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Tag: 2020
EMS1 | Inside EMS Podcast: Elephants In the Room
From EMS1 featuring AAA Communications Chair Rob Lawrence
What to do about the EMS elephants in the roomOur hosts discuss industry hot topics that will need to be addressed in the future, including the debate about responding with lights and sirensNov 6, 2020
This episode of Inside EMS is sponsored by ImageTrend, the creators of the free mobile app for first responders, CrewCare. It’s time to thrive.In this episode, host Chris Cebollero speaks with guest host Rob Lawrence about his recent keynote address at the American Ambulance Association’s Annual Conference. Lawrence shares his thoughts on his EMS “elephants in the room.” Where should EMS stand on the issue of responding with lights and sirens? Do EMS practitioners need college degrees? Listen to the discussion and join the debate in the comments below.
Legislative hurdles check hazard pay, PSOB benefits
May 22 at 2:20 PM | EMS1 | By AAA Communications Chair Rob Lawrence
In my last EMS One-stop column, I commented on the legislative to-do list to ensure that EMS receives the federal support it deserves right now as we staff the front lines and perhaps brace ourselves for COVID-19 round two as the nation craves a return to the normality and liberty enjoyed before the lockdown.
On May 15, 2020, the much talked about HEROES Act narrowly passed from the U.S. House of Representatives by a 208 to 199 vote to the Republican-controlled Senate. The HEROES Act proposed $3 trillion in tax cuts and spending to address the negative health and financial impacts of the COVID-19 pandemic. This included benefits for the public safety community, extensions to enhanced unemployment benefits, debt collection relief, direct cash payments to households and possibly even hazard pay.
EMS Week Message from President Reinert
On May 18, 2020, American Ambulance Association President Aarron Reinert shared a special message with EMS providers from across the nation.
Today, American Ambulance Association President Aarron Reinert shared a special message with #EMS providers from across…
Posted by American Ambulance Association on Monday, May 18, 2020
Happy EMS Week, and thank you for providing your communities with 24/7 on-demand mobile healthcare!
CMS Releases Update Guidance on Hospital EMTALA Obligations Related to COVID-19
On March 9, 2020, CMS published a memorandum to State Survey Agency Directors that provides updated guidance on the obligations of hospitals and critical access hospitals (CAHs) under the Emergency Medical Treatment and Labor Act (EMTALA). This guidance was issued in response to numerous inquiries regarding the EMTALA obligations of these facilities as they struggle to respond to the COVID-19 pandemic.
Under EMTALA, hospitals and CAHs with emergency departments have an obligation to provide an appropriate medical screening examination to any individual that comes into the emergency department seeking examination or treatment of an emergency medical condition. Hospitals and CAHs are further required to make a determination as to whether the patient actually has an emergency medical condition, and, if so, to provide stabilizing treatment within the hospital’s capabilities, or make appropriate arrangements to transfer the patient to a facility that does have the necessary capabilities.
The hospitals and CAHs had requested guidance on how they can fulfill their basic EMTALA obligations while minimizing the risks of exposure from COVID-19 infected individuals to their staff and other patients in their emergency departments.
Note: in summarizing the CMS guidance document, references to a “hospital” will include both hospitals and CAHs.
Acceptance of Patients Suspected or Confirmed to be Infected with COVID-19
CMS indicated that hospitals with the capacity and the specialized capabilities needed to provide stabilizing treatments are required to accept transfers from hospitals without the necessary capabilities. CMS indicated that it would take into account the recommendations of the Centers for Disease Control (CDC) in assessing a hospital’s capabilities and capacity. CMS further indicated that the presence or absence of negative pressure rooms (Airborne Infection Isolation Room (AIIR)) would not be the sole determining factor related to determining when an EMTALA transfer is required. CMS is advising hospitals to coordinate with their state and local public health officials regarding the appropriate placement of individuals who meet specific COVID-19 assessment criteria, as well as the most current standards for treating patients confirmed to be infected with COVID-19.
CMS is further confirming that hospitals have the ability to set up alternative screening sites on the hospital campus, i.e., the initial medical screening exam does not need to take place in the emergency department. CMS is confirming that individuals may be redirected to an alternative screening site after being logged into the emergency department. This redirection can even take place outside the entrance to the emergency department. Medical screening exams conducted in alternative screening sites must still be conducted by qualifying personnel (i.e., physicians, NPs, Pas, or RNs).
