Earlier today, Senators Catherine Cortez Masto (D-NV), Susan Collins (R-ME), Debbie Stabenow (D-MI) and Bill Cassidy, MD (R-LA) introduced the Preserving Access to Ground Ambulance Medical Services Act of 2023. The legislation would extend the temporary Medicare ambulance add-on payments for an additional three years.
“We thank Senators Cortez Masto, Collins, Stabenow, and Cassidy for introducing the Preserving Access to Ground Ambulance Medical Services Act and for their strong support for ground ambulance services and the communities and patients we serve,” said AAA President Randy Strozyk. “The disparity between Medicare reimbursement and the costs of providing services has grown significantly through reductions in reimbursement and skyrocketing expenses for labor, ambulances, and equipment. This bill would help reduce that gap and maintain access to vital ground ambulance services for communities around the country.”
The Senate version of the bill would go even further by increasing the add-on payment levels for urban from 2% to 3.4% urban, for rural from 3% to 4.3% rural and for super rural from 22.6% 26.2%. The last extension of the add-on payments was scheduled to end on December 31, 2022, but our champions on Capitol Hill were able to secure a two-year extension through December 31, 2024. The additional three-year extension is critical to keep the add-on payments in place through ambulance data collection and provide time to Congress to then use the data to reform the Medicare ambulance fee schedule.
Representatives Brad Wenstrup (R-OH), Terri Sewell (D-AL), Buddy Carter (R-GA) and Paul Tonko (D-NY) introduced the House version (H.R. 1666) of the bill on March 17. The House bill would be a three-year extension of the add-on payments at their present levels.
This progress is the result of tireless advocacy on the part of AAA volunteer leaders, staff, and consultants made possible by the sustained support of our members. It is critical that AAA members reach out to both their Senators and Representatives to cosponsor the respective versions of the Preserving Access to Ground Ambulance Services Act of 2023. It is vital that we generate a groundswell of support in the Congress for extending the add-on payments and will need that support to then also advocate for the higher add-on percentages when Congress negotiates on Medicare payment extensions.
On November 23, 2022, CMS posted the 2023 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in the calendar year 2023 for the various levels of ambulance service and mileage. These allowable reflect an 8.7% inflation adjustment over the calendar 2022 rates. The 2023 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.
Please note that these files reflect the Medicare allowable based on current federal law. Accordingly, the 2023 Public Use Files do not include the current add-ons (i.e., 2% for urban, 3% for rural, and the super-rural bonus), as these add-ons are currently scheduled to expire on December 31, 2022.
The AAA is actively working with congressional offices to not only extend but hopefully increase, the Medicare ambulance add-ons by the end of the year. If you have not already written to your members of Congress about extending the add-ons at increased levels, please do so today by using the AAA online advocacy tool by clicking here.
Unfortunately, in recent years, CMS has elected 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 will be publishing a reformatted version of the CMS Medicare Ambulance Fee Schedule that includes the state and payment locality headings. The reformatted fee schedule will be available on the AAA website in the coming days.
The AAA will also be publishing an updated version of its Medicare Rate Calculator, which we expect to have available on our website once we have a better sense of the timing of the extension of the add-ons.
Yesterday, Senators Catherine Cortez Masto (D-NV) and Susan Collins (R-ME) introduced the Protecting Access to Ground Ambulance Medical Services Act of 2021 (S. 2037). Senators Cortez Masto and Collins were joined by Senators Debbie Stabenow (D-MI), Bill Cassidy (R-LA), Patrick Leahy (D-VT) and Bernie Sanders (D-VT) as primary cosponsors and leads on the legislation.
S. 2037 is identical to H.R. 2454 by Representatives Terri Sewell (D-AL), Devin Nunes (R-CA), Peter Welch (D-VT) and Markwayne Mullin (R-OK) and would extend the temporary Medicare ground ambulance increases of 2% urban, 3% rural and the super rural bonus payment for five years. The increases are currently scheduled to expire on December 31, 2022. The five-year extension would allow for the increases to remain in place during the two-year delay on ambulance data collection due to the COVID-19 public health emergency, an analysis of the data by MedPAC and subsequent action by the Congress to reform the Medicare ambulance fee schedule.
