AAA Operations & Human Resources Consultant Scott Moore, Esq has developed a summary of financial relief provisions from the recent CARES Act. The resource will help your organization evaluate in which programs it may qualify to participate.
CMS released published a guidance document summarizing some of the steps that it has taken to relieve the administrative burden on health care providers and suppliers during the current public health emergency. As part of that document, CMS indicated that it will be “pausing” the Prior Authorization Model for scheduled, repetitive non-emergency ambulance transports. Under this program, ambulance suppliers are required to seek and obtain prior authorization for the transportation of repetitive patients beyond the third round-trip in a 30-day period. Absent prior authorization, claims will be stopped for pre-payment review. The Prior Authorization Model is currently in place in Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, West Virginia, and the District of Columbia.
CMS indicated that this pause went into effect as of March 29, 2020, and will continue for as long as the current public health emergency continues. During this pause, claims for repetitive, scheduled, non-emergency transports will not be stopped for pre-payment review if the prior authorization has not been requested and obtained prior to the fourth round-trip. However, CMS indicated that claims submitted and paid during the pause without prior authorization will be subject to postpayment review.
CMS further indicated that during this period: (1) the MACs will continue to review any prior authorization requests that have previously been submitted and (2) that ambulance suppliers may continue to submit new prior authorization requests.
Ambulance suppliers in these areas will have to make a business decision on whether to continue to request prior authorization during the current crisis. Please note that there are significant benefits to obtaining prior authorization for your repetitive patient population. Specifically, claims that are submitted based on an affirmative prior authorization decision are excluded from future medical review.
The existing Prior Authorization Model is scheduled to expire on December 1, 2020. CMS has indicated that, at the present time, it does not plan an extension beyond December 1, 2020. CMS further indicated that the Prior Authorization Model will not be expanded beyond the current states and territories during the public health emergency.
CMS announced at the end of last week that it is expanding its Accelerated Payment Program. The goal of the program is to address cash flow problems arising from the public health emergency. The program functions as a short-term loan with no interest.
To qualify for advance/accelerated payments the provider/supplier must: (1) Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/supplier’s request form; (2) Not be in bankruptcy; (3) Not be under active medical review or program integrity investigation; and (4) Not have any outstanding delinquent Medicare overpayments.
Qualified providers/suppliers will be asked to request a specific amount using an Accelerated or Advance Payment Request form provided on each MAC’s website. Most providers and suppliers will be able to request up to 100% of the Medicare payment amount for a three-month period. All non-hospital Part A providers and Part B suppliers will have 210 days from the date of the accelerated or advance payment was made to repay the balance.
The provider/supplier can continue to submit claims as usual after the issuance of the accelerated or advance payment; however, recoupment will not begin for 120 days. Providers/ suppliers will receive full payments for their claims during the 120-day delay period. At the end of the 120-day period, the recoupment process will begin and every claim submitted by the provider/supplier will be offset from the new claims to repay the accelerated/advanced payment. Thus, instead of receiving payment for newly submitted claims, the provider’s/supplier’s outstanding accelerated/advance payment balance is reduced by the claim payment amount. This process is automatic.
None of the proposals offered so far on an economic stimulus package to address the impact of COVID-19 include our specific provisions to provide ambulance relief! Negotiators on a final package failed to reach an agreement over the weekend. There is still time to influence the final outcome! Please write to your members of Congress!
There are provisions in the packages that would help businesses, first responders and Medicare providers and suppliers. However, the AAA is advocating for specific help for ambulance services with the prioritization of COVID-19 resources, coverage of services, as well as direct financial assistance. The Congress has heard directly from the AAA about our requests and they need to hear from their constituents about assistance to your operations. If you have not yet contacted your members of Congress, please do so today!
Please e-mail today the health aides for your members of Congress!
It will take you only a few minutes per congressional office to email a letter. Just follow these steps.
1. USE LETTER TEMPLATE: CLICK HERE to access a draft letter. Please customize your letter including the cities and towns you serve, if you are sending to the office of a Senator or Representative and any additional details as to services you are providing during the COVID-19 outbreak and the financial impact on your operation.
2. LOOK UP HEALTH STAFFER AND EMAIL ADDRESS: CLICK HERE to access a list of the name of the health staffer and email address for all congressional offices.
