HHS OIG Issues Advisory Opinion on Community Paramedicine

HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions. The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions. Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include...

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AAA Releases 2019 State Medicaid Ambulance Rate Survey

The AAA is pleased to release its 2019 State Medicaid Rate Survey. This survey sets forth the fee-for-service Medicaid rates for all 50 states. For each state, the Survey lists the rate paid for each of the following procedure codes: A0428 – BLS Non-Emergency A0429 – BLS Emergency A0426 – ALS Non-Emergency A0427 – ALS Emergency A0433 – ALS-2 A0434 – SCT A0225 – Neonate Transport A0998 – Treatment, No Transport A0425 – Mileage A0422 – Oxygen A0382/A0398 – BLS/ALS Routine Disposable Supplies A0420 – Wait Time A0424 – Extra Attendant The rates set out in this survey are based on publicly available information provided by the various State Medicaid agencies. While the AAA has taken steps to verify the accuracy of the information on this Survey, it is possible that the rates provided in the Survey may not reflect changes to a state’s reimbursement policies that have not been made publicly available. These rates may not also not reflect any emergency budgetary measures or other temporary reductions imposed by a state. The AAA’s goal is to make this Survey as accurate as possible. Therefore, if you believe the rates for your state are inaccurate, please contact the AAA at...

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Talking Medicare: CMS Implements Further Dialysis Cuts

Talking Medicare: CMS Implements Further Cuts in Reimbursement for Dialysis Services; Medicare Payment Data Shows Continued Reduction in Overall Spending on Dialysis Transports, but Net Increase in Dialysis Payments in Prior Authorization States On October 1, 2018, CMS implemented an additional thirteen (13%) cut in reimbursement for non-emergency BLS transports to and from dialysis. This cut in reimbursement was mandated by Section 53108 of the Bipartisan Budget Act of 2018. This on top of a ten (10%) cut in reimbursement for dialysis transports that went into effect on October 1, 2013. As a result, BLS non-emergency ambulance transports to and from dialysis that occur on or after October 1, 2018 will be reimbursed at 77% of the applicable Medicare allowable. The payment reduction is partially the result of the reduction in the amounts paid for dialysis services. However, it is also reflective of an overall decline in the number of approved dialysis transports. For this, we can look primarily to the impact of a four-year demonstration project that requires prior authorization of dialysis transports in 8 states and the District of Columbia. As a reminder, the original prior authorization states were selected based on higher-than-average utilization rates and high rates of...

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Talking Medicare: DOJ Settlement Highlights Importance of Exclusion Testing

Talking Medicare: Recent DOJ Settlement Highlights Importance of Exclusion Testing On July 17, 2018, the U.S. Attorney for the District of Maine issued a press release on a settlement that had been reached with an ambulance service in Maine. As a result of this settlement, the ambulance service agreed to pay $16,776.74 to resolve allegations that it had submitted false claims to the Medicare and Maine Medicare Programs. While the Department of Justice’s press release referred to the matter as a civil health care fraud, that headline is somewhat misleading. The ambulance service was not alleged to “up-coded” its claims or to have billed for patients that did not require ambulance transportation. Rather, the ambulance service was accused of using monies paid to it by these federal health care programs to pay the salary and benefits of a woman hired to assist the company’s billing manager. The woman, who was not identified in news reports, had previously been excluded from participation in federal health care programs after surrendering her license as a pharmacy technician after being found to have inappropriately diverted certain controlled substances. The ambulance service apparently failed to conduct an exclusion test on this individual prior to placing...

