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GAPBAC Balance Billing Report Released to Congress

Written by Shawn Baird on . Posted in Executive, Legislative, Private Insurance, Regulatory, Uncategorized.

Read Full GAPBAC Report to Congress

A Message from GAPBAC Committee Member Shawn Baird

Please see below for a video message from former American Ambulance Association President Shawn Baird, who participated on the Ground Ambulance Patient and Billing Advisory Committee. A formal analysis of the complete report to Congress is forthcoming.

Video Transcript

Hello, I’m Shawn Baird, past president of the American Ambulance Association.

Together with my fellow ambulance profession representatives Ted Van Horne, Regina Crawford, and Rhonda Holden, I was privileged to speak on behalf of AAA members and the EMS profession as a whole during the deliberations of the Ground Ambulance and Patient Billing Advisory Committee, also known as GAPBAC.

Today, I’m excited to share with you the culmination of our efforts—the release of a report to Congress that could transform how ground ambulance services are reimbursed, ensuring better protection for patients against surprise medical bills as well as fair compensation for the essential mobile healthcare we deliver daily.

We know that the patient care and transport we provide every day, 24/7, is vital to the health and welfare of our communities. In many parts of the country, we are the only healthcare available within hours. I am excited that if Congress acts on these recommendations, patients can not only continue to depend on our vital care, but also be relieved of the financial stress of the unknown bill when insurance falls short of appropriate payment. Quite frankly, if adopted by Congress, these recommendations would take patients out of the middle between providers and insurers, and free us to remain focused on what we do best; taking care of patients, 24/7.

Let me rewind a bit and give you the full context for this report.

GAPBAC was formed following the American Ambulance Association’s successful advocacy efforts to carve ground ambulance services out of the No Surprises Act. Through the dedication of AAA volunteer leaders made possible by your dues investment, we were able to successfully educate legislators about the unique nature of EMS. We effectively highlighted our inability to pick and choose patients, our role as the safety net provider in rural and medically underserved urban areas, as well as our sky-high costs of readiness. Instead of rolling ambulance services into a one-size-fits-all healthcare billing scheme that wouldn’t work for EMS, legislators had the vision and foresight to create the GAPBAC committee.

The group’s charter was signed in November 2021, and the roster was announced in December 2022. We are proud that former American Ambulance Association board member Asbel Montes was selected to take the helm as Chair.

Since then, our committee, composed of patient advocates, physicians, EMS experts, government officials, and insurance industry representatives, has worked collaboratively to address a critical issue—out-of-network billing for ground ambulance patients covered by non-ERISA health plans.

This discussion presented an extraordinary challenge as ambulance services face skyrocketing costs, flat reimbursement from Medicare, and an unprecedented workforce shortage. At the same time, our patients were sometimes confused by the complex health insurance landscape including copays, deductibles, and policy limitations.

But the GAPBAC panel, with the help of experts including AAA’s own Kathy Lester, persevered. Through research, dialogue, and compromise, GAPBAC’s team members developed 14 key recommendations that, if adopted by Congress, would protect patients, financially sustain EMS, enhance transparency, and empower state and local governments to determine fair reimbursement rates for their residents.

While I urge you to read the report to Congress in its entirety, rest assured that the AAA advocacy team will soon share a concise summary with our membership.

As I mentioned, the release of this report has been no small task. The collaboration across various stakeholder groups was unprecedented in EMS history, and every voice brought valuable insights, driving us toward solutions that consider all perspectives on the complex mobile healthcare reimbursement landscape. Together, we’ve laid down a framework that I believe will lead to significant improvements, ensuring that millions more Americans are fully covered during some of the most critical moments of their lives.

As we present our final findings, I hope that the recommendations will be met with thoughtful consideration by Congress and regulators—the well-being of our patients and the integrity of our out-of-hospital healthcare system depend on it. Thank you to American Ambulance Association President Strozyk, the AAA board and committee chairs, and you, the AAA membership, for the overwhelming support through this journey. Together, we will continue to advocate for a sustainable future for EMS!

