CMS Open Door Forum & Member Q&A – November 7th

The Centers for Medicare and Medicaid Services has scheduled its next Ambulance Open Door Forum for Thursday, November 7 from 2:00-3:30 PM Eastern. If you plan to attend, please dial in at least 15 minutes before the call.

CMS Ambulance Open Door Forum

November 7 | 2:00 PM ET
Participant Dial-In Number:  1-888-455-1397
Conference ID #: 4676500

Questions?

Have more questions? The AAA is here to help! Following the ODF the AAA will be publishing a follow up blog post going over any updates and important announcements.

AAA Follow Up Q&A

November 7 | 4:00 PM ET
1-800-250-2600
Pin: 82802314#
Speakers: AAA Senior Vice President of Government Affairs, Tristan North; AAA Healthcare Lobbyist, Kathy Lester, Esq.

CMS Announces 2020 Ambulance Inflation Factor

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%.

CMS Announces Comment Period for National Expansion of Prior Authorization Process

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.

Submit Comments on Ambulance Data Collection System

Yesterday, the AAA submitted our comment letter to the proposed rule on changes for FY2020 to the Medicare ambulance fee schedule. The comment letter focused on the section of the proposed rule on the ambulance data collection system. For a copy of the detailed 28-page comment letter, please click here.

Read the AAA Comment Letter

The AAA is very pleased with the approach CMS is taking on data collection which is consistent with the intent of the Congress and the methodology developed and advocated by the AAA. While the AAA comment letter is extremely detailed, our only concern is CMS was not able to test or pilot the sampling methodology and data collection instrument prior to inclusion in the proposed rule. Testing would have allowed CMS to fine-tune the survey and may impact the quality of the first year of data.

Now, it is important that AAA members submit their own letters to demonstrate support for the AAA letter and its key points.

AAA members should go to www.regulations.gov and make three points as follows:

  • Our organization supports the approach CMS is proposing to collect ambulance data and we thank CMS and its contractors.
  • Since CMS was unable to test the sampling methodology and data collection tool, we are concerned about the potential quality of the first year of data. We therefore ask CMS to begin education of ambulance service suppliers and providers and work with the American Ambulance Association to adjust the methodology and tool, if necessary, for future data collections.
  • We fully support the specific comments submitted by the American Ambulance Association as to recommended improvements to the data collection tool.

All you need to do is click on www.regulations.gov and include the above three points. Add your first and last name and click “continue” to then finalize your submission.

The AAA has also developed a sample comment letter you can access by clicking here. Go to www.regulations.gov and instead of adding the three points in the comment back, upload your letter.  Please draft your own customized letter using the letter provided by the AAA as a guideline.

Sample Comment Letter

Comments are due by 5:00 pm on Friday, September 27, so please submit your comment letter today! Please also feel free to forward this email to state ambulance associations and other ambulance service organizations.

The AAA will be submitting a second letter in the next week just on seeking clarification around changes to PCS requirements in the proposed rule but will not be asking members to submit similar comments.

We greatly appreciate the work of CMS and its contractors in developing the ambulance data collection system.

Thank you in advance to all of you who take the time to submit comment letters.

Questions?: Contact Us:

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

CMS Announces Extension of Prior Authorization Program

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.

Financial Hardship Policies: Steps for Your Protection [Sponsored]

By Eric van Doesburg, MP Cloud Technologies

In an industry whose sole focus is to help those in need, it’s natural for us to want to assist patients financially when they’re in hardship situations.

Waiving deductibles and copays for patients that have either claimed poverty, or simply for bills that seem too small to make a difference has become common practice. Although this is well-intentioned, it can easily put your company in harm’s way.

“There is no question of if Medicare will audit you, but when.”

The Federal False Claims Act requires businesses to bill patient’s copays and deductibles unless the company puts in place a clearly defined, legally binding policy. Without such a
policy, any actions taken in regard to waiving payments would effectively overbill Medicare, leading to Medicare auditing the company for payment as well as instituting
additional penalties. And in this day and age, there is no question of if Medicare will audit you, but when.

You can still help out the less fortunate while working within the letter of the law, but only with the proper Financial Hardship Policies put into practice. We urge you to seek legal counsel when crafting
and adopting a hardship policy, however, be sure to consider the following points as you get started:

  • Make it clear that you are not offering kickbacks: Clearly state in your guidelines that you do not offer incentives, such as kickbacks, bribes, rebates, or waivers of copayments or deductibles, for anyone bringing your company business.
  • Define your threshold for financial hardship: There is no true definition of financial hardship; every case is different. Most standards suggest waiving copayments and deductibles for patients with a gross family income at or below 200% of the federal poverty guidelines. Your definition should be updated annually to ensure effective practices.
  • Assign a decision-maker: Granting waivers involves state and federal anti-fraud laws, so a compliance officer or administrator would be best suited to assign who is exempt and who is not.
  • Require Documentation: A valid documentation trail is required as evidence for a patient who claims financial hardship, such as W-2 forms, pay stubs, tax returns, or unemployment compensation.

Learn more about MP Cloud Technologies.

Preliminary Calculation of 2020 Ambulance Inflation Update

Section 1834(l)(3)(B) of the Social Security Act mandates that the Medicare Ambulance Fee Schedule be updated each year to reflect inflation. This update is referred to as the “Ambulance Inflation Factor” or “AIF”.

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 2019, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased by 1.65%.

CMS has yet to release its estimate for the MFP in calendar year 2020. However, assuming CMS’ projections for the MFP are similar to last year’s projections, the number is likely to be in the 0.6% range.

Accordingly, the AAA is currently projecting that the 2020 Ambulance Inflation Factor will be approximately 1.1%. 

Cautionary Note Regarding these Estimates

Members should be advised that the BLS’ calculations of the CPI-U are preliminary, and may be subject to later adjustment. The AAA further cautions members that CMS has not officially announced the MFP for CY 2020. Therefore, it is possible that these numbers may change. The AAA will notify members once CMS issues a transmittal setting forth the official 2020 Ambulance Inflation Factor.

CMS Open Door Forum & Member Q&A – August 28

The Centers for Medicare and Medicaid Services has scheduled its next Ambulance Open Door Forum for Wednesday, August 28 at 2:00 PM Eastern. If you plan to attend, please dial in at least 15 minutes before the call.

CMS Ambulance Open Door Forum

August 28 | 2:00 PM ET
Participant Dial-In Number:  1-888-455-1397
Conference ID #: 6609831

Questions?