CMS is also indicating that hospitals may set up screening sites at “off-campus, hospital-controlled” sites. Hospitals and community officials may encourage the public to go to these sites instead of the hospital for screening for influenza-like illnesses. However, a hospital cannot tell an individual that has already presented at their emergency department to go to an off-site location for their medical screening exam. Unless the off-campus site is already considered to be a dedicated ED (e.g., a free-standing ED) under EMTALA regulations, the EMTALA regulations would not apply to these off-site screening areas; however, the hospital would be required under its Medicare Conditions of Participation to arrange a referral/transfer to an appropriate hospital if the patient has a need for emergency medical attention.
Finally, communities may set up screening clinics at sites not under the control of a hospital. These sites would not be subject to EMTALA.
EMTALA Obligations when a Screening Suggests Possible COVID-19 Infection
To the extent a hospital determines, following a medical screening exam that a patient may be a possible COVID-19 case, the hospital is expected to isolate the patient immediately. CMS indicated that it expects that all hospitals will be able to provide medical screening exams and initiate stabilizing treatment while maintaining isolation requirements.
Once an individual is admitted to the hospital or the emergency medical condition ends, the hospital has no further obligations under EMTALA.
CMS is further reminding hospitals that the latest screening guidance from the CDC calls for hospitals to contact their State or local public health officials when they have a case of suspected COVID-19.
CMS Grants State of Florida’s 1135 Waiver Request for Coronavirus Response
On March 16, 2020, CMS approved an 1135 Waiver request submitted by the State of Florida. The State had requested the flexibility to waive prior authorization requirements, streamline its Medicaid enrollment process, and allow care to be provided in alternative settings to the extent an existing health care facility needs to be evacuated. The key provisions of the waiver are summarized below:
1. Payments to Out-of-State Providers: Under current CMS coverage guidelines, the Florida Medicaid Program had the authority to reimburse out-of-state providers that were not enrolled in the Florida Medicaid Program provided certain criteria were met. However, this authority was limited to situations involving: (a) a single instance of care furnished over a 180-day period or (b) multiple instances of care furnished to a single Florida Medicaid beneficiary over a 180-day period. Under the waiver, CMS is removing the 180-day restriction for the duration of the emergency.
2. Expedited Enrollments: With respect to providers that are not currently enrolled in the Medicare Program or with another State Medicaid Agency, CMS is waiving the following screening requirements: (a) the payment of the application fee, (b) the fingerprint-based criminal background checks, (c) the required site visits, and (d) the in-state/territorial licensing requirements. Under the waiver, the state would still be required to check enrolling providers against the OIG exclusion list, and confirm that the out-of-state provider is properly licensed in their home state.
3. Cessation of Revalidation Efforts: CMS granted Florida the authority to temporarily cease the revalidation of enrolled in-state Medicaid providers and suppliers who are directly impacted by the emergency.
4. Waiver of Prior Authorization Requirements: CMS has granted Florida the right to waive any prior authorization requirements that are currently part of the State Medicaid Plan. This waiver applies to services provided on or after March 1, 2020, and will continue through the termination of the emergency declaration.
5. Waiver Allowing Evacuating Facilities to Provide Services in Alternative Settings: CMS will allow facilities, including nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric residential treatment facilities, and hospitals to be reimbursed for services rendered during an emergency evacuation to an otherwise unlicensed facility. This waiver will extend for the duration of the declared emergency; however, CMS will require the unlicensed facility to seek licensure with the state after 30 days.
Understanding Medicare, Medicaid, and SCHIP Coverage of Ambulance Services under a Declared National State of Emergency
On March 13, 2020, President Donald J. Trump announced a national state of emergency in response to the COVID-19 pandemic. Previously, HHS Secretary Alex Azar had declared a public health emergency under Section 319 of the Public Health Service Act in response to COVID-19.
This has prompted many AAA members to ask what impact, if any, these declarations have on the coverage of ambulance services under federal health care programs?