Shawn Baird
Immediate Past President
American Ambulance Association

 

What The Guardian Missed About US Ambulance Balance Billing

Written by Shawn Baird on . Posted in Advocacy Priorities, Executive, Legislative, News, Press, Private Insurance, Regulatory.

Media Response

The letter to the editor below was submitted to The Guardian on July 23, following the July 21 publication of the article referenced.

To the Editor of The Guardian,

On July 21, The Guardian published Jessica Glenza’s “Plan to end exorbitant ‘surprise’ ambulance bills heads to Congress.” The inflammatory title and lack of context do no justice to the years of bipartisan collaborative effort leading to the forthcoming report to Congress. As a member of the Advisory Committee on Ground Ambulance and Patient Billing (GAPB) and Immediate Past President of the American Ambulance Association, I believe it is critical to set the record straight.

It is essential to understand that EMS directly bills patients instead of insurers only as a last resort. Sadly, as a frequent entry point to healthcare, EMS often faces the unenviable task of educating people about their limited insurance coverage or high deductibles, both of which are out of our control. As mobile healthcare is entirely decentralized in the United States, it is often unfeasible for small or volunteer-staffed ambulance services to negotiate sustainable in-network rates with dozens of insurance plans. The GAPB Advisory Committee’s recommendations seek to remedy this foundational disconnect between patients, EMS providers, and health plans.

The article notes that some EMS providers are owned by private equity, but overlooks that the vast majority of ambulance services in the United States are small, often conducting only a few dozen patient transports per day. These community-based services—some of which are the sole healthcare provider for miles—face skyrocketing costs for wages, fuel, and medical supplies that threaten their ability to keep their doors open. The collaborative work of the GAPB Advisory Committee sought to address these challenges by proposing recommendations that, if adopted by Congress, would help alleviate these financial pressures while also enhancing patient protection from surprise insurance denials.

The article implies that Patricia Kelmar was the only representative of the public interest on the panel. In fact, another Committee participant was explicitly appointed to represent patient advocacy groups, and as healthcare providers, EMS professionals and physicians consistently advocate for our patients’ well-being. The committee’s composition, as established by Congress within the No Surprises Act, was intentionally diverse and included stakeholders ranging from physicians to elected officials to insurance providers to ensure balance.

Additionally, it is important to clarify that the Health Affairs research cited in the article does not provide data on actual balance bills received by patients. Rather, it roughly estimates only potential balance bills as calculated based on a flawed estimation process. Even if we were to accept Health Affairs estimates as fact, the average balance bill calculated according to their methods would be just a few hundred dollars. This is far from the sole and extreme outlier bill cited in the piece. This distinction is critical as it underscores the need for data-driven policy decisions based on real-world evidence rather than projections and one-off examples. 

Finally, the piece misses entirely the largest challenge with the Committee’s recommendations and their potential adoption by Congress. Based on longstanding legal precedent, ERISA plans, which cover about half of Americans through their employers, would not be bound by any legislation drafted based on our report. In Washington state and elsewhere, innovative “opt-in” clauses enable ERISA plans to voluntarily comply with state regulation. We encourage this and hope to see it replicated throughout the nation.

People become first responders because they have a passion for caring for others, and our communities trust them to do just that—24/7. Our Committee’s report to Congress includes 14 key recommendations designed to improve transparency, ensure fair reimbursement rates, and ultimately protect patients by strengthening state and local control. If these recommendations are adopted, they will help remove patients from the middle of billing disputes, allowing EMS providers to focus on our primary mission: delivering life-saving and life-sustaining healthcare around the clock.

For a detailed understanding of our recommendations and the Committee’s work, I encourage reading the full GAPB Advisory Committee report when it becomes available later this summer.

Shawn Baird
Immediate Past President, American Ambulance Association
Member, Advisory Committee on Ground Ambulance and Patient Billing
Portland, Oregon

HealthAffairs | Health Insurance Coverage Projections

Written by AAA Staff on . Posted in Private Insurance.