Have more questions? The AAA is here to help! Following the ODF the AAA will be publishing a follow up blog post going over any updates and important announcements.

AAA Follow Up Q&A

August 28 | 3:00 PM ET
1-800-250-2600
Pin: 82802314#
Speakers: AAA Senior Vice President of Government Affairs, Tristan North; AAA Healthcare Lobbyist, Kathy Lester, Esq.; AAA Medicare Regulatory Committee Chair, Krista Cuthbert; and AAA Payment Reform Committee Chair, Asbel Montes.

New SNF Consolidated Billing Edits: FAQs

On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that it stated would better identify ground ambulance transports that were furnished in connection with an outpatient hospital service that would be bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime.

Unfortunately, the implementation of these new edits has been anything but seamless. Over the past few weeks, I have received numerous phone calls, texts, and emails from AAA members reporting an increase in the number of Medicare claims being denied for SNF Consolidated Billing.

This FAQ will try to explain why you may be seeing these denials.  I will also try to provide some practical solutions that can: (1) reduce the number of claims denied by the edits and (2) help you collect from the SNFs, when necessary.

Please note that, at the present time, there is no perfect solution to this issue, i.e., there is nothing that you can do to completely eliminate these claim denials.  The solutions discussed herein are intended only to minimize the disruption to your operations caused by these denials.  

I am new to Medicare ambulance billing. Can you explain what the SNF Consolidated Billing regime is, and how it operates?

Under the SNF Consolidated Billing regime, SNFs are paid a per diem, case-mix-adjusted amount that is intended to cover all costs incurred on behalf of their residents.  Federal regulations further provide that the SNF’s per diem payment generally the cost of all health care provided during the beneficiary’s Part A stay, whether provided by the SNF directly, or by a third-party.  This also includes the majority of medically necessary ambulance transportation provided during that period.  For these purposes, the “Part A Period” refers to the first 100 days of a qualified SNF stay.

However, medically necessary ambulance transportation is exempted from SNF Consolidated Billing (referred to hereafter as “SNF PPS”) in certain situations.  This includes medically necessary ambulance transportation to and from a Medicare-enrolled dialysis provider (whether free-standing or hospital-based).  Also excluded are ambulance transportations:

  • To an SNF for an initial admission;
  • From the SNF to the patient’s residence for a final discharge (assuming the patient does not return to that SNF on the same day);
  • To and from a hospital for an inpatient admission;
  • To and from a hospital for certain outpatient procedures, including, without limitation, emergency room visits, cardiac catheterizations, CT scans, MRIs, certain types of ambulatory surgery, angiographies (including PEG tube procedures), lymphatic and venous procedures, and radiation therapy.

For a fuller description of the SNF Consolidated Billing Regime, including a discussion of when ambulance services may be separately payable by Medicare Part B, I encourage members to consult the AAA Medicare Reference Manual.

Purchase the 2019 Medicare Reference Manual

Can you explain what prompted CMS to implement these new edits? 

In 2017, the HHS Office of the Inspector General conducted an investigation of ground ambulance claims that were furnished to Medicare beneficiaries during the first 100 days of a skilled nursing home (SNF) stay. The OIG’s investigation consisted of a review of all SNF beneficiary days from July 1, 2014 through June 30, 2016 to determine whether the beneficiary day contained a ground ambulance claim line. The OIG excluded beneficiary days where the only ambulance claim line related to: (1) certain emergency or intensive outpatient hospital services or (2) dialysis services, as such ambulance transportation would be excluded from SNF Consolidated Billing.

The OIG determined that there were 58,006 qualifying beneficiary days during this period, corresponding to $25.3 million in Medicare payments to ambulance suppliers. The OIG then selected a random sample of 100 beneficiary days for review.  The OIG determined that 78 of these 100 beneficiary days contained an overpayment for the associated ambulance claims, as the services the beneficiary received did not suspend or end their SNF resident status, nor was the transport for dialysis. The OIG determined that ambulance providers were overpaid a total of $41,456 for these ambulance transports.  The OIG further determined that beneficiaries (or their secondary insurances) incurred an additional $10,723 in incorrect coinsurance and deductibles. Based on the results of its review, the OIG estimates that Medicare made a total of $19.9 million in Part B overpayments to ambulance suppliers for transports that should have been bundled to the SNFs under SNF Consolidated Billing regime.  The OIG estimated that beneficiaries (and their secondary insurances) incurred an additional $5.2 million in coinsurance and deductibles related to these incorrect payments.

The OIG concluded that the existing edits were inadequate to identify ambulance claims for services associated with hospital outpatient services that did not suspend or end the beneficiary’s SNF resident status, and which were not related to dialysis. The OIG recommended that CMS implement additional edits to identify such ambulance claims.

The OIG’s report prompted CMS to issue Transmittal 2176 in November 2018.  This transmittal instructed the CWF Maintainer and the Medicare Administrative Contractors (MACs) to implement a new series of edits, effective April 1, 2019.

Can you provide a simple overview of how these new CWF edits operate?

Before we turn to the new edits, I think it is important to understand that CMS has had long-standing edits to identify outpatient hospital services that should be bundled to the SNF under SNF PPS.  These edits work by comparing the Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes on the outpatient hospital claim to applicable lists of excluded codes.  To the extent the HCPCS or CPT code appears on the applicable list of excluded codes, the outpatient hospital claim will bypass the edit for SNF PPS, and be separately payable by the MAC.  To the extent the HCPCS or CPT code on the outpatient hospital claim does not appear on the applicable list of excluded codes, the claim will be denied as the responsibility of the SNF.  The new CWF edits for ambulance claims simply extend the existing process one step further, i.e., they compare the ambulance claim to the associated hospital claim.

Conceptually, the new edits “staple” the ambulance claim to the outpatient hospital claim, with our coverage piggybacked on whether the outpatient hospital claim is determined to be bundled or unbundled.

How would I identify a claim that is denied for SNF Consolidated Billing?

Typically, the denial will be evidenced by a Claim Adjustment Reason Code on the Medicare Remittance Advice.  The denial will typically appear as an “OA-190” code, with the following additional explanation: “Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.  The “OA” stands for “Other Adjustment,” and is intended to notify you that the SNF is the correct payer.  Note: in some instances, the denial may appear as “CO-190” on the remittance advice.  However, the effect of the denial is the same, i.e., they are indicating that the SNF is financially responsible for payment.