The legislation would also help ensure that rural zip codes in large urban counties remain rural following geographical changes under the fee schedule as a result of the 2020 census data. The current definition using rural urban commuting areas (RUCA) in Goldsmith Modification areas would be modified for zip codes with 1,000 people or less per square mile would also be rural. Ground ambulance service providers and suppliers could also petition the Centers for Medicare and Medicaid Services (CMS) to make the argument that a specific zip code should be rural. It is vital that this provision be implemented before CMS makes changes from the 2020 census data which will likely occur in 2023.
The AAA has been leading the effort on the legislation with the support of the International Association of Fire Chiefs, International Association of Fire Fighters, National Association of EMTs, National Rural Health Association and the National Volunteer Fire Council.
The AAA will be launching a Call to Action shortly requesting AAA members to ask their Senators to cosponsor S. 2037, and reach out to their Representatives to cosponsor H.R. 2454 if they have not already done so.
We greatly appreciate the leadership of Senators Cortez Masto, Collins, Stabenow, Cassidy, Leahy, and Sanders on this vitally important legislation.
Thank you @SenCortezMasto, @SenatorCollins, @SenBillCassidy, @SenStabenow, @SenatorLeahy, and @SenSanders for collaborating to support America's #EMS providers in the pandemic and beyond! #SupportEMS #AlwaysOpen #MobileHealthcare #NotJustaRide pic.twitter.com/q7Divtby8z
— AmericanAmbulanceAsc (@amerambassoc) June 10, 2021
Happy National Rural Health Day! Thank you to all of the ambulance service providers who work hard providing life-saving treatment in rural areas every day.
In part of our ongoing advocacy efforts, the AAA sent a letter today to the Rural Caucuses in the United States Senate and House of Representatives. Addressed to leadership of the caucuses, Sen. Pat Roberts (R-KS), Sen. Heidi Heitkamp (D-ND), Rep. Adrian Smith (R-NE), and Rep. Tim Walz (D-MN), this in-depth letter highlights the critical work that our members do every day around the country and raises important issues affecting the industry. Issues covered in the letter include:
Stabilizing the Ambulance Fee Schedule
- Make the add-ons permanent and build them into the base rate
- Use new data from the ambulance cost collection program to ensure reimbursement is adequate going forward
- New data should be used to assess the problems with the current ZIP-code methodology for determining rural and super-rural services
Ambulance Fee Schedule Reform
- Proposed alternative models for rural ambulance services
- Encouraging Congress to look at alternative destination options for ambulance service providers
Recognizing Ambulance Services as Providers of Health Care
- Moving non-fire-based ambulance services from suppliers to providers under Medicare
The letter also highlights some of the burdensome regulations facing ambulance service providers that the AAA has recommended Congress address through its Red Tape initiative. These include:
Removing Unnecessary Regulatory Burdens:
- Reduce the burdens created by the Physician Certificate Statement
- Simplify the 855B Ambulance Enrollment Form
- Address burdensome requirements of the patient signature on claims and the strict application of the revocation of billing authority
This letter from the AAA to Congressional leaders is just one part of the AAA’s ongoing effort to educate Congress on the crucial role ambulance service providers play in America’s healthcare system. The AAA wants Congress to know that in many rural areas of the country, ambulances are the medical safety net, yet face extreme challenges to staying in business thanks to below cost reimbursement and burdensome regulations. The AAA will continue to pursue this list of priorities with our members next year and going forward.
Again, Happy Rural Health Day to our members – thanks for all that you do!
If you have any questions about our letter or rural advocacy, please contact us:
Questions?: Contact Us
If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.
Tristan North – Senior Vice President of Government Affairs
firstname.lastname@example.org | (202) 802-9025
Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
email@example.com | (202) 802-9027
Aidan Camas – Manager of State & Federal Government Affairs
firstname.lastname@example.org | (202) 802-9026
Thank you for your continued membership and support.
As part of the Bipartisan Budget Act of 2018 (BBA 2018), the Congress instructed CMS to develop a cost collection system to collect cost and revenue data related to the provision of ambulance services. Ambulance services are defined by federal law to include all levels of emergency and non-emergency services.
CMS is in the first phase of this process. The Congress instructed the Agency to engage with stakeholders before specifying through notice and comment rulemaking the data collection system. By law, CMS is required to specify the final system by December 31, 2019. CMS must also identify the first group of providers and suppliers selected for the first representative sample by that date as well. It appears that the goal is to have the contractor develop a proposal before the 2019 rulemaking cycle which will begin next summer.