Health Insurance Coverage Projections For The US Population  And Sources Of Coverage, By Age, 2024–34

Abstract

In the Congressional Budget Office’s projections of health insurance coverage, 92.3 percent of the US population, or 316 million people, have coverage in 2024, and 7.7 percent, or 26 million, are uninsured. The uninsured share of the population will rise over the course of the next decade, before settling at 8.9 percent in 2034, largely as a result of the end of COVID-19 pandemic–related Medicaid policies, the expiration of enhanced subsidies available through the Affordable Care Act health insurance Marketplaces, and a surge in immigration that began in 2022. The largest increase in the uninsured population will be among adults ages 19–44. Employment-based coverage will be the predominant source of health insurance, and as the population ages, Medicare enrollment will grow significantly. After greater-than-expected enrollment in 2023, Marketplace enrollment is projected to reach an all-time high of twenty-three million people in 2025.

Read on HealthAffairs

CMS Announced Medicare Accelerated and Advance Payments in Response to Change Healthcare Cyberattack

Written by Brian Werfel on . Posted in News, Private Insurance.

On March 9, 2024, the Centers for Medicare and Medicaid Services (CMS) announced the creation of the Change Healthcare/Optum Payment Disruption (CHOPD) Program.  Under the CHOPD Program, CMS will make accelerated payments to Part A providers and advance payments to Part B suppliers that have experienced claims disruptions as a result of the Change Healthcare cyberattack.

Under the CHOPD Program, qualifying providers and suppliers will be eligible to apply for and receive Medicare advances of up to 30 days of their average Medicare payments.  Applications for payment advances must be made to the provider’s or supplier’s Medicare Administrative Contractor (MAC).  The 30-day payment advance will be based on the average Medicare payments to the provider or supplier between August 1, 2023 and October 31, 2023.  Specifically, CMS will compute the total amounts paid to the provider during this period, and then divide by 3 to arrive at the 30-day average amount.

Advance payments received through the CHOPD Program are considered a loan.  Therefore, these amounts must be repaid through offsets against future Medicare payments.  Recoupments will commence on the date the advance payments are received by the provider or supplier.  These recoupments will be equal to 100% of future payments, and will continue until the earlier to occur of: (1) the full repayment of the advance payment or (2) 90 days.  In the event a balance remains after 90 days, the MAC will generate a demand notice for the outstanding balance, which must be repaid within 30 days.  If the provider does not repay the outstanding balance within that period, interest will start to accrue on the outstanding balance.

Providers and suppliers with multiple National Provider Identifiers (NPIs) may be eligible for multiple advance payments.

Eligibility Requirements

To qualify for advance payments, a provider or supplier must meet the following requirements:

  1. Advance payments may be requested for individual providers or suppliers, i.e., a unique NPIs and Medicare ID (PTAN) combination.
  2. The provider or supplier must not currently be receiving Periodic Interim Payments.
  3. The provider or supplier must make the following certifications:
  4. The provider/supplier must certify that they have experienced a disruption in claims payment or submission due to a business relationship the provider/supplier has with Change Healthcare or another entity that uses Change Healthcare, or the provider’s/supplier’s third-party payers have with Change Healthcare or another entity that uses Change Healthcare.
  5. The provider/supplier must not be able to submit claims to receive claims payments from Medicare.
  6. The provider/supplier has been unable to obtain sufficient funding from other available sources to cover the disruption in claims payment, processing, or submission attributable to the cyberattack
  7. The provider/supplier does not intend to cease business operations and is presently not insolvent.
  8. The provider/supplier, if currently in bankruptcy, will alert CMS about this status and include case information.
  9. Based on its information, knowledge and belief, the provider/supplier is not aware that the provider/supplier or a parent, subsidiary, or related entity of the provider/supplier is under an active healthcare-related program integrity investigation in which the provider/supplier or a parent, subsidiary, or related entity of the provider/supplier: (1) is under investigation for potential False Claims Act violations related to a federal healthcare program; (2) is a defendant in state or federal civil or criminal action (including a qui tam False Claims Act action either filed by the Department of Justice or in which the Department of Justice has intervened; or (3) has been notified by a state or federal agency that it is a subject of a civil or criminal investigation or Medicare program integrity administrative action; or (3) has been notified that it is the subject of a program integrity investigation by a licensed health insurance issuer’s special investigative unit.
  10. The provider/supplier is enrolled in the Medicare program had has not been revoked, deactivated, precluded, or excluded by CMS or the HHS Office of the Inspector General.
  11. The provider/supplier does not have any delinquent Medicare debts.
  12. The provider/supplier is not on a Medicare payment hold or payment suspension.
  13. The provider/supplier will use the funds for the operations of the specific provider/supplier for which they were requested.