Frequently, the denial will be accompanied by Remittance Advice Remark Code “N106,” which indicates “Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF.  You must request payment from the SNF rather than the patient for this service.”

I have heard you refer to the new CWF edits as over-inclusive.  What do you mean by that?

When CMS elects to implement a new edit to the CWF, it has to make some decisions on how to structure the edit.  Two typical decisions that must be made are:

  1. Will the edit be conditional based on the submission of other Medicare claims? And
  2. Is the edit designed to be under- or over-inclusive?

For these purposes, a conditional edit is one where the coverage or lack of coverage depends, in part, on the claims submitted by other health care providers that furnished services to the same beneficiary (typically on the same date).  As you are probably aware, the Medicare rules for all Part B payments prohibit payment whenever the service has been paid for, directly or indirectly, under Medicare Part A.  Thus, all edits for hospital and SNF bundling are conditioned, in part, on the patient’s Part A inpatient status at the time of transport.

By contrast, an unconditional edit is one that operates the same regardless of other types of claims for the same patient.  For example, with respect to ambulance claims, the MACs medical necessity edits are unconditional, i.e., they apply to all ambulance claims, regardless of the patient’s inpatient status at a Part A facility.  The edits for origin/destination modifiers are another example of an edit that is typically unconditional.

In addition, CMS has to decide whether to make an edit under- or over-inclusive.  This is because no edit can be perfectly tailored to be applied to all qualifying claims, but no non-qualifying claims.  An “underinclusive” edit is one that is designed to identify the majority – – but not all – – of the claims that should be denied based on the edit criteria.  By contrast, an “overinclusive” edit is one that would deny not only all of the qualifying claims, but also some non-qualifying claims.

In many instances related to EMS coverage, the underlying facts and circumstances of the transport are ultimately what determines the coverage.  It is frequently difficult – – if not impossible – – to fully describe these circumstances with enough specificity on the electronic claim for CMS to perfectly apply its edits.  For that reason, CMS has historically elected to design its ambulance edits to be underinclusive.

Unfortunately, the new SNF edits are both conditional AND overinclusive.  To further complicate matters, they are not only conditioned on the claim of a single Part A provider, but two separate Part A providers, i.e., in order for the new edits to work properly, CMS is reliant upon information from both the SNF and the hospital to properly apply its new edits.

I recently received a denial for an emergency transport from an SNF to the hospital for an emergency room visit.  I thought emergency ambulance transports were excluded from SNF PPS?

They are. The denial was likely the result of your claim being submitted prior to Medicare’s receipt of the associated outpatient hospital claim.

As noted above, the new edits are both conditional and overinclusive.  In this context, they are designed to deny the ambulance claim UNLESS there is a hospital outpatient claim for that same patient with the same date of service.  If there is no hospital outpatient claim on file when your ambulance claim hits the system, the edit indicates that the MAC should deny your claim for SNF PPS.

OK, that makes some sense.  Does that mean I have to appeal the denial?

In theory, no.  The instructions in Transmittal 2176 make clear that the CWF should “adjust” the ambulance claim upon receipt of the associated hospital claim.  For these purposes, that adjustment should take the form of re-processing the ambulance claim through the edits to compare it to the associated hospital claim, and to bypass the new CWF edits if the hospital claim contains an excluded code.

However, there is no timeframe for how quickly these adjustments should take place.  Most ambulance providers are reporting that they are seeing few, if any claims, being reprocessed.

I submitted several claims without knowing the patient was in the Part A Period of an SNF stay.  These claims were initially paid, but a few days later, I received a recoupment request from the MAC indicating that the claim was the responsibility of the SNF under SNF PPS. 

As noted above, the edits were designed to deny claims to the extent CMS was unable to determine whether they should be bundled to the SNF, i.e., to deny if the associated hospital claim was not already in the system.  Therefore, in theory, it should be impossible for the ambulance provider to receive a payment and then a recoupment for SNF PPS.

I suspect the situation described above is one where the ambulance claim is submitted prior to CMS’ receipt of the associated SNF claim for the patient.  As noted above, in order for the edits to work properly, both the associated hospital and SNF claims must be in the system.  While CMS clearly contemplated the possibility that the ambulance claim might be submitted prior to the associated hospital claim, they do not appear to have considered the possibility that the ambulance claim might beat the associated SNF claim into the system.

When that happens, there is nothing in the CWF to indicate that the patient was in a Part A SNF Stay.  As a result, the claim bypasses these new edits entirely, and frequently ends up being paid by the MAC.  I suspect what happens next is that the SNF claim hits the system, and triggers CMS to automatically recoup the payment for the ambulance claim.

What should happen at that point is the ambulance claim should then be run through the new edits.  If the hospital claim is already in the system, the ambulance claim gets “stapled” to that claim, and then either passes the edit or gets denied based on the information on the hospital claim.  If the hospital claim is not in the system, the ambulance provider gets the “interim” denial discussed above, and the claim should be further adjusted if and when the hospital claim is submitted.

However, at this point, it is entirely possible that these claims are not being put through the edit.  The AAA has asked CMS to look into whether the new edits are working as intended in these situations.

This sounds like a complete mess:  

Not really a question, but you are not wrong.

This sounds extremely complicated.  Is there anything I can do to reduce the possibility that my claims get denied?

I think it is important to distinguish between: (1) denials that are correct based on the HCPCS or CPT codes on the associated hospital claim and (2) denials that are based solely on the timing of your claim, i.e., denials based on your claim being submitted prior to the submission of the associated hospital claim.  For these purposes, I will refer to the latter category as “interim denials.”

At the onset, I think all members should recognize that there is nothing you can do to eliminate denials for claims that are properly bundled to the SNF based on the HCPCS or CPT codes on the associated hospital claim.

For numerous reasons, I think the proper focus should be on reducing the interim denials.  First and foremost, the difficulty with an interim denial is that you don’t know whether that denial will ultimately prove to be correct, or whether the claim will ultimately be reprocessed and paid by the MAC.  Second, even if the claim will be reprocessed, there currently appears to be a significant delay in “when” that reprocessing takes place.  Finally, without knowing whether the claim will be reprocessed (and whether that reprocessing will result in a payment), you can’t know whether you should be billing the SNF.

What information would be helpful in reducing these interim denials?

You would need to know the following data points prior to the submission of your claim:

  1. Whether the patient was in a Part A SNF Stay on the date of transport?
  2. What was the specific procedure/service the patient received at the hospital?

