costs of Adequate Housing for Civilians in That Military Housing Area or Portion Thereof Differs from the Current BAH Rates by More than 20 Percent
Defense, Authority for reimbursement of certain coalition nations for support provided to United States military operations (Expires 12/31/22)
Defense, Authority to provide assistance to counter the Islamic State in Iraq and Syria (Expires 12/31/22)
Defense, Authority to provide assistance to the vetted Syrian groups and individuals. (Expires 12/31/22)
Defense, Authority to provide temporary increase in rates of Basic Allowance for Housing (BAH) under certain circumstances (Expires 12/31/22)
Defense, Authority to Support Operations and Activities of the Office of Security Cooperation In Iraq (Expires 12/31/22)
Defense, Authority to waive annual limitation on premium pay and aggregate limitation on pay for Federal civilian employees working overseas (Expires 12/31/22)
Defense, Extension of Certain Expiring Bonus and Special Pay Authorities (Expires 12/31/22)
Defense, Income Replacement Payments for Reserve Component Members Experiencing Extended and Frequent Mobilization for Active Duty Service (Expires 12/31/22)
No Objection to Inclusion in a CR if Not Enacted First in Other Legislation
Defense, Information Operations, and Engagement Technology Demonstrations
Defense, One-time Uniform Allowance for Officers Who Transfer to the Space Force
Defense, Increased Percentage of Sustainment Funds Authorized for Realignment to Restoration and Modernization at Each Installation
Defense, Pilot Program for the Temporary Exchange of Cyber and Information Technology Personnel
Defense, Reauthorization of Authority to Order Retired Members to Active Duty in Highdemand, Low-density Assignments
Financial Services/General Government:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
FCC, FCC General, and Incentive Auction Authority Continuation (NOTE: Extension of auction authority through 9/30/2024 is recommended)
GSA, Pilot Programs for Authority to Acquire Innovative Commercial Items Using General Solicitation Competitive Procedure (NOTE: also covered by DHS)
SBA, Assistance for Administration, Oversight, and Contract Processing Costs
SBA, Commercialization Readiness Pilot Program for Civilian Agencies
SBA, Phase 0 Proof of Concept Partnership Pilot Program
SBA, Pilot Program to Accelerate DOD Awards
SBA, SBIR Commercialization Assistance Pilot Programs
SBA, SBIR Phase Flexibility
SBA, Small Business Innovation and Research (SBIR)
SBA, Small Business Technology Transfer (STTR)
Homeland Security:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Homeland Security, DHS Joint Task Forces
Homeland Security, E-Verify Program
Homeland Security, National Computer Forensics Institute
Homeland Security, National Flood Insurance Program
Homeland Security, Raising the H-2B Cap
Homeland Security, National Cybersecurity Protection System (NCPS) Authorization, including EINSTEIN
Homeland Security, Counter Threats Advisory Board
Homeland Security, Pilot Programs for Authority to Acquire Innovative Commercial Items Using General Solicitation Competitive Procedure (NOTE: also covered by GSA)
Homeland Security, Protection of certain facilities and assets from unmanned aircraft (Also DOJ)
No Objection to Inclusion in a CR if Not Enacted First in Other Legislation
Homeland Security, Authority to grant special immigrant status to religious workers other than ministers
Homeland Security, Waiver of Foreign Residence Requirements for Physicians Working in Underserved Areas (“Conrad State 30” Program)
Interior/Environment:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Interior, Omnibus Public Land Management Act of 2009
Labor/HHS/Education:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Labor, Trade Adjustment Assistance (TAA) for Workers Program (Expired 7/1/22)
HHS, TANF
HHS, Promoting Safe and Stable Families Program
HHS, Liability protections for health professional volunteers at community health centers (HRSA)
HHS, Medical Countermeasures Innovations Partner
HHS, Maternal, Infant, and Early Childhood Home Visiting Program
HHS, Interdepartmental Serious Mental Illness Coordinating Committee
HHS, Increase in Medicaid FMAP for territories
SSA, Demonstration Project Authority (Expires 12/31/22)
No Objection to Inclusion in a CR if Not Enacted First in Other Legislation
HHS, Additional support for Medicaid home and community-based services during the COVID-19 emergency (Expired 3/31/22)