To the extent a provider or supplier is approved for an advance payment, they must then execute a Terms and Conditions document acknowledging the following:

  1. That the funds were advanced from the Medicare Trust Fund, and represent an advance on claims payments.
  2. The accelerated and advance payment is not a loan, and cannot be forgiven, indebtedness cannot be reduced, and there are no flexibilities regarding repayment timelines. CMSI will use its standard recoupment procedures to recover these amounts.
  3. Repayment will commence immediately via 100% recoupment of Medicare claims payment owed to the provider/supplier, as the provider/supplier submits claims and claims are processed, after the date on which the payment is granted. Recoupment will continue for a period of 90 days.
  4. A demand will be issued for any remaining balance on Day 91 following the issuance of the advance payment.
  5. Interest will start to accrue 30 days after a demand is issued consistent with the interest rate established under applicable interest authorities.
  6. CMS will proceed directly to demand the advance payments if any certifications or acknowledgements are found to be falsified.
  7. Grant of an advance payment is not guaranteed and payments will not be issued once the disruption to claims servicing is remediated, regardless of when a request is received. CMS may terminate the program at any time.
  8. CMS maintains the right to conduct post payment audits related to any advance payments issued under this program.

CMS Statement on Continued Action to Respond to the Cyberattack on Change Healthcare

Written by AAA Staff on . Posted in Legislative, News, Private Insurance.

From the Centers for Medicare & Medicaid Services on March 9

The Centers for Medicare & Medicaid Services (CMS) is continuing to monitor and assess the impact that the cyberattack on UnitedHealth Group’s subsidiary Change Healthcare has had on all provider and supplier types. Today, CMS is announcing that, in addition to considering applications for accelerated payments for Medicare Part A providers, we will also be considering applications for advance payments for Part B suppliers.

Over the last few days, we have continued to meet with health plans, providers and suppliers to hear about their most pressing concerns. As announced previously, we have directed our Medicare Administrative Contractors (MACs) to expedite actions needed for providers and suppliers to change the clearinghouse they use and to accept paper claims if providers need to use that method. We will continue to respond to provider and supplier inquiries regarding MAC processes.

CMS also recognizes that many Medicaid providers are deeply affected by the impact of the cyberattack. We are continuing to work closely with States and are urging Medicaid managed care plans to make prospective payments to impacted providers, as well.

All MACs will provide public information on how to submit a request for a Medicare accelerated or advance payment on their websites as early as today, Saturday, March 9.

CMS looks forward to continuing to support the provider community during this difficult situation. All affected providers should reach out to health plans and other payers for assistance with the disruption. CMS has encouraged Medicare Advantage (MA) organizations to offer advance funding to providers affected by this cyberattack. The rules governing CMS’s payments to MA organizations and Part D sponsors remain unchanged. Please note that nothing in this statement speaks to the arrangements between MA organizations or Part D sponsors and their contracted providers or facilities.

For more information view the Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/change-healthcare/optum-payment-disruption-chopd-accelerated-payments-part-providers-and-advance

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

Written by Amanda Riordan on . Posted in Advocacy Priorities, Balance Billing, News, Press, Private Insurance.

 

Read the full article

GAPBAC | Follow Up from Committee Meeting #2

Written by AAA Staff on . Posted in Advocacy Priorities, Executive, Government Affairs, Private Insurance, Regulatory.

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

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

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

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

 

FAIR Health | Ground Ambulance Services in the United States

Written by AAA Staff on . Posted in Balance Billing, Executive, Finance, Legislative, News, Press, Private Insurance, Regulatory, State-Level Advocacy.