3. SEND E-MAILS TO STAFFERS: Copy and paste the email address of the health staffer and copy and paste the letter as the body of the e-mail and send.
While the Congress may not include all of our requests in this stimulus package, there are likely to be future legislative vehicles in which the AAA will continue to press for passage of additional relief for ambulance service organizations and personnel.
On March 9, 2020, CMS published a memorandum to State Survey Agency Directors that provides updated guidance on the obligations of hospitals and critical access hospitals (CAHs) under the Emergency Medical Treatment and Labor Act (EMTALA). This guidance was issued in response to numerous inquiries regarding the EMTALA obligations of these facilities as they struggle to respond to the COVID-19 pandemic.
Under EMTALA, hospitals and CAHs with emergency departments have an obligation to provide an appropriate medical screening examination to any individual that comes into the emergency department seeking examination or treatment of an emergency medical condition. Hospitals and CAHs are further required to make a determination as to whether the patient actually has an emergency medical condition, and, if so, to provide stabilizing treatment within the hospital’s capabilities, or make appropriate arrangements to transfer the patient to a facility that does have the necessary capabilities.
The hospitals and CAHs had requested guidance on how they can fulfill their basic EMTALA obligations while minimizing the risks of exposure from COVID-19 infected individuals to their staff and other patients in their emergency departments.
Note: in summarizing the CMS guidance document, references to a “hospital” will include both hospitals and CAHs.
Acceptance of Patients Suspected or Confirmed to be Infected with COVID-19
CMS indicated that hospitals with the capacity and the specialized capabilities needed to provide stabilizing treatments are required to accept transfers from hospitals without the necessary capabilities. CMS indicated that it would take into account the recommendations of the Centers for Disease Control (CDC) in assessing a hospital’s capabilities and capacity. CMS further indicated that the presence or absence of negative pressure rooms (Airborne Infection Isolation Room (AIIR)) would not be the sole determining factor related to determining when an EMTALA transfer is required. CMS is advising hospitals to coordinate with their state and local public health officials regarding the appropriate placement of individuals who meet specific COVID-19 assessment criteria, as well as the most current standards for treating patients confirmed to be infected with COVID-19.
CMS is further confirming that hospitals have the ability to set up alternative screening sites on the hospital campus, i.e., the initial medical screening exam does not need to take place in the emergency department. CMS is confirming that individuals may be redirected to an alternative screening site after being logged into the emergency department. This redirection can even take place outside the entrance to the emergency department. Medical screening exams conducted in alternative screening sites must still be conducted by qualifying personnel (i.e., physicians, NPs, Pas, or RNs).
CMS is also indicating that hospitals may set up screening sites at “off-campus, hospital-controlled” sites. Hospitals and community officials may encourage the public to go to these sites instead of the hospital for screening for influenza-like illnesses. However, a hospital cannot tell an individual that has already presented at their emergency department to go to an off-site location for their medical screening exam. Unless the off-campus site is already considered to be a dedicated ED (e.g., a free-standing ED) under EMTALA regulations, the EMTALA regulations would not apply to these off-site screening areas; however, the hospital would be required under its Medicare Conditions of Participation to arrange a referral/transfer to an appropriate hospital if the patient has a need for emergency medical attention.
Finally, communities may set up screening clinics at sites not under the control of a hospital. These sites would not be subject to EMTALA.
EMTALA Obligations when a Screening Suggests Possible COVID-19 Infection
To the extent a hospital determines, following a medical screening exam that a patient may be a possible COVID-19 case, the hospital is expected to isolate the patient immediately. CMS indicated that it expects that all hospitals will be able to provide medical screening exams and initiate stabilizing treatment while maintaining isolation requirements.
Once an individual is admitted to the hospital or the emergency medical condition ends, the hospital has no further obligations under EMTALA.
CMS is further reminding hospitals that the latest screening guidance from the CDC calls for hospitals to contact their State or local public health officials when they have a case of suspected COVID-19.