HHS, Suspension of Medicare Sequestration (Expired 3/31/22)
HHS, Medicare IPPS adjustment for low-volume hospitals
HHS, Medicare-dependent hospital (MDH) program
HHS, Puerto Rico Medicaid Payment
HHS, Restriction on Alaska Native Regional Health Entities
HHS, Tick-Borne Diseases Working Group
HHS, Exception for eligible professionals based in ambulatory surgical centers with respect to incentives for meaningful use of certified EHR technology (Expires 12/31/22)
HHS, Incentives for Qualifying Alternative Payment Model Participants (Expires 12/31/22)
HHS, Medicare add-on payments for ground ambulance services (Expires 12/31/22)
HHS, Medicare add-on payments for rural home health services (Expires 12/31/22)
HHS, Temporary Increase in Medicare Physician and Non-physician Practitioners Payments (Expires 12/31/22)
Military Construction/VA:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
VA, Adaptive Sports Assistance Program (formerly limited to Paralympics)
VA, Co-Pays for Hospital and Nursing Home Care
VA, Homeless and Seriously Mentally Ill Veterans- Additional Services at Certain Locations
VA, Homeless and Seriously Mentally Ill Veterans- Treatment/ Rehab
VA, Manila, Philippines Regional Office
VA, SAH – Assistive Technology Grants
VA, Transportation of Beneficiaries
VA, Advisory Committee on Minority Veterans
VA, Advisory Committee on Education (Expires 12/31/22)
VA, Advisory Committee on Homeless Veterans (Expires 12/31/22)
VA, SAH for Veterans Temporarily Residing with Family (Expires 12/31/22)
Transportation/HUD:
Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Transportation, Next Generation 9-1-1
CY2023 Medicare Ambulance Fee Schedule Comment Letter
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CMS End of PHE Roadmap
CMS Prepares Providers and Suppliers for the End of the Public Health Emergency:
CMS Issues Updates on the End of Emergency Waivers and Flexibilities Issued during the PHE
By Kathy Lester, J.D., M.P.H.
Even though it appears that the Biden-Harris Administration will extend the COVID-19 Public Health Emergency (PHE) for at least another 90 days, CMS has begun the process of preparing for the termination of waivers and flexibilities that have been in effect during the pandemic. During the PHE, the American Ambulance Association has worked closely with CMS and Congress to make sure that ground ambulance services were prioritized and provided with waivers and flexibilities to support their integral role as a front-line medical response during the pandemic.
CMS announced its roadmap for the end of the PHE on August 18. The roadmap includes a summary of the policies that will terminate at the end of the PHE, but also notes that CMS intends to keep some policies in place even after the PHE ends. Examples of policies that will continue after the PHE is allowed to expire include certain morbidity and mortality reporting requirements on long-term care facilities and certain telehealth services expanded by Congress.
In its announcement, CMS indicated particular concern about patient safety. “As mentioned by Lee A. Fleisher, M.D.; Michelle Schreiber, M.D.; Denise Cardo, M.D.; and Arjun Srinivasan, M.D., in February 17, 2022, New England Journal of Medicine Perspective, ‘Safety has also worsened for patients receiving post-acute care, according to data submitted to the Centers for Medicare and Medicaid Services (CMS) Quality Reporting Programs…’”
As part of this announcement, CMS released a fact sheet detailing the current status of the Medicare waivers and flexibilities for ambulance providers and suppliers. Some of the policies highlighted in this fact sheet include:
- Vaccine Reimbursement Rates: CMS will continue to pay approximately $40 per dose for administering COVID-19 vaccines in outpatient settings for Medicare beneficiaries through the end of the calendar year that the COVID-19 PHE ends. Effective January 1 of the year following the year that the COVID-19 PHE ends, CMS will set the payment rate for administering COVID-19 vaccines to align with the payment rate for administering other Part B preventive vaccines. CMS plans to continue to pay a total payment of approximately $75 per dose to administer COVID-19 vaccines in the home for certain Medicare patients through the end of the calendar year that the COVID-19 PHE ends.
- Alternative Destination: CMS indicates that it will include this issue in future rulemaking.