From FAIR Health in February 2022

“Currently, no federal law protects consumers against “surprise” bills from out-of-network ground ambulance providers. Some state and local governments regulate ground ambulance surprise billing practices; however, such laws may not apply to all health plans or ambulance providers in an area. Because of the substantial policy interest in ground ambulance services, FAIR Health drew on its vast database of private healthcare claims to illuminate multiple aspects of such services across the nation, including utilization, costs, age, gender, diagnoses and differences across states.”

Download PDF Report

AETNA/CVS Deal Along with Uber Concepts May Finally Change Ambulance Industry

Written by Mark Postma on . Posted in Community, Government Affairs, News, Press, Private Insurance, Reimbursement.

Mark Postma, AAA President & Asbel Montes, AAA Payment Reform Chair

The recent merger of Aetna/CVS may be the catalyst that finally brings the change that the ambulance industry has been advocating for over the past several years. This new healthcare strategy supports the ambulance industry’s ideas that alternative patient destinations are needed in EMS.

To explain this better, one must understand the current state of ambulance reimbursement via the 911 system or equivalent. At this point in time most commercial payers of healthcare (Insurance) as well as Medicare will not pay for 911 ambulance transportation to any destination other than the “nearest appropriate” hospital based emergency room; arguably, the most expensive and least efficient form of healthcare. The continuation of this policy discounts the advanced capabilities of both EMS and new clinical settings and the savings that can be achieved through innovative change. In addition, at the same time that the cost of healthcare in general is increasing, reimbursement from all payers is decreasing, creating a significant challenge for providers. Medicare consistently pays providers below cost for providing life-saving services and state Medicaid agencies are consistently underfunding the critical services to the un- and under-insured populations that have allowed intermediaries to delay or not pay ambulance services.

Much of the U.S. population believes that vital 911 EMS services or the equivalent are provided free or included in their local property taxes. This is generally not the case. While EMS services must be at the ready on a 24/7/365 basis, they are not paid for being on call, but only when the service is used.

Many communities have governing rules that require 911, or the equivalent, paramedic services to arrive on-scene within 8-12 minutes of receiving the call. This cost of readiness is VERY expensive. Skyrocketing personnel costs, ambulances, equipment, and other high cost drugs only exacerbate an already fragile reimbursement structure. Although recent articles about calling Uber or Lyft sound intriguing, these drivers and cars are not prepared for any type of injury. Nor can they alert the hospital in critical situations to have the heart cath lab ready or a trauma surgeon on standby, shortening the time to definitive care when time matters most. Emergency paramedics are highly trained, are nationally and/or state certified, and provide services on state regulated ambulances equipped to manage all types of emergencies. Ambulances are also often strategically placed to arrive in that 8-12 minute response time requirement. However, there is one piece missing from the ambulance scenario that allows for Uber/Lyft to succeed; your personal credit card is on file with them. NO GUARANTEED PAYMENT, NO TRANSPORT. The cost of providing ambulance services “on call” with life-saving equipment, medications, and personnel at the ready is steep. When you consider the many regulations providers must adhere to outside of patient care, the cost increases even more. This misunderstanding of the cost often results in patients being stunned when they receive a bill for services provided and feel that it is excessive. However, comparing the cost of a life-saving ambulance transport to an Uber/Lyft ride is like comparing the cost of building a house to putting up a tent.

On the other hand, these highly trained paramedics, with vehicles that are comprehensively (medically) equipped to meet the highest safety standards, have no credit card on file. They do not treat you based on your ability to pay. In fact, approximately less than half of ambulance patients have insurance, and when commercial insurance does pay, they are increasingly paying only a percentage of the total bill, leaving their insured left to pay the balance. In a time of an emergency, insurers should not place an additional burden on their insured through underpayment or claiming out of network status. In addition, although many emergency 911 calls begin as a “frantic call for help,” not all are life threatening and require the highest level of care; however, they do need some type of a health care intervention.