The short answer is that these declarations give CMS the authority under Section 1135 of the Social Security Act to waive certain Medicare, Medicaid, and SCHIP Program requirements. This waiver authority includes, but is not necessarily limited to:
• Waiving certain conditions of participation and/or certification requirements;
• Waiving certain pre-approval requirements;
• Waiving the requirements that a provider or supplier be licensed in the state in which they are providing services;
• Waiving EMTALA requirements related to medical screening examinations and transfers; and
• Waiving certain limitations on payments for services provided to Medicare Advantage enrollees by out-of-network providers.
One situation where an 1135 waiver may be of use to an ambulance provider or supplier would be where the ambulance provider or supplier is sending vehicles and crews to a state that is outside its normal service area. The ambulance provider or supplier is unlikely to be licensed by the state in which it is responding. As a result, under normal circumstances, it would be ineligible for payment under federal health care program rules. The 1135 waiver would permit it to submit claims for the services it furnishes in the other state.
Of more immediate significance to the current national emergency, an 1135 waiver may permit hospitals and other institutional health care providers to establish an off-site treatment center for initial screenings of patients. For example, hospitals may establish triage sites in parking lots and other open spaces for the initial intake of patients suspected of being infected with the COVID-19 virus. In theory, this waiver could also extend to drive-thru testing sites to the extent they are operated by the hospital or another health care provider. When a hospital has obtained an 1135 waiver to operate an off-site treatment center, the off-site area becomes a part of the hospital for Medicare payment purposes. Therefore, ambulance transports to an approved off-site treatment area should be submitted to Medicare using the “H” modifier for the destination.
COVID-19 Message from President Aarron Reinert
President
American Ambulance Association
Dear Fellow AAA Members,
I write to you today during what we all recognize as an extraordinary time for EMS. As we collectively serve on the very front lines of the COVID-19 epidemic, we know that the most challenging times are still ahead. However, I am heartened by the collective resolve of the members of the American Ambulance Association to provide 24/7 on-demand mobile healthcare, no matter the circumstances.
As President of the Association, I am sharing below a brief summary of the AAA’s activities to support its members in the face of this devastating disease.
COVID-19 Content & Approach
- Coronavirus Working Group—AAA Region III Director Tom Tornstrom, Executive Director of Gundersen Tri-State Ambulance, has been appointed to lead the AAA Coronavirus Working Group. The team includes AAA’s lobbyists, leadership, staff, and members from across the nation. We meet frequently and collaborate constantly to track challenges and find solutions to EMS issues relating to COVID-19 response. Sample topics include:
- First responder safety and wellness
- Reimbursement for alternative destinations, treatment in place, and mobile testing
- Paperwork reduction / waivers
- Advocating for policies in federal legislation that support mobile healthcare and redacting those that can negatively impact the industry
Members will receive updates via our Digest e-newsletter as we continue to make progress on these and other issues.
- Representation in Stakeholder Groups—From CMS to Congress to local mayors, AAA has representatives and members working with legislators, regulators, and officials at every level of government to advocate for EMS. Simultaneously, AAA leaders are working to showcase mobile healthcare’s unique strengths and capabilities for addressing the viral threat.
- Member Newsletter—The frequency of our member Digest e-newsletter has been increased from weekly to near-daily to ensure that we are curating and communicating the most relevant and important information.
- COVID-19 Archive—All AAA posts related to the virus can be found on our website. A COVID-19 resource link has been added to the top navigation of the AAA website for easy access by providers.
Association Events & Operations
- Stars of Life—Out of an abundance of caution, the Stars of Life event in Washington has been canceled. All blocked rooms will be canceled and refunded by the hotel, and all attendee registration fees will be refunded by diflucan. Staff is working on the development of meaningful ways to celebrate 2020 Stars outside of the context of an in-person event.
- Ambulance Cost Education (Cost Collection)—A plan is in place to move ACE Gold cost collection education from face-to-face to an interactive online learning environment. Subscribers can expect additional updates in early April.
- Headquarters—Association staff is all working remotely whenever possible. Staff is adhering to strict health, hygiene, and social distancing. All order fulfillment, mail processing, and other functions have been moved offsite.
Please don’t hesitate to reach out to staff at info@ambulance.org or 202-802-9020 if we can be of any assistance. Thank you again for your service to your communities during this very difficult time.
Aarron Reinert
President, American Ambulance Association
COVID-19 Data Visualization from Johns Hopkins
Kudos to the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) the development of this excellent COVID-19 data visualization.