If you knew with certainty that the patient was not in the Part A Period of their SNF stay, you would know that the new edits would be inapplicable to your claim, and you could submit it to Medicare as part of your normal billing workflow.

If you also knew the specific procedure/service the patient received at the hospital, you would also be in a position to know whether the service was the financial responsibility of the SNF, assuming the patient was in the Part A Period.  When you know the claim is the financial responsibility of the SNF, you could then immediately invoice the claim to the SNF.  If your arrangement with the SNF requires you to first obtain a Medicare denial, you would also have the option of submitting the claim and getting the proper OA-190 denial, and then invoicing the SNF. Note: in these situations, you would receive the oA-190 denial regardless of whether your claim was submitted prior to the hospital claim.

By contrast, when you know the patient is in the Part A Period AND the procedure/service is one that would be excluded from SNF PPS, you can avoid the interim denial by ensuring that your claim is not submitted until after the associated hospital claim. In other words, this is a situation where holding your claim for a reasonable period of time might be beneficial.

We currently ask the SNF to provide information on the patient’s Part A status.  However, they frequently tell us that they don’t know, or that we are not entitled to this information.  What can we do?

First, they are absolutely permitted to share this information with you.  Both you and the SNF are “covered entities” under the HIPAA Privacy Rule.  In this instance, information on the patient’s Part A status would be helpful to you in managing your payment practices.  The regulations at 45 C.F.R. 164.506(c)(3) permit one covered entity to share protected health information with another covered entity for the payment activities of that entity.

However, it is important to note that, while the SNF may share that information with you, the Privacy Rule does not require them to provide you with this information absent a written authorization from the patient.

This information is critical to navigating the new edits.  If you haven’t been asking for it up until this point, I would strongly encourage you to consider having a discussion with the local SNFs to explain why you will be asking for this information in the future.  You may also want to consider developing a specific form that they must complete (similar to the PCS form) that would provide this information.

We have asked for this information in the past, and are typically told that if we continue to ask, the SNF will consider using our competitor, who doesn’t ask too many questions. 

I understand.  I would try to explain to the SNF that the reason you are asking for this information is to be able to make an intelligent determination on whether the transport is likely to the be financial responsibility of the SNF.  This information allows you to avoid denials in certain instances where they would otherwise not be responsible.  If they don’t provide you with this information, the foreseeable consequence is that you will end up getting interim denials from Medicare, which may leave you no choice but to bill the SNF for the transport.

I feel bad for the person that asked the previous question.  Fortunately for me, we are the only ambulance provider in the area, so the threat of going to a competitor rings a bit hollow.  Do I have any additional options to get this information?

You do.  I would try to insert language into your agreements with the SNFs that obligate them to provide you with this information.  You could also try to insert language that makes them financially responsible whenever they fail to provide this information.

We don’t have agreements with the local SNFs.  Do we need an agreement?

One of the foreseeable consequences of this new edit is that it will increase the frequency with which you bill the SNFs.  One of the most common complaints I hear is that SNFs refuse to pay their bills.  In most instances, the problem is that the ambulance service lacks a written agreement with the SNF, and, as a result, they frequently end up in disputes about when the SNF is responsible.  A written agreement that clearly spells out when the SNF is responsible can not only minimize the potential for misunderstandings, but also afford you greater remedies when the SNF refuses to pay.

With respect to the new edits, what should that agreement say?

You should consult with your local attorney regarding the applicable language.  However, conceptually, you want to include language that indicates that a Medicare denial is conclusive evidence that the SNF is financially responsible.  This provision could then go on to provide that, in the event Medicare should reprocess and pay a particular claim, then you would refund the SNF’s payment.

What can I do to help the AAA in minimizing the administrative burden associated with these new edits?

The AAA is currently conducting a survey of members to help get a sense of the magnitude of the issues created by these new edits. If you would like to participate in the survey, you can click here.

Take the Survey

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

ET3 Model Application Portal Now Open

Emergency Triage, Treatment and Transport (ET3) Model Application Portal is Now Open!

On August 5, 2019, the Center for Medicare and Medicaid Innovation (CMMI) announced that it had opened its Request for Application (RFA) Online Portal. The Online Portal can be found on the ET3 Model website. The Online Portal can also be accessed directly by clicking here.

As a reminder, CMMI will be hosting a webinar about the Online Portal on Thursday, August 8, 2019.  This webinar will take place from 12:00 p.m. to 1:30 p.m. EDT. If you are interested in participating in this webinar, you can register by clicking here.

Ambulance Cost Collection Rule Summary

The proposed rule sets the foundation for the data collection system for ground ambulances.  It proposes a stratified random sample method, that is very similar to the one the AAA proposed via the work we commissioned through The Moran Company. We are working through the stratification categories, which are slightly different than those we identified.

CMS also proposes the cost and revenue data elements it plans to use.  There are some details in the proposed rule text and others will be in the proposed tool that will be posted the CMS website today.

CMS also proposes the collection period and penalties for failing to report.

While the data collection provision was the key component for ground ambulance services, CMS also proposed changes to the PCS requirement sought by the AAA. CMS is proposing to reference the PCS also as non-physician certification agreements. The agency is further proposing to clarify that the focus is on the certification of the medical necessity provisions and the form of the certification statement is not prescribed.  As part of the non-physician statement, CMS is proposing expanding the staff of you may sign the statement when an attending physician is unable to sign.

Download Full PDF Summary by Kathy Lester, Esq.

CMS Releases Proposed Cost Collection Rule

Today, CMS has released the proposed rule that would establish the ambulance fee schedule cost collection system as required by statute. The AAA is currently reviewing the rule and will provide a more detailed summary in the coming days.

On Tueusday, July 30 at 12:00pm Eastern, the AAA will be hosting a free webinar during which AAA counsel will provide an overview of the proposals in the rule. Do not miss out on this chance for the most up to date information.

Read the Proposed Rule

Sign Up for the Webinar

Questions?: Contact Us:

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

House Energy & Commerce Subcommittee Takes Action on Balance Billing

On July 11, 2019, the House Energy and Commerce Committee Health Subcommittee held a markup in which they advanced 10 health care bills, including legislation on surprise/balance billing. This legislation, H.R. 3630, the No Surprises Act attempts to address out-of-network surprise medical bills. The AAA Government Affairs team has been in regular communication with the Energy and Commerce Committee and member offices leading up to the markup to ensure that the ground ambulance industry and AAA members were not negatively impacted by the legislation or any introduced amendments.