- Treat in Place: CMS indicates that the waiver will end with the end of the PHE.
- Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization: CMS notes that it has already returned to the full model operations including post-payment reviews of claims submitted during the PHE.
- Signature Requirements: Absent indications of potential fraud and abuse, CMS will not review claims for dates of service during the COVID-19 PHE for compliance with the signature requirements.
- Appeal Flexibilities: CMS will allow some of the flexibilities related to the timing of appears to continue consistent with existing authority for appeals once the PHE ends.
The AAA will continue to monitor the PHE and any changes in the waivers and flexibilities specific to ground ambulance services. We encourage members to reach out to our team if concerns or questions arise as CMS winds down the PHE.
CMS Ambulance Open Door Forum Summary
On August 18, 2022, the Centers for Medicare and Medicaid Services (CMS) held its most recent Ambulance Open Door Forum (ODF). As is typically the case, CMS started the ODF with a series of announcements, before opening the call to questions from the ambulance industry.
The first announcement related to proposed changes to the regulations governing the medical necessity requirements for non-emergency, scheduled, repetitive ground ambulance services. Specifically, CMS is proposing to modify the so-called “special rule” for repetitive, scheduled non-emergency services (set forth in the regulations at 42 C.F.R. §410.40(e)(2)(ii)). CMS indicated that these proposed changes would provide necessary and ensure the consistent application of the documentation requirements by its contractors. The proposed change would add language indicating that both the Physician Certification Statement and “additional documentation from the beneficiary’s medical record” could be used to support medical necessity for the ambulance transport. The new language would further indicate that these documents must provide detailed explanations that are consistent with the beneficiary’s current medical condition. On the ODF, CMS encouraged the industry to submit comments on these proposed changes. However, CMS indicated that, because these changes were the subject of ongoing rulemaking, it would not be able to answer any questions on the ODF.
The second announcement related to the proposed changes to the Medicare Ground Ambulance Data Collection System (GADCS) included in the July 2022 Proposed Rule. CMS and its contractor, the Rand Corporation, went through a detailed PowerPoint presentation that summarized these proposed changes. That PowerPoint presentation can be accessed by clicking here.
As part of its discussion of the GADCS, CMS also announced the implementation of an automated process for requesting hardship exemptions and informal review of determinations that an ambulance provider is subject to a financial penalty for failing to properly submit its cost data.
The final announcement related to ambulance services furnished by Rural Emergency Hospitals (REHS). In the FY 2023 Outpatient Hospital Proposed Rule, CMS is proposing to codify in its regulations the statutory requirement that ambulance services furnished by entities that are owned and operated by REHS will be paid under the Medicare Ambulance Fee Schedule. CMS is also proposing to revise the origin and destination requirements to include REHS as both a covered origin and covered destination for ambulance services.
The ODF concluded with a brief Q&A period. All of the questions posed to CMS related to the GADCS. One of the questions placed to CMS was whether it would permit ambulance suppliers to prospectively seek a hardship exemption, i.e., to permit an ambulance supplier to ask now that it be relieved of the financial penalties for failing to report its cost data. The person posing the question specifically referenced ambulance suppliers impacted by the severe flooding in the State of Kentucky. CMS confirmed that an ambulance supplier had to be notified that it was subject to a financial penalty before it was eligible to seek a hardship exemption.
CMS Issues FY2023 Medicare Ambulance Fee Schedule Proposed Rule
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CMS | Ambulance Ground Transport: Comparative Billing Report in April
In late April, CMS will issue a Comparative Billing Report (CBR) on Medicare Part B claims for ambulance ground transport. Use the data-driven report to compare your billing practices with those of peers in your state and across the nation.
CBRs aren’t publicly available. Look for an email from cbrpepper.noreply@religroupinc.com to access your report. Update your email address in the Provider Enrollment, Chain, and Ownership System to ensure delivery.
For More Information:
- View a webinar recording
- Visit the CBR website
- Register for a live webinar on May 11 from 3–4 pm ET
Issue Impacting Medicare Claims for Patients in a Part A SNF Stay
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Balance Billing | TX Judge Vacates Portions of NSA IFR
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