To engage with the stakeholders, CMS, through its contractor the RAND Corporation, is reaching out providers and suppliers to learn more about the costs and revenues associated with providing ambulance services.
During the American Ambulance Association’s annual meeting earlier this month, CMS through the RAND Corporation, convened a focus group where they selected several AAA members who were able to talk directly with the contractor. The discussion centered around characteristics of ambulance services that matter for determining costs. The group also talked about how data is currently captured at the state and local levels, as well as how data is tracked within ambulance services. There was also a lot of discussion about the importance of standardizing data elements and not relying upon different state or local definitions, which could confound the data and make it impossible to compare costs across states.
As we have reported previously, it is critically important that the data collected through this process is standardized and reflects the actual cost of providing ambulance services. It is important to make sure that the data is useable not only for supporting the ambulance add-ons after they next expire in 2023, but also to help implement broader reforms and innovative payment models.
CMS is now reaching out to others in the industry. If you receive an email or a phone call from RAND Corporation, please respond.
If you have questions about, or would like assistance with regard to, this project, please contact Tristan North at email@example.com.
On Thursday, July 12, the Centers for Medicare & Medicaid Services (CMS) released the “Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program” Proposed Rule (Proposed Rule).
As you know, the American Ambulance Association worked closely with the Congress to ensure passage of the Bipartisan Budget Act of 2018 (BBA) (Pub. L. 115-123, enacted on February 9, 2018). The BBA not only extended the ambulance add-ons for 5 years, but also authorized a cost collection system that would not be overly burdensome on ambulance providers and suppliers, but would provide sufficient information ideally to support the permanent extension of the add-ons and set the basis for new payment models, including alternative destinations, treatment/assessment without transport, and community paramedicine.
After passage of the BBA, the AAA engaged immediate with CMS to ensure the smooth implementation of these provisions. Those contacts resulted in guidance earlier this year implementing the add-ons retroactively to January 1, 2019.
Consistent with the statute and already-released guidance, the Proposed Rule extends the three add-ons: the 2 percent urban, 3 percent rural, and 22.6 percent super-rural add-ons. The Proposed Rule would codify the extension of the add-ons through December 31, 2022.
The Proposed Rule would implement the increase in the reduction in rates for non-emergency ambulance transports to/from dialysis facilities for services furnished on or after October 1, 2018. The 10 percent reduction applies for these transports furnished during the period beginning on October 1, 2013 and ending on September 30, 2018. The reduction will increase to 23 percent to conform the regulations to the statutory requirement for services furnished on or after October 1, 2018.
CMS does not request any information about the cost collection system in the Proposed Rule, but has been soliciting comments and recommendations through informal provider/supplier calls. Additionally, the AAA has been in regular contact with CMS on the structure, design, and data elements to ensure the successful implementation of this critically important system as well.
Although the most prominent ambulance provision passed in the Bipartisan Budget Act of 2018 (H.R. 1892) was the five-year extension of the Medicare add-ons, the Act also included important language directing the Centers for Medicare and Medicaid Services (CMS) to collect cost and other financial data from ambulance service suppliers and providers.
This week, an editorial from AAA Senior Vice President of Government Affairs Tristan North was featured in the June issue of JEMS‘s “EMS Insider”. Read the full article►
The AAA would like to take this opportunity to update members on a number of issues related to Medicare reimbursement:
- CMS and its contractors have begun adjusting claims for ground ambulance services to reflect the restoration of the temporary add-ons. Section 50203(a) of the Bipartisan Budget Act of 2018 retroactively reinstated the temporary add-ons for ground ambulance services. These add-ons increase the applicable Medicare allowables by 2% in urban areas, 3% in rural areas, and 22.6% in “super rural” areas (over and above the corresponding rural rate), retroactive to January 1, 2018. On a March 7, 2018 Open Door Forum, CMS indicated that it had updated the Medicare Ambulance fee schedule to reflect these higher rates, and that it has provided a Change Request to each of its Medicare Administrative Contractors (MACs). The AAA has confirmed that all MACs have successfully implemented the new rates, and that all are paying current claims at the correct rate. The AAA has further confirmed that MACs have started to adjust 2018 claims paid at the original (lower) rates. Unfortunately, neither CMS nor its MACs have committed to a firm timetable for the completion of all required adjustments; however, a number of MACs have indicated that they anticipate completing all required adjustments by the end of the second quarter of 2018.