Thanks to the attentive efforts of AAA members, staff, and consultants, there was no mention of ground ambulance during the markup of H.R. 3630, the No Surprises Act. While ground ambulance was not mentioned, Rep. Lujan (D-NM) highlighted the air ambulance transparency language that is included in the No Surprises Act and called for it to be strengthened further before this legislation is considered by the full Energy and Commerce Committee.

Over the course of the markup, Subcommittee Chairwoman Eshoo (D-CA) thanked Rep. Lujan for bringing attention to the “extraordinary costs” associated with air ambulance. Rep. Ruiz (D-CA) then expressed his ongoing concerns regarding the balance billing provisions of the No Surprises Act, citing the experience to date under California’s law. Rep. Ruiz asked to continue working with the Committee to address these issues before the bill is considered by the full Committee.  In response, Chairman Pallone (D-NJ) noted that the Energy and Commerce Committee’s approach had bipartisan support within the committee, and that it also had bipartisan support in the Senate HELP Committee. While the Chairman expressed a desire to secure all Members’ support for the bill as it moves through the full Committee, he made no promises to further change the bill.

The educational efforts undertaken during the last several months appears to have helped the Members of the Energy and Commerce Committee to understand the complexities involved in the local control and oversight of ground ambulance services; however, the risk that the Congress could modify this approach to supporting local control remains as the legislation moves forward. The AAA Government Affairs team and Balance Billing Working Group will remain vigilant regarding all balance billing proposals in order to prevent any that would negatively impact AAA members and the ground ambulance industry.

CMMI Releases Preview of ET3 RFA

On May 22, 2019, the Center for Medicare and Medicaid Innovation (CMMI) released a preview of the Request for Applications (RFAs). This documentation will be used by ambulance providers and suppliers to apply for inclusion as “Participants” in the Emergency Triage, Treat, and Transport (ET3) pilot program.

Webinar: Learn More About the RFA

June 13, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Kathy Lester, Rebecca Williamson, Asbel Montes
$99 for Members | $198 for Non-Members

Register Now

Relevant Background

On February 14, 2019, CMMI announced the creation of a new 5-year pilot program designed to give participating EMS agencies greater flexibility to address the needs of Medicare beneficiaries following a 911 call. The ET3 model would create a new payment model under which participating EMS agencies will be eligible for Medicare reimbursement for: (1) transportation to alternative treatment destinations and (2) treatment at the scene. At the time, CMMI indicated that it anticipated starting the ET3 model in early 2020. To that end, CMMI anticipated soliciting Requests for Participation in the Summer of 2019.

Participation in this pilot program is voluntary. Regardless of whether an ambulance provider or supplier participates in the pilot program, payment for ambulance transportation currently covered under the Medicare Ambulance Fee Schedule will not be affected.

The RFA provides a good deal of additional information regarding the proposed operation of the ET3 Model. These additional details are summarized below.

Eligibility Criteria/Application Process

To be eligible to participate, you must be a Medicare-enrolled ambulance provider or supplier.  In addition, CMMI is limiting eligibility to ambulance providers and suppliers that are located in a state or state in which at least 15,000 Medicare FFS emergency ambulances took place in calendar year 2017.  Note: based on this restriction, ambulance providers and suppliers in the State of Alaska would not be eligible for participation in the ET3 Model.

Medical Necessity Requirement

CMMI previously indicated that the existing medical necessity requirements would apply to ambulance transportation to alternative treatment destinations. In the RFA, CMMI reiterated this requirement. As a result, EMS agencies will only be eligible for reimbursement for transportation to alternative treatment destinations to the extent the beneficiary’s condition is such that safe transport by other means is contraindicated.

CMMI indicated that beneficiaries that do not meet the medical necessity requirements for ambulance transportation may still meet the medical necessity requirements for a Medicare-covered item or service furnished by a qualified health care practitioner, and, therefore, may allow an EMS agency to receive payment for treatment at the scene under the ET3 Model.

Payments under the ET3 Model

The ET3 Model provides for a number of new payment streams.  The two payment streams being made available to participating EMS agencies are: (1) payment for transportation of Medicare beneficiaries to alternative treatment destinations and (2) payment for treatment of the Medicare beneficiary at the scene, where such care was rendered by a qualified health care practitioner either at the scene or via telehealth.

Payment for Transportation to Alternative Treatment Destinations

When the ET3 Model was first announced, CMS indicated that the reimbursement to EMS agencies for providing transportation to alternative treatment destinations would be based on the corresponding BLS “base rate” in the area. However, in the RFA, CMMI indicates that the payment for transportation to an alternative treatment destination will now be made at either the applicable BLS emergency or ALS emergency base rate.  In order to qualify for payment at the applicable ALS emergency rate, the EMS agency must meet Medicare’s definition of “Advanced Life Support” (i.e., the provision of valid ALS intervention and/or the provision of a qualifying ALS assessment).  The payment for this base rate would include the current adjustments for transports provided in urban, rural, or super-rural areas.

The EMS agency would also be eligible for payment for all loaded mileage, at the applicable Medicare mileage rate. This payment would include all current adjustments, including the “bonus” paid for the first 17 rural miles.

Note: CMMI indicated that it would be creating an exception to general Medicare requirement that patients be transported to the nearest appropriate facility. Based on the language in the RFA, it appears clear that CMMI would cover all of the mileage to an alternative treatment destination, even where transportation to the nearest hospital ED would have been shorter.

Based on the language in the RFA, it appears that claims for transportation to alternative treatment destinations will be submitted using the normal ambulance HCPCS codes (i.e., A0427 for an ALS emergency and A0429 for a BLS emergency).

Payment for Treatment at the Scene

When the EMS agency facilitates in-person treatment by a qualified health care practitioner (QHP), the EMS agency will be paid an amount equivalent to the BLS emergency or ALS emergency base rate.  In order to qualify for payment at the applicable ALS emergency rate, the EMS agency must provide medically necessary supplies and services and either a qualifying ALS assessment or the provision of at least one ALS intervention. When the EMS agency facilitates treatment in pace via telehealth, the EMS agency will be paid a modified “telehealth originating site facility fee” equivalent to the applicable BLS emergency or ALS emergency base rate.

Claims submitted for treatment at the scene, whether by the QHP in person or via telehealth, will be submitted using a model-specific code (yet to be announced).