COVID-19 Update II for EMS
First Case of 2019 Novel Coronavirus in the United States
The New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County WA ‘Patient 1’. This was the first reported case of COVID 19 in the US. This seminal document, which given the magnitude of the case and its initial findings is released in full here
The work by Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, et al for the Washington State 2019-nCoV Case Investigation Team was turned round in just over 5 weeks and below is an ‘Executive summary’ ( as extracted from the paper) but the full paper and range of results should be read in full.
Patient Presentation
On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.
On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.
Viral Presence
Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24).
Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).
Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus
Day 8: Condition Improves
On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.
History Taking
This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.
Conclusion
There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID 19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken
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COVID-19 Coronavirus EMS Advisory 1
This guidance is written to offer American Ambulance Association members the situational background and a list of resources and websites with which to draw guidance and further updates on the latest situation with COVID-19, colloquially referred to as “Coronavirus.” Key information for this update has been drawn from the NHTSA EMS Focus series webinar What EMS, 911 and Other Public Safety Personnel Need to Know About COVID-19, which took place on February 24, 2020. The on-demand recording is available below.
General Information
Background
The COVID-19 Coronavirus Disease was first reported in Wuhan China in December 2019. CDC identifies that it was caused by the virus SARS – CoV-2. Early on, many patients were reported to have a link to a large seafood and live animal market. Later, patients did not have exposure to animal markets which indicates person-to-person transmission. Travel-related exportation of cases into the US was first reported January 21, 2020. For reference the first North American EMS experience of COVID-19 patient transport, including key lessons learned, can be found in the EMS 1 article Transporting Patient 1.
Spread and Identification
Global investigations are now ongoing to better understand the spread. Based on what is known about other coronaviruses, it is presumed to spread primarily through person-to-person contact and may occur when respiratory droplets are produced when an infected person costs or sneezes. Spread could also occur when touching a surface or object that has the virus on it and when touching the mouth, nose, or eyes. Again, research is still ongoing, and advice and guidance will inevitably follow.
For the cases that have been identified so far, those patients with COVID19 have reportedly had mild to severe respiratory illness with symptoms including fever and shortness of breath. Symptoms have typically appeared 2 to 14 days after exposure. Both the WHO and CDC advise that patients that have been to China and develop the symptoms should call their doctors.
COVID-19 Prevention and Treatment
To date, 30 international locations, in addition to the US, have reported confirmed cases of COVID-19 infection. Inside the US, two instances of person-to-person spread of the virus have been detected. In both cases, these occurred after close and prolonged contact with a traveler who had recently returned from Wuhan, China.
The CDC activated its Emergency Operations Center (EOC) on January 21 and is coordinating closely with state and local partners to assist with identifying cases early; conducting case investigations; and learning about the virology, transmission, and clinical spectrum for this disease. The CDC is continuing to develop and refine guidance for multiple audiences, including the first responder and public safety communities.
As at the date of publication there is still no specific antiviral treatment licensed for COVID-19, although the WHO and its affiliates are working to develop this.
The following are recommended preventative measures for COVID-19 and many other respiratory illnesses:
- Wash your hands often with soap and water for at least 20 seconds.
- Use an alcohol-based hand sanitizer with at least 60% if soap and water are not readily available.
- Avoid touching your eyes, nose, and mouth with unwashed hands.
- Avoid contact with people who are sick.
- Stay home when you are sick.
- Cover your cough or sneeze with a tissue, then throw it away.
- Clean and disinfect frequently touched objects and surfaces.
Interim Guidance for EMS and 911
The Centers for Disease Control (CDC) has issued its Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.
The guidance identifies EMS as vital in responding to and providing emergency treatment for the ill. The nature of our mobile healthcare service delivery presents unique challenges in the working environment. It also identifies that coordination between PSAPs and EMS is critical.
Key points are summarized below:
Recommendations for 911 PSAP Locations
The link between PSAPs and EMS is essential. With the advent of COVID19 there is a need to modify caller queries to question callers and determine the possibility that the call concerns a person who may have signs or symptoms and risk factors for COVID19.