- Further reduction in Medicare’s payment for non-emergency BLS transports to and from dialysis. The Bipartisan Budget Act of 2018 further required CMS to implement an additional 13% reduction in Medicare’s payment for scheduled, non-emergency BLS transports to and from dialysis. This reduction is on top of the existing 10% payment reduction. Collectively, this means that dialysis transports will be reimbursed at a rate that is 23% less than the rate that would otherwise be applicable to BLS non-emergency transports in your area. The AAA. is reminding members that this additional reduction in payments will go into effect for transports on or after October 1, 2018.
- CMS has updated its SNF Consolidated Billing file to resolve the error that resulted in certain ambulance claims being incorrectly denied as being the responsibility of the SNF. Each year, CMS updates the SNF Consolidated Billing file provided to MACs. This file contains several lists of Healthcare Common Procedure Coding System (HCPCS) codes, and provides instructions to the MACs on whether these codes: (i) should be accepted for separate payment under Medicare Part B or (ii) should always be denied for inclusion in the SNF Consolidated Billing system. Ambulance HCPCS codes (A0425, A0426, A0427, etc.) have always been included in the first list, as the issue of whether an ambulance transportation is bundled to the SNF is conditioned on the nature of the services that the patient will receive at the destination. To the extent the service the patient will receive at the destination is bundled, the ambulance services to and from that service will also be bundled, and vice versa. Note: there are two exceptions to this general rule. The first is that ambulance transportation to and from dialysis is specifically exempted from the SNF Consolidated Billing regime, and therefore will always be separately billable to Medicare Part B. The second exception relates to the provision of chemotherapy services furnished on an outpatient basis in a hospital. Chemotherapy services are generally bundled to the SNF; however, several years ago, Congress elected to exempt a number of particularly expensive forms of chemotherapy from the SNF bundle. In these instances, while the SNF is not responsible for the payment of the expensive chemotherapy, the SNF remains responsible for payment of the ambulance transportation to and from the hospital. Because ambulance codes may or may not be bundled to the SNF based on the nature of the transport, they are not automatically denied. Instead, the MACs are supposed to use further edits to identify those situations in which the ambulance transport would be bundled vs. separately payable. Unfortunately, in its 2018 update, CMS inadvertently left the ambulance HCPCS codes off the list of codes that are not automatically denied as being bundled to the SNF. As a result, ambulance providers have indicated that claims were being denied using remark code “OA109.” In some cases, claims for dates of service in 2016 or 2017 that were previously paid were being recouped. CMS recognized its error fairly quickly, and updated the SNF Consolidated Billing file in mid-February. All MACs were provided with updated instructions by February 27, 2018. Therefore, the issue has been resolved for current claims. What remains to be resolved is how CMS and its MACs will adjust or reprocess claims that were incorrectly denied. Several MACs have notified providers of the issue, and asked that they refrain from appealing the claims. These MACs are indicating that they will automatically adjust/reprocess affected claims. In other instances, the MACs have asked the providers to make a refund of affected claims that were previously paid, promising to then reprocess the entire claim. The AAA is advising members to carefully track the claims that were affected by this mistake, and to follow the instructions issued by their MAC for ensuring their reprocessing.
- CMS has delayed the mailing new ID cards to all Medicare beneficiaries. As part of the Medicare Access and CHIP Reauthorization Act of 2015, Congress mandated that CMS remove a beneficiary’s social security number (SSN) from their Medicare ID card by April 2019. As part of this initiative, CMS will be replacing the SSN-based Health Insurance Claim Number (HICN) with the new Medicare Beneficiary Identifier (MBI). CMS has already started mailing cards with the MBI to newly enrolling Medicare beneficiaries. CMS originally announced that it would be mailing new cards to existing Medicare beneficiaries starting in April 2018, but recently indicated that it would delay the mailing of new cards to existing Medicare beneficiaries until May 2018. From May to June, CMS will mail new cards to existing Medicare beneficiaries residing in Alaska, California, Delaware, Hawaii, Maryland, Oregon, Pennsylvania, Virginia, West Virginia, the District of Columbia, and the U.S. territories of American Samoa, Guam, and the Northern Mariana Islands. The mailing program will then be extended to additional states in 5 “waves” over the coming year. To the extent you provide services in the above-mentioned states, you may want to educate crewmembers and other employees on the differences between the HICN and the MBI. You may want to also consider updating your existing patient databases to include the new identifier. As a reminder, CMS will permit claims to be submitted with either the HICN or the MBI during a transition period running through December 31, 2019. Effective January 1, 2020, claims must be submitted with a patient’s MBI. This requirement applies regardless of whether the date of service occurred prior to the expiration of the transition period.