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Talking Medicare: GAO urges CMS to continue prior authorization

Talking Medicare: GAO urges CMS to continue prior authorization efforts On May 21, 2018, the Government Accountability Office (GAO) issued a report to the U.S. Senate Finance Committee on the use of prior authorization models by the Centers for Medicare and Medicaid Services (CMS). The GAO was asked to examine: (1) the impact of prior authorization on total expenditures, and the potential savings for items or service subject to prior authorization, (2) the reported benefits and challenges of prior authorization, and (3) CMS’ monitoring of these programs, and its plans for future prior authorization. To conduct its study, the GAO looked at payment data and other information provided by CMS. The GAO also interviewed CMS, the Medicare Administrative Contractors (MACs), and selected provider, supplier, and beneficiary groups. Prior authorization was first implemented by CMS in 2012 for certain power mobility devices (e.g., power wheelchairs) in seven states. Subsequent prior authorization models were implemented for non-emergency hyperbaric oxygen and home health services. Most relevant to our industry, CMS implemented a prior authorization model for repetitive, scheduled, non-emergency ambulance transportation in December of 2014. Originally, this model was implemented in only three states: New Jersey, Pennsylvania, and South Carolina. In January of...

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Talking Medicare: A Good Thing Poorly Explained

On April 13, 2018, CMS released two Transmittals, Transmittal 243 and Transmittal 4021, and a related MedLearns Matter Article (MM10550). Collectively, these documents clarify Medicare’s coverage of ambulance transportation of SNF residents in a stay not covered by Part B, but who have Part B benefits, to the nearest supplier of medically necessary services that are not available at the SNF. This clarification relates to both the ambulance transport to the site of medical care, and the return trip. In order to properly understand the clarification, it is helpful to review Medicare’s coverage of ambulance transportation provided to SNF residents. At the onset, it is important to note that Medicare draws a distinction between the first 100 days of a beneficiary’s SNF stay, and any subsequent days of the same stay. The first 100 days are commonly referred to as the “Part A Period.” Under current Medicare rules, all ambulance transportation provided during the Part A Period is the financial responsibility of the SNF, unless a specific exemption applies. Outside the Part A Period, Medicare’s coverage rules generally mirror the rules applicable to ambulance transports that originate at the patient’s residence. However, there is an exception that relates to transportation...

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First Interim Evaluation Report on Medicare Prior Authorization

Talking Medicare: First Interim Evaluation Report on Medicare Prior Authorization (An 80-page report confirming what you already likely suspected) On February 28, 2018, the Centers for Medicare and Medicaid Services (CMS) posted an interim report on its prior authorization demonstration project for repetitive, scheduled, non-emergent ambulance transportation. The report, titled First Interim Evaluation Report of the Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT), was conducted by Mathematica Policy Research, a nonpartisan think tank. Mathematica studied the impact of the prior authorization model on Medicare payments, ambulance utilization, and patient quality of care. Background CMS implemented the prior authorization demonstration project in December 2014 in three states: New Jersey, Pennsylvania, and South Carolina (referred to in the report as “Year 1 States”). These states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) subsequently expanded the demonstration project to five additional states (Delaware, Maryland, North Carolina, Virginia, and West Virginia) and the District of Columbia on January 1, 2016 (referred to in the report as “Year 2 States”). The goal of the demonstration project was to study the impact of...

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Talking Medicare: Low Volume Settlement Option

Low Volume Settlement Option – A Viable Solution to the ALJ Backlog? The Centers for Medicare and Medicaid Services (CMS) recently announced a new initiative to help relieve some of the appeals backlog at the ALJ level. Titled the “Low Volume Settlement Option,” this new initiative appears, on its face, to offer ambulance providers and suppliers a viable alternative to the multi-year wait for an ALJ hearing. First some background. In January 2017, CMS announced that there has been a 1,222% increase in the number of appeals submitted to the Office of Medicare Hearings and Appeals, which operates the ALJ hearing system. The dramatic increase in the number of appeals was the result of several program integrity initiatives implemented by CMS in prior years, most notably, the creation of the Recovery Audit Contractor Program (RACs). As a result, there were more than 650,000 appeals pending at the ALJ-level as of September 30, 2016. CMS simultaneously disclosed that it currently processed approximately 92,000 appeals per year. Doing the math, this meant that CMS could clear the existing ALJ backlog in a little over 7 years at its current pace. Of course, that made no allowance for new appeals that would be...

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