Performance-Based Payment Adjustment for EMS Agencies

EMS agencies that provide transportation to alternative treatment destinations and/or treatment at the scene may be eligible for performance-based payment adjustments of up to 5%, based upon meeting certain performance and reporting metrics. These adjustments will become available no earlier than Year 3 of the ET3 Model, and are not guaranteed.  Performance-based payment adjustments would be based on performance during the previous year (e.g., if the EMS agency meets the performance criteria in Year 3, it would see an increase in Year 4). These performance-based payment adjustments apply only to payments under the ET3 Model, i.e., they do not apply to Medicare payments made under the current Medicare Ambulance Fee Schedule.

Payment for Non-Participant Partners

When an EMS agency transports a patient to an alternative treatment destination, that facility will bill Medicare for the services it renders to the beneficiary using its normal claims submission procedures.

Payment for Qualified Health Care Practitioners

A QHP that partners with an EMS agency to provide treatment at the scene will bill Medicare using the applicable HCPCS code for the services it furnished under existing Medicare FFS rules.  When that service is furnished via telehealth, the QHP must submit a claim to Medicare for telehealth services furnished from the distant site.  QHPs that provide services to Medicare beneficiaries during non-business hours (defined as being from 8:00 p.m. to 8:00 a.m. local time) will be eligible for a 15% increase in the payment rates normally applicable to their in-person or telehealth services.

Notice of Funding Opportunity for 911 Dispatch Centers

Separate from the RFA process, CMMI expects to allocate funding to governmental entities and their designees that operate 911 dispatch centers.  The purpose of this funding is to support the successful implementation of medical triage lines integrated into the local 911 system.  These Notice of Funding Opportunity (NOFOs) will be released following the first round of Participant selection (i.e., likely in the Fall/Winter of 2019).

Application Timelines

The RFA is the first of up to three potential RFAs that will be used to select EMS agencies to participate in the ET3 Model as “Participants.” CMMI is indicating that it hopes to select enough EMS agencies to participate to capture up to 30% of the existing volume of Medicare FFS emergency ground ambulance transports. Additional RFAs will be considered based on available funding and evidence that the ET3 Model is working as intended.

CMMI is not currently accepting applications. Round 1 applications will be accepted via an application portal that will be opened at a later date. Information on the applicable process, including the date the application portal will be opened will be posted on the ET3 Model website: https://innovation.cms.gov/initiatives/et3

Application Submission Process

If you elect to apply for participation in the ET3 Model, you will be required to identify a “region” in which you propose to implement the model. CMMI indicates that this region should be a county or equivalent entity, or multiple counties or equivalent entities.

In selecting Participants, CMMI indicated that it will give preference to applicants who propose a region that includes at least one county (or county-equivalent) where at least 7,500 Medicare FFS emergency ground ambulance transports occurred in 2017. CMMI provided a list of the number of Medicare FFS emergency ground ambulance transports that occurred in each county (organized by state)  That list can be obtained by clicking here.

Applicants will be required to participate in the transportation to alternative treatment destination (ATD) portion of the program. Applicants will have the option – – but not be required – – to propose the creation of a program to provide treatment at the scene in conjunction with QHPs.  Note: CMMI indicated that applicants that elect to implement the treatment at the scene intervention will earn additional points towards their overall application score.

In order to implement the ATD portion, you will be required to partner with alternative destination sites (e.g., Urgent Care Centers), which must be enrolled in Medicare or employ or contract with Medicare-enrolled practitioners, and which must be able to accept and treat Medicare FFS beneficiaries.  If you elect to implement the treatment at the scene portion, you must also partner with QHPs to provide treatment at the scene. These contractual partners are referred to in the RFA as “Non-Participant Partners” (NPPs). To qualify, you must contract with NPPs that can ensure the availability of services for ET3 Model beneficiaries on a 24 hours per day, 7 days a week basis. CMMI will have the right to accept or reject a proposed Non-Participant Partner.

Applicants will also be required to describe their strategy for engaging other payers in their proposed service area, or explain how they can successfully implement the model for Medicare FFS beneficiaries only.

Accountability and Performance Metrics/Ongoing Educational Commitments

Participants in the ET3 will be required to report certain metrics to CMMI and its contractors. You will also be required to participate in what CMMI is calling a “Learning System.”  This is a structured approach to sharing, integrating, and actively applying quality improvement concepts, tactics, and lessons designed to improve the likelihood of success of the model. At a minimum, this will include consistent participation in monthly ET3 Model learning activities, and participation in at least one in-person event, with the location to be determined by CMMI at a later date.

The above is a brief summary of the new information available regarding the ET3 Model. It is not intended to be a complete discussion of all of the requirements for participation. AAA Members are strongly encouraged to read the RFA for themselves to determine whether they want to participate in the ET3 Model.

CMS Releases ET3 Request for Applications (RFA)

Just minutes ago, the Centers for Medicare & Medicaid Services (CMS) announced the release of the Request for Applications (RFA) for the Emergency Triage, Treat, and Transport (ET3) Model. The RFA can be found here.

CMS is not accepting applications at this time but has released the RFA so that those ambulance services thinking about submitting an application can review it. In the notice, CMS also shared some FAQs on ET3.

The AAA team is currently reviewing the RFA and will be sending out a notice with additional details shortly.

New SNF PPS Edits Highlight the Importance of Facility Agreements

On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that are intended to better identify ground ambulance transports that are furnished in connection with an outpatient hospital service that is properly bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime.

These edits work by comparing the ambulance claim to the associated outpatient hospital claim.  Hospital claims were already subject to CWF edits designed to identify outpatient hospital services that should be bundled to the SNF.  These hospital edits operate by referencing a list of Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes that correspond to outpatient hospital services that are expressly excluded from SNF Consolidated Billing.  Hospital claims for outpatient services that are submitted with one of these excluded codes bypass the existing CWF edits, and are then sent to the appropriate Medicare Administrative Contractor for further editing and payment.  Hospital claims submitted without one of these codes are denied for SNF Consolidated Billing.

The new ambulance edits will extend these process one step further.  The ambulance claim will be associated with the outpatient hospital claim on the same date.  To the extent that hospital claim is bundled under SNF Consolidated Billing, the associated ambulance claim will also be bundled.  To the extent the hospital claim is unbundled, the associated ambulance claim will be unbundled.