- Extension of prior authorization project for scheduled, repetitive transports. In December 2017, CMS indicated that it would be extending the prior authorization program for an additional year. This program is currently in place for the states of Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, West Virginia, and the District of Columbia. The extension of the program is limited to those states. CMS has further indicated that it will be making a determination on possible national expansion at some point in the near future. CMS recently released its first interim report on the prior authorization program. As expected, that report indicated that prior authorization has been successful in reducing Medicare expenditures on scheduled, repetitive transports, without any material impact on beneficiary access to and quality of care.
Have any questions about these updates? Contact Brian Werfel at firstname.lastname@example.org
CMS held its latest Open Door Forum on Wednesday, March 7, 2018. As with past Open Door Forums, CMS started the call with the following series of announcements:
Medicare Fee Schedule – CMS indicated that the Bipartisan Budget Act of 2018, enacted on February 9, 2018, contained several provisions that impacted the payment of ambulance claims under the Medicare Ambulance Fee Schedule:
- Temporary Add-Ons for Ground Ambulance – CMS indicated that Section 50203(a) of the bill extended the temporary add-ons for ground ambulance services for an additional five years, retroactive back to January 1, 2018. As extended, these add-ons will expire on December 31, 2022. These add-ons increase Medicare’s allowable for ground ambulance base rates and mileage by 2% in urban areas, 3% in rural areas, and by 22.6% (over the applicable rural rate) for services provided in so-called “super rural” areas.
- Cost Reporting – CMS indicated that Section 50203(b) of the bill would require ground ambulance providers and suppliers to submit cost data to CMS. CMS noted that the new law requires CMS to develop, no later than December 31, 2019, a data collection system to collect cost, revenue, utilization, and certain other information related to ground ambulance services. The law provides that cost data will be collected using a survey methodology, with a representative sample of ambulance providers and suppliers being asked to submit cost data in any given year. Finally, CMS noted that, starting on January 1, 2022, providers or suppliers that fail to submit the requested cost data would be subject to a 10% reduction in their Medicare payments, unless otherwise exempted on the basis of significant hardship.
- Additional Reduction in Medicare Payment for Dialysis Transports – Section 53108 of the bill provides that the Medicare allowable for non-emergency, basic life support transports to and from dialysis will be subject to a further 13% reduction. This reduction would go into effect for dialysis transports with dates of service on or after October 1, 2018. This would be on top of the existing 10% reduction in Medicare’s payment for dialysis transports, for a total reduction of 23%.
Temporary Enrollment Moratorium – CMS indicated that the temporary moratorium on the enrollment of new ground non-emergency ambulance providers in Texas was lifted on September 1, 2017. CMS further indicated that the enrollment moratorium was extended for the states of New Jersey and Pennsylvania for an additional six months on January 29, 2018. CMS will need to make a determination on or before July 29, 2018 on whether to lift the moratorium or extent it for an additional six months in that state.
Following the announcements, CMS moved into a brief Question & Answer period. Most of the questions were not answered on the call; instead, CMS took the contact information of the person asking the question, and indicated that they would respond directly to them at a later date. However, the following questions were answered:
- CMS indicated that a Change Request had been sent to all Medicare Administrative Contractors (MACs) informing them of the new, adjusted fee schedule amounts. CMS further indicated that this Change Request, which it indicated was confidential, provided further instructions to the MACs on when and how to adjust claims initially paid at the original 2018 rates.
- CMS confirmed that the adjusted rates are retroactive to January 1, 2018. Accordingly, CMS indicated that claims paid at the original 2018 rates will be adjusted by the MACs at some future date.
- CMS indicated that it recently released its First Interim Evaluation Report on the Medicare Prior Authorization Model for repetitive, non-emergency ground ambulance transports. CMS further indicated that it was still reviewing this report, and that no decision has yet been made on the extension of this model within the existing 9 states and the District of Columbia and/or the expansion of the model to additional states.