On March 16, 2020, CMS approved an 1135 Waiver request submitted by the State of Florida. The State had requested the flexibility to waive prior authorization requirements, streamline its Medicaid enrollment process, and allow care to be provided in alternative settings to the extent an existing health care facility needs to be evacuated. The key provisions of the waiver are summarized below:
1. Payments to Out-of-State Providers: Under current CMS coverage guidelines, the Florida Medicaid Program had the authority to reimburse out-of-state providers that were not enrolled in the Florida Medicaid Program provided certain criteria were met. However, this authority was limited to situations involving: (a) a single instance of care furnished over a 180-day period or (b) multiple instances of care furnished to a single Florida Medicaid beneficiary over a 180-day period. Under the waiver, CMS is removing the 180-day restriction for the duration of the emergency.
2. Expedited Enrollments: With respect to providers that are not currently enrolled in the Medicare Program or with another State Medicaid Agency, CMS is waiving the following screening requirements: (a) the payment of the application fee, (b) the fingerprint-based criminal background checks, (c) the required site visits, and (d) the in-state/territorial licensing requirements. Under the waiver, the state would still be required to check enrolling providers against the OIG exclusion list, and confirm that the out-of-state provider is properly licensed in their home state.
3. Cessation of Revalidation Efforts: CMS granted Florida the authority to temporarily cease the revalidation of enrolled in-state Medicaid providers and suppliers who are directly impacted by the emergency.
4. Waiver of Prior Authorization Requirements: CMS has granted Florida the right to waive any prior authorization requirements that are currently part of the State Medicaid Plan. This waiver applies to services provided on or after March 1, 2020, and will continue through the termination of the emergency declaration.
5. Waiver Allowing Evacuating Facilities to Provide Services in Alternative Settings: CMS will allow facilities, including nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric residential treatment facilities, and hospitals to be reimbursed for services rendered during an emergency evacuation to an otherwise unlicensed facility. This waiver will extend for the duration of the declared emergency; however, CMS will require the unlicensed facility to seek licensure with the state after 30 days.
On March 13, 2020, President Donald J. Trump announced a national state of emergency in response to the COVID-19 pandemic. Previously, HHS Secretary Alex Azar had declared a public health emergency under Section 319 of the Public Health Service Act in response to COVID-19.
This has prompted many AAA members to ask what impact, if any, these declarations have on the coverage of ambulance services under federal health care programs?
The short answer is that these declarations give CMS the authority under Section 1135 of the Social Security Act to waive certain Medicare, Medicaid, and SCHIP Program requirements. This waiver authority includes, but is not necessarily limited to:
• Waiving certain conditions of participation and/or certification requirements;
• Waiving certain pre-approval requirements;
• Waiving the requirements that a provider or supplier be licensed in the state in which they are providing services;
• Waiving EMTALA requirements related to medical screening examinations and transfers; and
• Waiving certain limitations on payments for services provided to Medicare Advantage enrollees by out-of-network providers.
One situation where an 1135 waiver may be of use to an ambulance provider or supplier would be where the ambulance provider or supplier is sending vehicles and crews to a state that is outside its normal service area. The ambulance provider or supplier is unlikely to be licensed by the state in which it is responding. As a result, under normal circumstances, it would be ineligible for payment under federal health care program rules. The 1135 waiver would permit it to submit claims for the services it furnishes in the other state.
Of more immediate significance to the current national emergency, an 1135 waiver may permit hospitals and other institutional health care providers to establish an off-site treatment center for initial screenings of patients. For example, hospitals may establish triage sites in parking lots and other open spaces for the initial intake of patients suspected of being infected with the COVID-19 virus. In theory, this waiver could also extend to drive-thru testing sites to the extent they are operated by the hospital or another health care provider. When a hospital has obtained an 1135 waiver to operate an off-site treatment center, the off-site area becomes a part of the hospital for Medicare payment purposes. Therefore, ambulance transports to an approved off-site treatment area should be submitted to Medicare using the “H” modifier for the destination.
Read a summary of President Trump’s proposed stimulus package developed by analysts from AAA lobbying firm Akin Gump.
As was the case following September 11, and during the Great Recession, President Trump and Congress have managed to bridge partisan divides and quickly develop several legislative packages to address the expanding impact of the coronavirus (COVID-19) on America’s public health system and the broader economy. Phase 1—the supplemental appropriations bill—has already become law. Phase 2—targeted relief for individuals, including paid family leave—has passed the House and is poised to pass the Senate this week. Phase 3—broader economic stimulus designed to deliver cash to individuals to help them weather the downturn, as well as industry-specific relief—is being crafted as we write, hopefully with a bipartisan agreement and quick enactment in a matter of days, not weeks. Continue reading►
The Centers for Medicare and Medicaid Services (CMMI) has released its initial list of applicants selected to participate in the ET3 pilot program. CMMI notes that the list is not final as it still needs to execute participation agreements with the applicants. CMMI will issue a final list once it completes the process.