It is this high volume of low acuity patients who do not have primary care physicians and who currently by law must be transported to hospitals that continue to bottleneck emergency rooms. This bottleneck then requires ambulances to be “on the wall” at local hospital emergency rooms. The cost to the 911 EMS system rapidly begins a domino effect where all the patients begin to be diverted/directed to other hospitals causing an overflow to the next hospital. In large EMS systems, this domino effect can bring emergency rooms at all available hospitals to capacity quickly. EMS units are unable to go on additional emergency calls because they are caring for a patient while waiting on hospital staff to become available to take over. They also cannot leave that hospital with the patient to go to another hospital due to federal laws that prohibit this movement.

So why does the AETNA/CVS excite the leaders of EMS organizations? Most people assume that since this acquisition just occurred, Walgreens will probably follow suit with another insurer. Other local pharmacy “CVS types” may partner with local hospitals or medical insurance cooperatives as well. This leads the ambulance industry to believe that the capacity to transport patients to alternative locations could greatly change the landscape of EMS. The idea that local CVS/Walgreens/clinics could receive low acuity patients breaks open the bottleneck and can provide several benefits for the ambulance service and patient. One benefit is that adding these stores/clinics greatly increases the resources for caring for low acuity patients and could potentially double the locations an ambulance can transport to, which will allow for quicker transport times and increase efficiencies. Lastly, and most importantly, diverting the low acuity patients to these additional community resources would reduce overflow in the emergency departments and allow true emergency patients to be transferred over more quickly to receive the higher level of care they require. This scenario is also a win for the patient. They could be transported to the most appropriate location to care for their needs and therefore can be billed more accurately for services they require rather than the emergency department fees which are usually costlier.

To make this happen, obviously the CVS system needs to evolve to receive these patients. More importantly, ambulance reimbursement by federal, state, and private payers must evolve to meet the demands of the market. Due to the complexities of how EMS services are provided because of state and local regulations, mandatory response times, service area parameters, and others, reimbursement for these services must be adequately paid for by Medicare, Medicaid, and private insurers. Today EMS agencies can only “hope” that their patients have a source of payment!

Although one would think that this state of concern for EMS services is being monitored, it currently has only a very small voice in the healthcare continuum. Federal agencies seem to want to look at what EMS will look like in 10 to 25 years rather than where EMS is today and where it can develop over the next few years. EMS reform needs to happen soon to save these systems from bankruptcy and/or the public from higher taxation.

We hope that this merger will be the beginning of alternative EMS/ambulance destinations with allocated reimbursements that meet the costs of providing high quality, efficient, and necessary 911 ambulance services.

Mark Postma, COO, Sunstar Paramedics
American Ambulance Association, President
Works for Sunstar Paramedics, Florida’s largest EMS provider
MPostma@sunstarems.com, 727-224-0295

Asbel Montes, Vice President, Acadian Ambulance Service, Inc.
American Ambulance Association, Chair-Payment Reform Committee
Works for Acadian Ambulance Service, Inc., Louisiana’s largest EMS provider
Asbel.Montes@acadian.com, 337-291-3310

Response to Kaiser Health News Ambulance Billing Article

Written by Mark Postma on . Posted in Medicaid, Medicare, News, Press, Private Insurance, Reimbursement.

Below is the American Ambulance Association’s Response to a recent Kaiser Health News article on ambulance billing. It was reprinted in several metropolitan areas on November 20, 2017.

To the Editor:

I write today in response to Melissa Bailey’s November 20 piece about ambulance balance (“surprise”) billing. While we disagree with the characterization of ambulance services in the article, we welcome the ongoing public dialogue about how unsustainable reimbursement for emergency medical services results in cost-shifting to patients.

Missing from the article is a true understanding of the sky-high cost of readiness for emergency medical services. Ambulance service providers offer their communities 24/7/365 on-demand mobile healthcare. Skilled staff and ambulances—high-tech emergency rooms on wheels—are ready to respond to a 9-1-1 call at a moment’s notice to help patients with issues ranging from stroke to heart attack to trauma to childbirth. EMS is also on the very front lines of the surge in opioid overdoses, providing naloxone (Narcan) to hundreds of patients each day. Keeping supplies, medications, equipment, and personnel at-the-ready requires a significant ongoing investment, regardless of whether or not an ambulance is out responding to a call. Cost comparisons between EMS and the rideshare app Uber may make for catchy sound bites, but they are misleading and misguided.