Have questions? Please write to the Werfels at email@example.com.
The Great Medicare Debate: Should I Hold My Medicare Claims?
By: Brian S. Werfel, Esq. and Rebecca Williamson, Chair, AAA Medicare Regulatory Committee
Ambulance suppliers face an important decision at the start of every calendar year on whether to hold their Medicare claims for the first few weeks of the calendar year.
This decision historically revolved around the patient’s Medicare Part B deductible ($183 in 2018). The argument in favor of holding claims was that a brief claims hold would allow time for the patient’s deductible to be satisfied by another health care provider, thereby relieving the ambulance supplier of the time and expense involved in billing the patient (or their secondary insurance) for the deductible. Ambulance suppliers that hold claims believe that this ultimately results in higher collections. The argument against holding claims is that any increase in overall collections is likely to be minimal, and that the resulting disruption to the company’s cash flow more than offsets any potential benefits from those higher collections.
This year, the debate is complicated by the events surrounding the expiration of the temporary add-ons for urban, rural, and super-rural ground ambulance transports on December 31, 2017. These temporary add-ons increased the Medicare allowables by 2%, 3%, and 22.6%, respectively. Congress failed to act upon these temporary add-ons prior to its adjournment. However, there remains strong bipartisan support for reinstating these add-ons – – and Medicare extenders for other types of Medicare providers – – early in the 2018 Legislative Calendar. The AAA’s political consultants believe these Medicare extenders will likely be included in the next government funding legislation, which must be passed by January 19, 2018.
Assuming our temporary add-ons are reinstated, they are likely to be made retroactive to January 1, 2018. This would require CMS to retroactively adjust claims previously paid at the current (lower) rate. This may also require secondary payers, including State Medicaid Programs, to retroactively adjust their payment amounts to reflect increased cost-sharing amounts. There is precedent for these sort of retroactive adjustments. Most recently, the Affordable Care Act, which was enacted on March 23, 2010, provided for a reinstatement of these same temporary add-ons, retroactive to January 1, 2010.
In this inaugural edition of the Great Medicare Debate, AAA Medicare Regulatory Committee Chair Rebecca Williamson and AAA Medicare Consultant Brian S. Werfel, Esq. debate the merits of holding claims pending a resolution of the add-on issue vs. submitting claims.
Ambulance suppliers would likely benefit from holding their claims for some period of time pending clarity on the status of our temporary add-ons.
Rebecca Williamson, Chair of the AAA’s Medicare Regulatory Committee:
According to CMS, 73% of all ambulance service suppliers bill less than 1,000 Medicare covered transports per year. Additionally, 54% of ambulance suppliers bill less than 250 Medicare covered transports per year. Assuming an average claim amount of $400.00 per call (base rate plus mileage), an ambulance supplier with 1,000 Medicare covered transports per year could collect approximately $320,000.00 per year in a best case scenario ($400,000.00 X 80%). This leaves the service with copays of $80,000.00 to be collected from patients. By adding $183.00 as a deductible for each of these 1,000 patients, the collection from Medicare decreases to only $173,600.00. This means the service now must collect an additional $43,400.00 . In other words, if the patient has not met the deductible, the deductible is applied first and a $400.00 allowable becomes a $217.00 allowable. Medicare now pays 80% of $217.00 which is $173.60. Multiplied by 1,000 claims, Medicare pays a total of $173,600.00 and the balance owed to the supplier is the deducible of $183,000.00 and copayments of $43,400.00.
By holding claims for a brief period, usually thirty days, ambulance services increase the likelihood that another provider, often a hospital, will file claims with Medicare first, meaning collecting patients’ deductibles becomes the facilities’ responsibility.
Of course these numbers are only examples and many factors affect the actual billing and collection process. Some Medicare beneficiaries will promptly pay the deductible, many will have secondary payers or insurances, and a certain percentage will be dually eligible for Medicare and Medicaid, all of which results in higher collection ratios for the ambulance service. However, in plain terms, collecting $320,000.00 versus $173,600.00 can make a very real difference in the viability of a small service. Each service should look carefully at its own payer mix, patient statistics, and demographics to determine individual service projections.