Applicants from 36 states and the District of Columbia were selected to participate in the program. Approximately 200 applicants were approved with instances in which the same ambulance service organization submitted applications for multiple counties as well as more than one organization submitting an application for the same county. CMMI has sent notifications to each of the applicants letting them know to expect a follow up email with the partnership agreement, program guidance and additional details.
The ET3 program is a five-year voluntary pilot program designed to test the potential benefit to the Medicare program and patients of ambulance service providers and suppliers furnishing treatment in place as well as transport to alternative destinations. For more information about the ET3 program, please go the ET3 website.
This past Tuesday and Wednesday, respectively, the House Ways & Means and Education & Labor Committees marked up their proposals on balance or “surprise” billing. As we reported on Monday of this week, the Ways & Means Committee proposal, the Consumer Protections Against Surprise Medical Bills Act (H.R. 5826), did not include a provision on ground ambulance services. The House Education & Labor proposal, The Ban Surprise Billing Act (H.R. 5800), however, included a provision to create a federal advisory committee to recommend restrictions on the ability of ground ambulance service providers and suppliers to balance bill.
The Ways & Means Committee reported out H.R 5826 favorably by voice vote. While the Education & Labor Committee also reported out H.R. 5800 favorably, the vote was 30 to 13 as a block of its Committee members preferred the approach of the Ways & Means proposal on how to address balance billing for other providers. It is now up to House leadership to determine next steps on how the chamber will approach a final package on balance billing.
While H.R. 5800 as reported out by the Education & Labor Committee still includes the provision on ground ambulance services, Chairman Scott (D-VA) and Ranking Member Foxx (R-NC) prior to mark up had removed the most problematic language in the bill. As introduced, H.R. 5800 would have given the Department of Health and Human Services the authority to issue regulations to restrict balance billing based on the findings of the advisory committee. This would have eliminated federal lawmakers from being able to evaluate the recommendations prior to the changes being implemented. The language was removed in the chairman’s mark of the bill, and thus the Congress would now have an opportunity to debate and craft legislation on the recommendations.
The AAA along with the International Association of Fire Chiefs (IAFC), International Association of Firefighters (IAFF) and National Association of EMTs (NAEMT) had advocated against the ground ambulance provision. We thank Chairman Scott, Ranking Member Foxx and members of the Committee for listening to our concerns and removing the regulation authority language.
Only one of the four pieces of legislation on balance billing reported out by congressional committees includes a provision on ground ambulance services. We will continue to advocate to preserve the ability of local governments to determine the rates and standards for their EMS systems and against the inclusion of a ground ambulance provision in a final package on balance billing.
We will keep you apprised of new developments on the issue.
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On January 30, 2020, the Centers for Medicare and Medicaid Services (CMS) announced the roll-out of its “Healthy Adult Opportunity” (HAO) initiative. Under the initiative, participating states will have a portion of their current federal Medicaid funding converted to block grants. In return, the states will gain greater flexibility in providing for the health care needs of certain portions of their existing Medicaid populations.
In a letter directed to State Medicaid Directors, CMS outlined the details of how the HAO initiative would operate. The initiative will be operated under CMS’ 1115 waiver authority. In order to participate, a state must submit an application setting forth the specific demonstration projects it intends to implement. CMS reiterated that participation in the HAO initiative is voluntary. CMS further indicated that it will review state applications on a case-by-case basis and make an independent decision on whether the proposed policies merit approval. States with existing Section 1115 waivers that cover eligible populations will be permitted to transition existing demonstrations into the HAO initiative.
CMS indicated that HAO demonstrations will generally be approved for an initial 5-year period, and successful demonstrations may be renewed for a period of up to 10 years.
A summary of some of the major provisions of this initiative is provided below.