The International Academy of Emergency Dispatch (IAED) recommends that agencies using its Medical Priority Dispatch System (MPDS) should use its Emerging Infectious Disease Surveillance (EIDS) Tool within the Sick Person and Breathing Problem protocols. For those that are not MPDS users, IAED is offering its EIDS surveillance Tool for Coronavirus, SRI, MERS and Ebola-free of charge under a limited use agreement.
Recommended Personal Protective Equipment (PPE)
The CDC recommends that while involved in the direct care of patients the following PPE should be worn:
- Single pair of disposable examination gloves
- Disposable isolation gown
- Respiratory protection (N95 or higher)
- Eye Protection (goggles or disposable face shield)
EMS Transport of a Patient Under Investigation (PUI) or Patient with Confirmed COVID19
- Notify receiving healthcare facility so appropriate precautions can be put in place
- Discourage family and contacts from riding in transport vehicle
- Isolate the vehicle driver from the patient compartment by closing the windows between compartments and ensuring that the vehicle ventilation system is set to the non-recirculated mode
- Document patient care
Cleaning EMS Transport Vehicles After Transporting PUI or Patient
- Don PPE for cleaning with disposable gown and gloves, facemask, and goggles or face shield if splashes are anticipated
- Routine cleaning and infection procedures should follow organizational standard operating procedures
- Use protect use products with EPA-approved emergent viral pathogens claims
Once transport is complete, organizations should notify state or local public health authorities for follow up. Additionally agencies should (if not done already) develop policies for assessing exposure risk and management of EMS personnel, report any potential exposure to the chain of command, and watch for fever or respiratory symptoms amongst staff.
Employers Responsibilities
While not specific to COVID-19, agencies should:
- Assess current practices and policies for infection control
- Job- or task-specific education and training
- PPE training and supply
- Decontamination processes and supplies
Local EMS Considerations
- PPE supplies
- 911 and EMD call taking activities
- Appropriate approach to potential patients
- Educational resources for EMS personnel
- Interaction with local public health/healthcare systems/emergency management
- Interaction with local fire and law enforcement
- Considerations for local jails
Further Reading
- World Health Organization (WHO)—For a wider perspective, the WHO provides both a daily live online briefing and written situation report.
- FirstWatch—FirstWatch Solutions maintains a Health Intelligence site that is available for all to use. The site is not limited to COVID19 but is a useful reference to emerging health trends. Additionally, FirstWatch, in partnership with the Paramedic Chiefs of Canada, is presenting regular webinars on COVID-19 which can be located via the Health Intelligence web page.
- Updated information about COVID19
- Infection prevention and control recommendations
- Additional information for healthcare personnel
- CDC’s case definition for a person under investigation (PUI) for COVID19
- CDC Quarantine Station Contact List
- Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)
- Exposure risk and management
- Infectious Disease Playbook
Conclusion
The COVID19 situation constantly evolving. Agencies should defer to their local EMS authorities, Public Health departments, and the CDC for definitive guidance. Going forward, the AAA will continue to both monitor the disease and alert issues to the membership.
CMS Posts 2020 Public Use File
On December 2, 2019, CMS posted the 2020 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in calendar year 2020 for the various levels of ambulance service and mileage. These allowables reflect a 0.9% inflation adjustment over the 2018 rates.
The 2020 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.
Unfortunately, CMS has elected in recent years to release its Public Use Files without state and payment locality headings. As a result, in order to look up the rates in your service area, you would need to know the CMS contract number assigned to your state. This is not something the typical ambulance service would necessarily have on hand. For this reason, the AAA has created a reformatted version of the CMS Medicare Ambulance Fee Schedule, which includes the state and payment locality headings. AAA members can access this reformatted fee schedule at the link below.
Cost Data Collection: So You’ve Been Selected—Now What?
It’s finally here! For almost a decade the American Ambulance Association has been preparing for this moment: collecting cost data in order to justify the reimbursement inadequacies of our current payment system. As Benjamin Franklin stated, “By failing to prepare, you are preparing to fail.” So prepare we did!
Our research indicated that due to industry capacity, a provider sample and survey approach would be preferable to a mandatory cost reporting structure. Congress agreed! Our research indicated that different organizational structures made us unique healthcare providers and as such, EMS’s special nature should be considered in the collection tool developed. Congress agreed! No one knows our industry better than we do and the final rule from the Centers for Medicare and Medicaid Services indicates they listened!