The piece states that our nation’s 14,000 ambulance service providers received 1,200 Better Business Bureau complaints spread over three years. While certainly not optimal, this is a tiny, unrepresentative fraction of the tens of millions of responses ambulance service providers conduct annually. In fact, BBB 2016 statistics show that ambulance services receive far fewer complaints than hospitals, physicians, dentists, and many other trusted healthcare providers.

The article also offhandedly mentions that balance billing occurs when private insurers and ambulance service providers are unable to agree about fair reimbursement rates. This glosses over the dark reality that it would be hard to categorize the process that occurs between the insurer and ambulance services as a “negotiation.” Instead, insurers often present an all-or-nothing proposition to force ambulance service providers to accept contracts at unsustainably low reimbursement rates. Unlike the multi-billion dollar insurance behemoths, most ambulance services are small and operate on razor-thin margins. In fact, 73% of ambulance services provide fewer than 1,000 Medicare transports per year—just three per day. Ambulance services do not turn down insurance network contracts out of greed, but instead out of necessity. Facing reimbursement rates below the cost of the services they provide, they must decline these agreements in order to keep their doors open and continue to provide healthcare to their communities. Unfortunately, this sometimes creates a situation where out-of-network ambulance costs are shouldered by patients via balance billing, instead of insurers.

In addition to challenges receiving fair compensation from private insurance, EMS is stretched thin by ultra-low Medicare and Medicaid reimbursement rates. In fact, in 2007 and 2012 GAO studies showed that without temporary, Congress-authorized percentage increases in EMS payments, ambulance services would receive reimbursement from government payors below the cost of operations. These are often the very same unsustainable rates that private insurers are attempting to strong-arm EMS providers into accepting for network contracts.

Finally, when someone calls 9-1-1 in need of emergency medical care, it is key to recall that, unlike in other industries, an ambulance responds regardless of the patient’s ability to pay. In many cases, the patient does not have insurance and is financially unable to reimburse the ambulance service provider. Therefore, EMS provides a significant amount of uncompensated care, the cost of which must be spread across all payors in order for them to continue their life-saving operations.

Ambulance services provide an essential, on-demand healthcare benefit to their communities. Unfortunately our current healthcare payment structure means that much of this care is not compensated equitably, resulting in the necessity of balance billing patients. While there are no quick fixes for this issue, we encourage consumers to educate themselves about their own insurance coverage. We also ask for your support of legislation that provides sustainable reimbursement for ambulance providers, including the bipartisan US Senate Bill 967. Together, we can ensure the future of mobile healthcare in our great nation.

Mark Postma
President
American Ambulance Association
“Representing EMS In America”

 

Patient Satisfaction and the Collections Conundrum

Written by Ted Williams on . Posted in Patient Care, Private Insurance, Reimbursement, Technology, Uncategorized.

Emergency Strikes

The year was 2001—seems like a distant memory. Expecting our first child, my wife and I were living in Modesto, California, thinking about cradles and nurseries. We were so excited—the little one we’d been expecting was on his way! Excitement quickly changed to deep concern as we learned there were some major complications with the pregnancy and our baby was in serious jeopardy. Life’s pause button was pushed as everything else in the world came to a screeching halt.

An ambulance transport and emergency delivery later, we found ourselves in our new home—the neonatal intensive care unit. For the next four months, we worked with medical teams around the clock to slowly usher our new 1-pound, 4-ounce son, Noah (now 15 years old), into the world.

Financial Domino Effects

This was an incredibly stressful time in our lives. Of all the things that burdened us, one of the most memorable was the nearly $5,000 invoice we received for a specific service. With no clue how we would pay this, I finally worked up the courage to pick up the phone and call the number on the invoice. The provider was demanding immediate payment before sending the bill to collections.