The Medicaid Program is a joint federal and state program that provides free or low-cost health coverage to nearly 65 million Americans. The Program is administered by each state, with the federal government reimbursing states for a percentage of their qualifying Medicaid expenditures. The amount of federal matching funds is based on a statutory formula that compares a state’s per capita income to the national average. States with lower per capita incomes receive a higher Federal Medical Assistance Percentage (FMAP). FMAPs range from 50% to a maximum of 83%. In addition, the federal government provides higher matching rate (called an Enhanced FMAP) for certain services or populations. For example, the federal government currently pays 90% of the costs of providing health care to those covered by the Medicaid expansion included in the Affordable Care Act.
Under the HAO initiative, participating states would forego the FMAP for certain Medicaid populations. Instead, these states would receive a fixed amount of federal funding (i.e., a block-grant), which will be calculated based on either a total expenses or per-enrollee basis. To the extent the state spends more than its budgeted amount, it would not be eligible for additional federal matching funds. To the extent the state ends up spending less than its budgeted amount, the state would participate in the cost-savings.
The HAO initiative is focused on the non-mandatory adult Medicaid populations, i.e., individuals that are under the age of 65, and who are not eligible for Medicaid on the basis of disability, or their need for long term care, and who are not otherwise eligible under a State Medicaid Plan. In other words, this initiative is largely targeted at those individuals that become eligible for Medicaid as a result of the Affordable Care Act.
Under the HAO initiative, states will have the ability to design benefit packages that closely resemble the benefit packages provided by private insurers. At a minimum, this would include benefit packages that cover all of the Essential Health Benefits (EHBs) required for commercial insurances sold on the State ACA Exchanges. States may also design federally qualified health center coverages that facilitate the use of value-based payment design among safety-net providers.
Beneficiaries that are shifted into HAO demonstration projects will retain certain beneficiary protections, including all federal disability and civil rights laws, fair hearing rights, and limits on their mandatory cost-sharing amounts.
One major change would be to state’s coverage of prescription drugs. The initiative would give states the flexibility to offer formularies under an HAO demonstration project similar to those provided in commercial health insurance markets. This would remove the current mandate that states provide a so-called “open formulary.” States that elect to establish their own formulary would be required to comply with the EHB requirements regarding prescription drug benefits. States would also be required to cover substantially all drugs used to treat: (1) mental health disorders (i.e., antipsychotics and antidepressants), (2) HIV (i.e., antiretroviral drugs), and (3) opioid use disorders (i.e., all forms, formulations, and delivery mechanisms) where there are rebate agreements in place with the manufacturers.
In theory, this would permit states to cover only a single drug for many pharmaceutical classes.
States would have the flexibility to impose additional cost-sharing obligations on beneficiaries covered under a demonstration program, subject to two broad limitations:
States would be given the flexibility to discontinue the coverage of Alternative Benefit Plan wrap-around services, including non-emergency medical transportation (NEMT) and early and periodic screening, diagnostic and treatment services (EPSDT) for individuals aged 19-20.
On December 2, 2019, CMS posted the 2020 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in calendar year 2020 for the various levels of ambulance service and mileage. These allowables reflect a 0.9% inflation adjustment over the 2018 rates.
The 2020 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.
Unfortunately, CMS has elected in recent years 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 has created a reformatted version of the CMS Medicare Ambulance Fee Schedule, which includes the state and payment locality headings. AAA members can access this reformatted fee schedule at the link below.
It’s finally here! For almost a decade the American Ambulance Association has been preparing for this moment: collecting cost data in order to justify the reimbursement inadequacies of our current payment system. As Benjamin Franklin stated, “By failing to prepare, you are preparing to fail.” So prepare we did!
Our research indicated that due to industry capacity, a provider sample and survey approach would be preferable to a mandatory cost reporting structure. Congress agreed! Our research indicated that different organizational structures made us unique healthcare providers and as such, EMS’s special nature should be considered in the collection tool developed. Congress agreed! No one knows our industry better than we do and the final rule from the Centers for Medicare and Medicaid Services indicates they listened!
So your ambulance service was selected for the 2020 reporting period—now what? Here is your 10 STEP PLAN.
Subscribe to email updates from the American Ambulance Association’s Ambulance Cost Education page, www.ambulancereports.org. Not only will we make sure you get the latest information disclosed from the Centers for Medicare & Medicaid Services, but we will also provide you with quick tutorials on how to fill out the cost data collection instrument. Most importantly, you can purchase AMBER! This software provides an easy, quick solution for you to input your data, with built-in tutorials to walk you through the data collection process.