In order for these new edits to work properly, there must be an outpatient hospital in Medicare’s claim history. If the ambulance claim beats the hospital claim into the system, the ambulance claim will be rejected. If and when an outpatient hospital claim with the same date of service enters Medicare’s system, the initial rejection of the ambulance claim will be overturned, and the ambulance claim will be reprocessed using the same edits.

It is important to note that the new edits were designed to reject the ambulance claim as a bundled service unless the hospital claim indicates that it should not be bundled.  In other words, these edits are designed to be “over inclusive.”  This over-inclusiveness creates the potential for ambulance denials in situations that, on their face, would not appear to be bundled.

A few examples will help illustrate this point. Imagine a situation where the patient elects, for whatever reason, to pay out-of-pocket for their hospital care (in a situation where that care would not be bundled to the SNF), and, as a result, the hospital does not submit a bill to Medicare for its services.  Based on how the new edits are designed, your ambulance claim for the transport to that excluded service will be rejected based on the lack of a hospital claim. Or maybe the patient has both Medicare and the V.A., and has elected to have the V.A. be the primary payer for their required hospital care.  Again, there would likely be no outpatient hospital claim submitted to Medicare on that date of service, resulting in the rejection of your ambulance claim.

I can see your point, but those examples are pretty far-fetched.  How big an issue is this really?

I agree those examples are pretty far-fetched.  However, there are other situations that create the same problem.  For example, what about an emergent response to transport an SNF patient to the hospital for necessary emergency services?  Imagine if you are called to respond late at night (e.g., 11:30 p.m.) tonight.  Now imagine that, by the time you get to the patient, load them into the vehicle, and transport them to the ED, it has crossed over midnight into the next day.

What date of service is going to be on the hospital’s claim?  Almost certainly, the hospital will use tomorrow’s date.  As a result, when your claim hits Medicare’s system, there will not be an associated hospital claim, which will result in your claim being rejected as the responsibility of the SNF.  In this situation, Medicare’s edit has worked as intended, but the result is the denial of a claim that should be separately payable by Medicare Part B.

Okay, I can see how this might be annoying,
but I can appeal the claim and likely win on appeal, right? 

Yes and no.  The problem is that you are not likely to win on either of the first two levels of appeal, as they are likely going to rely upon the information in the CWF.  I can see you possibly winning your appeal at the ALJ level…5 to 7 years from now.

In other words, the appeals process is unlikely to provide an acceptable resolution.  Instead, I think the majority of ambulance providers are going to look to the SNFs to make good in these situations.  Of course, the SNFs are likely going to disclaim liability, arguing (correctly) that ambulance transportation to an ED is an excluded service.

This is where the agreement with the SNF comes into play.  One key purpose of contracts is to allocate known risks between the parties.  In this instance, the “risk” that needs to be addressed is the possibility that Medicare might incorrectly reject your claim thinking it is bundled to the SNF.  I would argue that this risk should be absorbed by the SNF.  The transport to the ED should have suspended the patient’s SNF stay, which would have allowed you to receive a separate payment from Medicare.  However, the fact that your claim was rejected is proof positive that the CWF does not reflect the suspension of the patient’s SNF stay.  Indirectly, it also serves as proof that the SNF received a per diem payment for the patient on that date.  To me, the fact that they accepted the per diem payment means they accepted the risk of a bundled ambulance service on that date.  I would also argue that it was their failure to properly suspend the patient’s SNF stay that set in motion your denial.  Either way, I would be looking to the SNF for payment.

Based on my experience, the typical agreement with an SNF does not address this situation.  Frequently, these agreements do not even address the specifics of SNF Consolidated Billing.  Instead, I tend to see general language indicating that the ambulance provider will bill the SNF when payment responsibility lies with the SNF under an applicable federal or state health care program.  I doubt that language is going to convince an SNF to take financial responsibility for the situation discussed above.

The good news is that your existing agreements can easily be revised to address this situation.  The language I would recommend is something along the lines of:

“The parties acknowledge and agree that a denial from Medicare for SNF consolidated billing shall constitute conclusive evidence that a transportation service is the financial responsibility of the facility.” 

In sum, the new SNF Consolidated Billing edits are going to increase the frequency with which we are forced to look to the SNFs for payment.  In most instances, it will be a situation where the SNF is legally responsible under SNF Consolidated Billing.  However, there will also be situations where the over-inclusive nature of the edits results in the claim being incorrectly denied as the SNF’s responsibility.  The question becomes how you want to handle these incorrect denials.  Do you want to appeal and hope CMS reverses its decision?  Or do you want to hold the SNF responsible?  If you want to hold the SNF responsible, you will likely need to revise your agreements with the SNFs.

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

Member Update on Balance Billing

This morning Ruth Hazdovac and Aidan Camas of AAA staff and Kathy Lester, Esq, Healthcare Consultant to the AAA attended a briefing held by the House Energy & Commerce Committee on the issue of surprise/balance billing. At the briefing, staff for Chairman Frank Pallone (D-NJ) and Ranking Member Greg Walden (R-OR) announced that they would be releasing a bipartisan discussion draft, the No Surprises Act, which would “protect consumers from surprise medical bills and increase transparency in our health care system.”

As of now, ground and air ambulances are NOT included in the discussion draft. However, the committee is asking for comments on ground and air ambulance and recommendations on how to provide relief to the consumer in this area. The AAA has a Balance Billing Work Group that is hard at work developing a policy recommendation that will work for our members.

The House Ways and Means Health Subcommittee Chairman Lloyd Doggett also announced today that the Health Subcommittee will hold a hearing next week entitled “Hearing on Protecting Patients from Surprise Medical Bills.” AAA Staff will be at the briefing and provide a timely update to membership on any developments.

The AAA team will be submitting comments and policy recommendations based off the work of the Balance Billing Work Group to both the Energy & Commerce and Ways & Means Committee to ensure that the views of our members are well represented. We will also be reaching out to AAA members in the states of key policymakers on the Committees to submit comments, as well. The AAA will also provide members with key talking points in the event they are contact by their Members of Congress or their staff.