So your ambulance service was selected for the 2020 reporting period—now what? Here is your 10 STEP PLAN.
STEP 1: Sign up for the latest information on ambulance cost data collection.
Subscribe to email updates from the American Ambulance Association’s Ambulance Cost Education page, www.ambulancereports.org. Not only will we make sure you get the latest information disclosed from the Centers for Medicare & Medicaid Services, but we will also provide you with quick tutorials on how to fill out the cost data collection instrument. Most importantly, you can purchase AMBER! This software provides an easy, quick solution for you to input your data, with built-in tutorials to walk you through the data collection process.
STEP 2: Know what is included in your National Provider Identification (NPI) number.
It is important that you review the information in the Provider Enrollment, Chain, and Ownership System (PECOS) which supports the Medicare Provider and Supplier enrollment process. You will want to make sure the information that you provide in the cost data collection tool, at a minimum, matches what is in this system or on your CMS 855B Medicare enrollment application. Pay close attention to the following:
- Practice location(s)
- Vehicle Information
- Ownership
STEP 3: “Tele” a Friend!
More than 2,600 ambulance suppliers and providers were selected for the 2020 reporting period (Zip file download of services selected for 2020). Please reach out to your colleagues. Now is not the time to let competition or friendly rivalries stop us from communicating best practices. Call your fellow mobile healthcare providers!
STEP 4: Know your accounting “status.”
How you recognize cost and revenue will be extremely important in determining how you report. Cash accounting recognizes revenue and expenses only when money actually exchanges hands. Accrual accounting recognizes revenue and expenses when billed, not when money exchanges hands. This status will be key in determining how you report costs and revenues.
STEP 5: Know your mileage.
For every ambulance and non-ambulance vehicle that you use related to patient care, you will need to know the odometer readings at the beginning and end of 2020. Make sure you have a system to record the odometer readings accurately.
For example, you have a 2016 ambulance where the odometer reading on 1/1/2020 is 10,212. If on 12/31/2020 the odometer reading is 74,112, you will have the option of recording the full mileage of 63,900 in the data collection tool. This is another window into the “cost of readiness.”
STEP 6: Set up and Identify payer categories.
As identified by the Medicare Ground Ambulance Data Collection System (PDF download), there are nine payer type categories for billing ambulance transportation. Know these categories and set them up in your system now, prior to billing for ambulance transports in 2020. If you use a billing agency, seek confirmation that they have a way to identify these nine payer types. You may not have select reports to identify the numbers yet within these categories but that can be set up later in the reporting year.
Setting up your system NOW to identify these payer categories is critical as it will be too administratively burdensome to fix this retroactively.
STEP 7: Know if you share support services or stand alone.
Support services are services such as maintenance, dispatch, billing, materials management, human resources and other services that support patient care. You will need to know if you share these services with other entities such as fire, police, air ambulance, hospital or other entity not related to ground ambulance care.
If you share, then you will have to work out an allocation model to assign the costs and revenue appropriately. If you do not share support services, then you do not need to work about any of the questions related to allocation.
STEP 8: Identify sources of revenue and cost categories.
Check your systems. Now is the time to make sure you can identify all sources of revenue you receive whether from billing for an ambulance transport or from a grant or local tax. Understand your costs, especially those related to salary, vehicles, facilities and medical supplies. That is the first step in the ability to categorize appropriately.
STEP 9: Don’t panic!
Take a deep breath—It is not as complicated as it may seem. There are resources available and assistance for you and your ambulance services as outlined in STEP 1.
STEP 10: Repeat Step 1!
See, that wasn’t too bad, was it? Now you have a 10 Step Plan!
In all seriousness, while it may seem a bit daunting at first, breaking down the cost data collection process into small steps will ensure that our industry is prepared and the figures we enter into this cost data collection tool will glean useful information. It is imperative that we get this right the first time to avoid any unintended consequences, such as decreased reimbursements and other impactful changes that could harm the patients we serve.
As the saying goes, “the rising tide lifts all boats.” More than ever, we need to help and assist our colleagues as we navigate this new world of ambulance reimbursement.
So, what’s next? Cost data collection, my friend! Jump on board.
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.
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.
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.