It is important that you review the information in the Provider Enrollment, Chain, and Ownership System (PECOS) which supports the Medicare Provider and Supplier enrollment process. You will want to make sure the information that you provide in the cost data collection tool, at a minimum, matches what is in this system or on your CMS 855B Medicare enrollment application. Pay close attention to the following:
More than 2,600 ambulance suppliers and providers were selected for the 2020 reporting period (Zip file download of services selected for 2020). Please reach out to your colleagues. Now is not the time to let competition or friendly rivalries stop us from communicating best practices. Call your fellow mobile healthcare providers!
How you recognize cost and revenue will be extremely important in determining how you report. Cash accounting recognizes revenue and expenses only when money actually exchanges hands. Accrual accounting recognizes revenue and expenses when billed, not when money exchanges hands. This status will be key in determining how you report costs and revenues.
For every ambulance and non-ambulance vehicle that you use related to patient care, you will need to know the odometer readings at the beginning and end of 2020. Make sure you have a system to record the odometer readings accurately.
For example, you have a 2016 ambulance where the odometer reading on 1/1/2020 is 10,212. If on 12/31/2020 the odometer reading is 74,112, you will have the option of recording the full mileage of 63,900 in the data collection tool. This is another window into the “cost of readiness.”
As identified by the Medicare Ground Ambulance Data Collection System (PDF download), there are nine payer type categories for billing ambulance transportation. Know these categories and set them up in your system now, prior to billing for ambulance transports in 2020. If you use a billing agency, seek confirmation that they have a way to identify these nine payer types. You may not have select reports to identify the numbers yet within these categories but that can be set up later in the reporting year.
Setting up your system NOW to identify these payer categories is critical as it will be too administratively burdensome to fix this retroactively.
Support services are services such as maintenance, dispatch, billing, materials management, human resources and other services that support patient care. You will need to know if you share these services with other entities such as fire, police, air ambulance, hospital or other entity not related to ground ambulance care.
If you share, then you will have to work out an allocation model to assign the costs and revenue appropriately. If you do not share support services, then you do not need to work about any of the questions related to allocation.
Check your systems. Now is the time to make sure you can identify all sources of revenue you receive whether from billing for an ambulance transport or from a grant or local tax. Understand your costs, especially those related to salary, vehicles, facilities and medical supplies. That is the first step in the ability to categorize appropriately.
Take a deep breath—It is not as complicated as it may seem. There are resources available and assistance for you and your ambulance services as outlined in STEP 1.
See, that wasn’t too bad, was it? Now you have a 10 Step Plan!
In all seriousness, while it may seem a bit daunting at first, breaking down the cost data collection process into small steps will ensure that our industry is prepared and the figures we enter into this cost data collection tool will glean useful information. It is imperative that we get this right the first time to avoid any unintended consequences, such as decreased reimbursements and other impactful changes that could harm the patients we serve.
As the saying goes, “the rising tide lifts all boats.” More than ever, we need to help and assist our colleagues as we navigate this new world of ambulance reimbursement.
So, what’s next? Cost data collection, my friend! Jump on board.
The Centers for Medicare and Medicaid Services has scheduled a call for Thursday, December 5 from 1:30-3:00 PM Eastern to review the new Ambulance Cost Data Collection System. If you plan to attend, register here.
CMS Ambulance Cost Data Collection
The American Ambulance Association is pleased to announce the publication of its 2018 Medicare Payment Data Report. This report is based on the “Early Edition” of the 2018 Part B National Summary Data File (previously known as the Bess Report). The report consists of an overview of total Medicare spending nationwide, and then a separate breakdown of Medicare spending in each of the 50 states, the District of Columbia, and the various other U.S. Territories.
For each jurisdiction, the report contains two charts: the first reflects data for all ambulance services, with the second limited to dialysis transports. Each chart is further broken down by HCPCS code. The charts provide information on the total number of allows services and the total Medicare payments for CYs 2017 and 2018. Percentage changes will allow members to view payment trends over the past year.
2018 National & State-Specific Medicare Data
Questions? Contact Brian Werfel at bwerfel@aol.com.