Me? Collections? But I’m the good guy, right? People should be reaching out to care for me. What just happened? After days of multiple information exchanges between me, the billing office and my insurance carrier, we finally figured it out—all charges were to be covered by insurance.

While our care through this time was generally very good, this unexpected charge put a cloud over the provider who lacked the proper information—despite a 120-day inpatient stay. Why did the provider send our bill to collections without contacting us? Where was the disconnect? Does this still happen today?

Fast Forward 15 Years to Smarter Billing and Collections

Sadly, this is not an isolated incident. Everyone knows a person with a similar story. But what if this patient billing story could be different? What if instead of multiple collection agency invoices demanding payment, I had been contacted early in the process? Or better yet, what if everything had occurred behind the scenes between provider and payor?

Technology advancements have narrowed the data gap that created these and other tensions for patients, providers and insurance carriers. Health care providers today can better serve their patients and communities through technology. The systems required to instantly supply insurance information and ensure patient-friendly billing are now available. It’s a matter of awareness and investment. Two key technology strategies are rapidly emerging to make collection letters and calls a thing of the past.

Real-Time Insurance Discovery

Insurance discovery solutions help providers find hidden insurance coverage for patients up front versus after the fact. Especially in emergency or self-pay situations, patients may have coverage the provider doesn’t know about. Finding coverage provides a tremendous boost to patient satisfaction and financial engagement.

For providers, finding and securing coverage early in the encounter helps billing teams circumvent months of patient statement and collection efforts. Operational costs are reduced and payor reimbursement is hastened. Best practices are rapidly emerging on how to incorporate real-time insurance discovery within patient registration and billing workflows.

Payment Likelihood Determinations

Where insurance coverage can’t be found or high deductibles result in exorbitant patient financial responsibilities, checking “payability” becomes crucial. Patients with minimal cash reserves or low propensity to pay can be moved to charity care, Medicaid, or account write-off. Families likely to qualify for financial assistance are also quickly identified by using payment likelihood applications.

Billers and collectors are more efficient and effective without damaging patient relations or community reputation. It is often a smarter long-term decision to write off patient balances in those cases where personal bankruptcy is only one medical bill away.

Proactive financial engagement, insurance discovery and smart collections are in the early stages in healthcare. However, provider organizations that embrace more patient-friendly billing strategies can significantly promote patient satisfaction and long-term community benefits.

Ted Williams has been a featured presenter at regional and national EMS conferences, including the state medical associations, ambulance networks, and technology user group conferences. Williams is a founder of Payor Logic, a national provider of healthcare revenue cycle solutions.

UnitedHealthCare Denials for ALS-2 Claims

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

Talking Medicare

with Brian S. Werfel, AAA Medicare Consultant

Over the past few weeks, we have received emails from ambulance providers across the country reporting that UnitedHealthCare (UHC) has started to deny claims for the ALS-2 base rate. Affected claims include both commercial and Medicare Advantage claims. These providers are reporting that UHC is requiring the use of Current Procedural Terminology (CPT) Codes to support the ALS-2 level of service.

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

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

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

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

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

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

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

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

Administration’s Proposed Rule on Marketplace Stabilization

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

The Centers for Medicare & Medicaid Services (CMS) has released the “Marketplace Stabilization Proposed Rule” (Proposed Rule). Overall, the rule proposes a series of modifications to the Marketplaces that align with requests made by issuers in an attempt to keep them in the Marketplaces. The background section of the Proposed Rule emphasizes the concerns of issuers and the Agency’s interest in making sure that consumers have more plan options for 2018. Comments are due March 7.

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

Changes to Open Enrollment/Special Enrollment Periods

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

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

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

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

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

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

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

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

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

Network Adequacy

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

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

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

Interpretation of the Guaranteed Availability Requirement

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

De Minimis Variation in the Actuarial Values

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

Essential Community Providers

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

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

[2]Id.

[3]Id.

[4]Id.

[5]Id.

[6]Id.

[7]Id.

[8]Id.

[9]Id.

[10]Id.

[11]Id.

[12]Id.

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