Another good reason to hold claims, this year in particular, is the almost certainty of Congress reinstating the extenders. For those of us who have been in this industry for a long time, the expiration of the add-ons this year is a painful reminder of 2010 when the extenders expired and were not reinstated until March 23, 2010. It wasn’t until July 2010 that CMS even began the process of correcting previously processed claims , and by January 2011 many claims were still outstanding and had not been completely reprocessed. Also by that time, which could have been as long as a year after the date of service, many secondary payers were either unwilling or unable to retroactively correct the reprocessed claims. Some Medicaid states, such as Oklahoma, simply did not have the manpower or ability to even attempt it.
The administrative burden imposed on ambulance suppliers by having claims retroactively reprocessed by CMS, then reprocessed again by secondary payers – potentially incorrectly, if at all – along with the many manual adjustments required in-house, make it even more attractive to advocate and advise holding claims for as long as financially feasible. Of course not every service has the cash reserve to be able to do this, and I would generally not advise holding claims for as long as it may take for Congress to reinstate the extenders and for CMS to implement the correction for services who cannot afford to, but for those who can, not only will they almost certainly increase the amount of payments collected, they will decrease overhead administrative costs.
I am very optimistic that Congress will include the ambulance extenders in legislation as well as being optimistic that it will be sooner rather than later. I know others disagree, but the higher likelihood of it happening versus not, make this a good bet to take.
Ambulance suppliers should disregard the status of the temporary add-ons when making their decision on whether to hold claims for some period of time
By: Brian S. Werfel, Esq.:
Rebecca makes a strong argument about the benefits of holding claims. Moreover, I have long advocated in favor of holding claims for the patient’s deductible. For these reasons, I would understand if ambulance suppliers elect to hold claims for the patient deductible. However, I would question the wisdom of holding claims pending further clarity on the status of the temporary add-ons.
My argument against holding claims for that reason boils down to a single word: uncertainty. In this context, I am referring to four specific types of uncertainty:
- Uncertainty over whether the temporary add-ons will be extended.
- To the extent legislation is passed extending the temporary add-ons, uncertainty as to whether the higher rates will be made retroactive to January 1, 2018.
- To the extent legislation is passed extending the temporary add-ons, uncertainty as to how quickly CMS will implement the revised rates for new claims and adjust claims paid at the original, lower rates.
- Uncertainty over how the various secondary payers will handle their adjustments.
With respect to the extension of the add-ons, I agree that they are likely to be included with other Medicare adjusters in the budget resolution that must pass before January 19, 2018. Likewise, at this point, there is no reason to think that these add-ons will not be made retroactive to January 1, 2018. However, there are no guarantees. It is possible that the Republicans and Democrats fail to reach agreement on the larger budgetary issues, including the status of the so-called “Dreamers”, and a government shutdown results.
My larger concern relates to how quickly CMS revises its fee schedule, and implements instructions to its contractors. As Scott noted above, the last time we faced this issue was in 2010. The Affordable Care Act was signed into law on March 23, 2010. However, CMS didn’t issue a transmittal to its contractors until May 21, 2010, and even then, didn’t instruct its contractors to start paying the higher rates until July 6, 2010.
In other words, if you elected to hold claims to avoid having them paid and then reprocessed, you would have needed to hold claims for more than 6 months.
To me, the strongest argument for holding claims is not how Medicare would handle the adjustment. I recognize the administrative burden created by having to post and then re-post the same claim once it was adjusted. However, I trust that CMS will eventually get it right (emphasis on eventually).
I have far less confidence in how the secondary payers, including State Medicaid Programs, will handle the adjustments. When this happened in 2010, we had numerous reports from A.A.A. members of secondary payers incorrectly processing the adjustment. For example, some State Medicaid Programs didn’t simply issue a supplemental check for the higher copayment. Instead, the Medicaid Program took back its initial payment, and then reprocessed the claim in its entirety. Unfortunately, in some instances, the Medicaid rates changed in the interim, and Medicaid then repaid a lower amount. In other instances, they failed to repay the patient’s deductible. Similar issues were noted with commercial secondary payers, Medicaid managed care organizations, etc.
In sum, if your company has historically held claims during the first few weeks of the year for the patient’s deductible, I see no reason to discontinue that practice. If, however, you historically submitted claims without regard to the patient’s deductible, I see little benefit to holding claims pending action by Congress on our add-ons.
Have any Medicare questions? Contact Brian at firstname.lastname@example.org