CMS Releases List of Ambulance Organizations Selected for Data Collection
The Centers for Medicare & Medicaid Services (CMS) has released the list of ambulance service providers and suppliers selected to provide data in the first year of data collection. CMS has published the data by National Provider Identifier (NPI) number and the AAA has also sorted the data by state in alphabetical order.
On Friday, CMS had made public the final rule on the Establishment of an Ambulance Data Collection System. The AAA will be issuing a Member Advisory tomorrow on the details of the final rule and changes from the proposed rule.
To access the list by NPI number click here and to access the list by state click here.
On October 4, 2019, CMS issued Transmittal 4407 (Change Request 11497), which announced the Medicare Ambulance Inflation Factor (AIF) for calendar year 2020.
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 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 2018, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased 1.6%. CMS further indicated that the CY 2020 MFP will be 0.7%. Accordingly, CMS indicated that the Ambulance Inflation Factor for calendar year 2019 will be 0.9%.
On October 29, 2019, the Centers for Medicare and Medicaid Services (CMS) posted a notice in the Federal Register announcing an opportunity for the public to provide comments on the proposed national expansion of the prior authorization process for repetitive, scheduled non-emergent ground ambulance transportation. CMS refers to this process as its “RSNAT Prior Authorization Model.” The CMS Notice can be viewed in its entirety at: https://www.govinfo.gov/content/pkg/FR-2019-10-29/pdf/2019-23584.pdf.
Under the Paperwork Reduction Act of 1995, federal agencies are required to publish a notice in the Federal Register concerning each proposed collection of information, and to allow 60 days for the public to comment on the proposed action. Interested parties are encouraged to provide comments regarding the agency’s burden estimates and other aspects of the proposed collection of information, including the necessity and utility of the proposed information for the proper performance of the agency’s functions, and ways in which the collection of such information can be enhanced.
In this instance, CMS is indicating that it is pursuing approval to potentially expand the existing RSNAT Prior Authorization Model nationwide. Currently, the RSNAT Prior Authorization Model is in place in 8 states (DE, MD, NJ, NC, PA, SC, VA, and WV) and the District of Columbia. National expansion is contingent upon CMS’ determination that certain expansion criteria have been met. CMS is indicating that if the decision is made to expand the program, such expansion may occur in multiple phases. CMS intends to use the information collected pursuant to this notice to determine the proper payment for repetitive scheduled non-emergent ambulance transportation.
In plain English, CMS is soliciting comments from stakeholders as to the efficacy of the current process, including whether the existing paperwork requirements are sufficient to ensure that approved patients meet the medical necessity requirements for an ambulance. CMS is also seeking suggestions for how to best expand the program nationally, e.g., whether it makes sense to expand the program in phases, etc.
The AAA Medicare Regulatory Committee has been monitoring the current model for several years. As a result, the AAA is in a good position to provide constructive feedback to CMS regarding the potential national expansion of the RSNAT Prior Authorization Model. These suggestions will be included in the AAA’s comment letter. The AAA also encourages members to offer their own comments. The AAA anticipates providing members with a sample comment letter in early December that members can use to submit their own comments.
To be considered, comments must be submitted no later than 5 p.m. on December 30, 2019. Comments may be submitted electronically by going to: http://www.regulations.gov. Commenters would then need to click the link for “Comment or Submission,” and follow the instructions from there. Comments may also be submitted by regular mail to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier: CMS-10708, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
On September 16, 2019, CMS published a notice in the Federal Register that it would be extending the prior authorization demonstration project for another year. The extension is limited to those states where prior authorization was in effect for calendar year 2019. The affected states are Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia and West Virginia, as well as the District of Columbia. The extension will run through December 1, 2020.
In its notice, CMS indicated that the prior authorization demonstration project is being extended “while we continue to work towards nationwide expansion.” This strongly suggests that CMS believes the program has met the statutory requirements for nationwide expansion under the Medicare Access and CHIP Reauthorization Act of 2015. However, CMS indicated that it would use the additional year to continue to test whether prior authorization helps reduce expenditures, while maintaining or improving the quality of care offered to Medicare beneficiaries.
CMS has also updated its CMS Ambulance Prior Authorization webpage to reflect the expansion of prior authorization in the existing states through December 1, 2020.