Congress Passes Ambulance Medicare Add-Ons
It is my pleasure to share with you that—just minutes ago—Congress passed the 5 year extension of the Medicare ambulance add-ons. The extension was part of the two-year budget deal reached by congressional leaders and passed by the Senate early this morning and then shortly thereafter by the House. The ambulance provisions in the final deal differ from the provisions passed earlier this week by the House in one key area – the collection of ambulance cost data. This means that we are truly in the endzone of the add-on payment extension process.
While we ask your continued patience as we jump through one last procedural hoop, I am confident that the add-ons will be back in effect as soon as the President signs the legislation. In today’s deeply divided political climate, I am proud of what we have accomplished through collaboration as an association and industry.
Here are the specifics of the final package:
- 5 year extension of the ambulance Medicare add-ons through December 31, 2022, retroactive to January 1, 2018.
- AAA’s preferred method of Cost data collection that provides flexibility to the Secretary of HHS in developing the system. Consultation with the industry is required so that it strikes the appropriate balance between obtaining meaningful data while not overly burdening or onerously penalizing the ambulance services.
- The penalty for failing to report required data would be a reduction in payment up to 10% for the year following the year in which the data should have been submitted. AAA objected to the house proposed penalty of up to a year of Medicare payments clawback or withholding of payments. A clause is included to wave the penalty in cases of hardship.
- A “pay-for” for the 5-year extension of the add-ons with a 13% cut to non-emergent dialysis transports – the AAA had objected to the offset and pushed for a cut targeted to just those entities which abuse the dialysis transport benefit. We were successful in reducing the initial cut from 22% to 13%. The AAA is actively working on other pay-for options that would replace the 13% cut with something targeting dialysis fraud and abuse.
Next Steps
All that remains to bring the add-ons into effect retroactively to January 1, 2018 are a few administrative formalities and the signature of the President, who has indicated his support of the agreement. Given the government shutdown, we are cautiously optimistic that this will proceed quickly. However, bumps are always a possibility—we will keep you informed! (Follow AAA on Twitter at @amerambassoc or Facebook for instant updates.)
Thank You
This week’s tremendous progress would not have been possible without months of effort by AAA volunteer leaders, advocacy experts, and staff, as well as support from our key champions in Congress.
I’d like to personally thank the AAA Government Affairs Committee, including Chair Jamie Pafford-Gresham and Vice Chair Shawn Baird, as well as the entire AAA Board for their hundreds of hours of hard work on this issue. We are all truly grateful for your dedication to moving mountains to find sustainable funding for EMS.
Last but certainly not least, thank you to the dozens of state ambulance associations and thousands of individual members who wrote letters to their Members of Congress in support of the add-ons. We truly couldn’t have made it this far without your support.
Again, thank you, and please stay tuned for final updates!
Mark Postma
President
American Ambulance Association
“Representing EMS in America”
House Passes Ambulance Medicare Add-Ons
Moments ago, the U.S. House of Representatives passed legislation which includes a five-year extension of the Medicare ambulance add-ons. The House voted 245 to 182 to pass a Continuing Resolution (CR) to fund the federal government beyond the current expiration date of February 8. The CR included a package of Medicare provider extenders including an extension of the temporary Medicare ambulance add-ons.
The ambulance provisions in the CR include the following:
- A five-year extension of the temporary Medicare ambulance increases of 2% urban and 3% rural to base and mileage rates and 22.6% to the base rate in super rural areas. The extension would be retroactive to January 1, 2018 and expire on December 31, 2022.
- The requirement for ambulance service suppliers to submit cost reports. The language is based on H.R. 3729 as reported by the House Ways and Means Committee but with new language providing the CMS Administrator with the discretion to apply a payment suspension or overpayment as the penalty for suppliers that do not submit timely, accurate and complete data after the initial two years.
- To offset the cost of the add-ons extension, a further reduction of 13% in Medicare reimbursement for BLS non-emergency transports to and from dialysis centers. The initial reduction was 22% but the AAA was able to help lower the estimated cost of the add-ons and thus lower the percentage of the offsetting cut.
The CR now goes to the Senate for its consideration. The Senate is likely to act tomorrow, February 7.
We will keep you posted of new developments. Thank you for your continued support of the American Ambulance Association.
Mark Postma
President
American Ambulance Association
“Representing EMS in America”