Questions? Contact Us

If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

Summary of March 28, 2019 Ambulance ODF

The Centers for Medicare and Medicaid Services (CMS) held its latest Open Door Forum on Wednesday, March 28, 2019.  As with past Open Door Forums, CMS started the call with the following announcements:

  1. Ambulance Cost Data Collection – CMS reminded the industry that the Bipartisan Budget Act of 2018, enacted on February 9, 2018, requires CMS to create a new cost data collection system by December 31, 2019.
  2. Emergency Triage, Treat, and Transport Model – A representative from the Innovation Center within CMS provided an overview of the “Emergency Triage, Treat, and Transport Model” or “ET3.” This is a 5-year pilot program intended to provide ambulance providers with greater flexibility to handle low-acuity 911 calls, by providing Medicare payment for: (a) ambulance transportation to alternative treatment destinations and (b) treatment at the scene. The CMS representative indicated that CMS is in possession of data that suggests that 16% of emergency ambulance transports to a hospital emergency department could have been resolved by transporting the patient to an alternative treatment site, e.g., an urgent care center. CMS estimates that had all of these patients elected to receive care in the lower-acuity setting, it would have saved the Medicare Program approximately $560 million each year. With respect to the operation of the model itself, CMS essentially repeated the information that had been previously provided on its webinars. You can view the AAA Member Advisory on the ET3 Model by clicking here.
  3. Ambulance Inflation Factor – CMS reiterated that the 2019 Ambulance Inflation Factor is 2.3%.

Following the announcements, CMS moved into a Question & Answer period. The majority of the questions related to the ET3 pilot program. As is typical, many questions were not answered on the call; instead, CMS asked the individual to submit their question in writing. However, the following questions were answered on the call:

  1. Payment Rates under ET3 – CMS was asked whether the BLS base rate payment would be the BLS emergency base rate. It was not clear that the CMS representative fully understood the question, although she indicated that it would.
  2. Eligibility for Government Agencies – CMS was asked whether governmental agencies that operate 911 centers would submit applications to participate as part of the RFA process in the Summer of 2019. CMS responded that governmental agencies that operate 911 centers would not submit RFAs, but would rather wait for the Notice of Funding Opportunity (NOFO), which will be issued after the ambulance providers and suppliers are selected for participation (expected to be the late Fall/Winter of 2019). CMS further confirmed that if the governmental agency also operated its own ambulance service that it would be eligible to apply for both aspects of the ET3 Model.
  3. Limit on Ambulance Providers – CMS was asked whether it would cap the number of ambulance providers and suppliers selected to participate in the program. CMS responded that, at the present time, it has no intent to cap the number of participating ambulance providers and suppliers at any specific number.
  4. Return Transports from Alternative Treatment Destinations – CMS was asked whether the model would provide for ambulance payment for the return transport after a patient was transported to an alternative treatment site. CMS indicated that the model does not provide for payment for the return transport.
  5. Definition of “Telehealth” – CMS confirmed that the model will use the same definition of “telehealth” used in other areas of the Medicare Program. CMS further confirmed that telehealth encounters require both audio and video connections.
  6. Approval of Alternative Treatment Sites – CMS confirmed that state and local regulatory agencies would have final approval over acceptable alternative treatment sites.
  7. Qualified Health Care Practitioner – CMS confirmed that a “qualified health care practitioner” would be an individually enrolled Medicare practitioner, which includes physicians and nurse practitioners. In some instances, it can also include physician’s assistants. CMS confirmed that the definition would not include registered nurses or advance scope paramedics.
  8. NOFO Funding – CMS indicated that, at the present time, it is not prepared to release additional details on the nature or size of the funding opportunities available to governmental agencies and their designees that operate or have authority over 911 centers.
  9. Medicare Advantage and Other Payers – CMS confirmed that the ET3 Model applies only to Medicare beneficiaries enrolled in FFS Medicare. It does not apply to Medicare Advantage enrollees, Medicaid recipients, etc.

Questions? Email Brian at bwerfel@aol.com

UPDATED: CMS Open Door Forum – Thursday, March 28

The Centers for Medicare and Medicaid Services has scheduled its next Ambulance Open Door Forum for Thursday, March 28 at 2:00 PM Eastern. If you plan to attend, please dial in at least 15 minutes before the call.

CMS Ambulance Open Door Forum

March 28 | 2:00 PM ET
Participant Dial-In Number:  1-800-837-1935
Conference ID #: 6695896

Questions?

Have more questions? The AAA is here to help! Following the ODF the AAA will be publishing a follow up blog post going over any updates and important announcements.

Update on New SNF Edits

CMS Set to Implement New Common Working File Edits to Identify Ambulance Services Provided in Connection with Outpatient Hospital Services that should be bundled to the SNF under Consolidated Billing.

In a Member Advisory issued last week, the AAA provided an update on a series of new Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019. 

In our discussion of the implementation specifics, we attempted to answer the question of what would happen when an ambulance claim is submitted prior to the receipt of the associated hospital outpatient claim, and where the associated hospital claim eventually hit Medicare’s system. Specifically, we indicated as follows:

“The Transmittal contains further instructions that the CWF be updated to identify previously rejected ambulance claims upon receipt of an associated hospital claim for the same date of service that contains an Exempted Code.  Once identified, the Shared System Maintainer (SSM) is supposed to adjust the previously rejected or denied ambulance claim.  At this point, the nature of that “adjustment” is unclear, i.e., it is unknown whether the SSM will automatically reprocess the ambulance claim for payment.  The AAA is seeking additional clarification from CMS on this important point.”

On March 15, 2019, CMS responded to our request for clarification. Specifically, CMS indicated that it has instructed the SSM and/or its Medicare Administrative Contractor (MAC) to automatically reprocess claims that were rejected for lack of an associated hospital outpatient claim.

Upon reprocessing, the claims will pass the edits to the extent the associated hospital claim contains a HCPCS or CPT code that indicates that the hospital outpatient service was excluded from SNF Consolidated Billing. Such claims would then be forwarded to the MAC for further editing, and either paid or denied. By contrast, when the associated hospital outpatient claim contains HCPCS or CPT codes that suggest the hospital services should be bundled to the SNF, the claim will be reprocessed and denied by the MAC with a remittance advice code indicating that the SNF is financially responsible.

AAA Webinar on New SNF Consolidated Billing Edits

March 27, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Esq.
$99 for Members | $198 for Non-Members

Join AAA Medicare Consultant Brian Werfel, Esq., to go over the new SNF Consolidated Billing edits that go into effect April 1, 2019. These edits are being implemented by CMS in response to 2017 investigation by the HHS Office of the Inspector General that determined that CMS lacked the appropriate claims processing edits to properly identify ambulance transports provided in connection with hospital outpatient services that are not expressly excluded from SNF PPS. The implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on what to do with these claims moving forward. Sign up today to make sure your service is ready!

Register for the Webinar