Balance Billing | TX Judge Vacates Portions of NSA IFR
This content is for AAA members only.
Please either or Join!
Tag: Balance Billing
FAIR Health | Ground Ambulance Services in the United States
From FAIR Health in February 2022
“Currently, no federal law protects consumers against “surprise” bills from out-of-network ground ambulance providers. Some state and local governments regulate ground ambulance surprise billing practices; however, such laws may not apply to all health plans or ambulance providers in an area. Because of the substantial policy interest in ground ambulance services, FAIR Health drew on its vast database of private healthcare claims to illuminate multiple aspects of such services across the nation, including utilization, costs, age, gender, diagnoses and differences across states.”
AAA 2022 Legislative Priorities
Yesterday, the American Ambulance Association Board of Directors approved the Association’s advocacy priorities for 2022. Our key initiatives reflect the challenges we face this year, including short-sighted threats to EMS balance billing, a worsening workforce shortage, the expiration of the temporary Medicare increases, and potential sequestration cuts.
We also continue to fight for you as you care for people first on the frontlines of the COVID-19 pandemic. We will sustain our efforts at securing additional funding for ground ambulance services to help address the increased costs of providing medical care and transport during the Public Health Emergency.
To achieve our collective goals, the AAA Board will need to mobilize the full voice of influence of the EMS community this year. If you have not already sent an email using the AAA advocacy system to your members of Congress, please do so today!
Staff will be reaching out to you at key points later in the year about letter writing for specific individual policy requests. But it is important that they hear from you now on all the top issues for ground ambulance services. They are:
Top AAA Advocacy Priorities for 2022
EMS Workforce Shortage
With the persistent shortage of ground ambulance service field personnel raising to a crisis level with the COVID-19 pandemic, the AAA moved the issue to a top policy priority. The AAA is currently working with key Congressional Committees of jurisdiction to hold hearings on the EMS workforce shortage. We are also developing legislation to specifically target increasing access for ground ambulance service organizations to federal programs and funding for the retention and training of health care personnel.
Balance Billing
The AAA successfully educated the Congress on the role of local government oversight and other unique characteristics of providing ground ambulance service organizations. As a result, the Congress directed the establishment of a Ground Ambulance and Balance Billing Advisory Committee to address the issue. The Committee is in the process of being formed and then has 180 days in which to make recommendations to the Congress. The AAA will be involved with the Committee and advocating that the Congress implement policies that meet the needs of our members.
Additional COVID-19 Financial Assistance
The AAA is advocating for additional financial assistance for ground ambulance service organizations to help address the increased costs of labor and other higher costs associated with providing health care during the COVID-19 pandemic.
Medicare Ambulance Relief
The temporary Medicare ambulance increases of 2% urban, 3% rural and the super rural bonus payment expire at the end of the year. The AAA will continue to push for passage of the provisions of the Preserving Access to Ground Ambulance Medical Services Act (S. 2037, H.R. 2454) before the provisions expire as well as for the adoption of language to ensure truly rural areas remain rural following changes to geographical designations based on the 2020 census.
Sequestration Cuts
The Congress delayed the additional 4% sequestration cut for only one yea. The AAA is working with other EMS and health care provider and supplier groups to permanently prevent the cut from going into effect as well as further extending the moratorium on the long-standing 2% cut.
Ambulance Cost Data Collection
With the 2-year delay of ambulance data collection due to the pandemic, the Medicare Payment Advisory Committee (MedPAC) will have little to no data to analyze in March 2023 in which to make recommendations to the Congress on Medicare ambulance payment policy and rates. The AAA is asking the Congress to push back the date of the MedPAC report and also expand the modified data collection timeline of two years to the intended four years.
On behalf of my fellow board members, I again thank you for your continued membership and participation. We look forward to serving you for many years to come.
Should you have any questions regarding our advocacy priorities, please contact AAA Senior Vice President of Government Affairs Tristan North at tnorth@ambulance.org.
Notice on Ground Ambulance and Patient Billing Advisory Committee
The Centers for Medicare and Medicaid Services (CMS) has filed for publication in the Federal Register the Solicitation of Nominations Notice for the Ground Ambulance and Patient Billing (GAPB) Advisory Committee. The Notice is scheduled to be included in the Federal Register for tomorrow, Tuesday, November 23.
The Congress created the GAPB Advisory Committee as part of The No Surprises Act enacted last year and currently being implemented by the Departments of Health and Human Services, Labor and the Treasury. The American Ambulance Association, International Association of Fire Chiefs, International Association of Fire Fighters, National Association of Emergency Medical Technicians, and the National Volunteer Fire Council successfully advocated that the Congress take into consideration the unique characteristics of ground ambulance services when determining balance billing policy for our services. The Congress excluded ground ambulance services from the provisions of The No Surprises Act and created the GAPB Advisory Committee to address balance billing.
The AAA has identified candidates, including AAA President Baird, who we will be supporting for inclusion on the Advisory Committee who we believe are well-positioned to represent the AAA membership. Once formed, the Advisory Committee has 180 days in which to report its recommendations to the Congress. The directive of the Committee is to review options to “improve the disclosure of charges and fees for ground ambulance services, better inform consumers of insurance options for such services, and protect consumers from balance billing.” We will be keeping the AAA membership continually informed of the actions and deliberations of the GAPB Advisory Committee.
Should you have any questions regarding the GAPB Advisory Committee, please contact AAA Senior Vice President of Government Affairs Tristan North. He can be reached at tnorth@ambulance.org.
EMS Provider Comments Needed on the “Surprise Billing” Interim Final Rule
The Department of Health and Human Services, Department of Labor, and the U.S. Treasury Department (Departments) have issued an Interim Final Rule (IFR) on “surprise billing” that will take effect September 13, 2021. However, the Departments are taking comments on the IFR. While the Congress expressly excluded ground ambulance organizations from the statute that the IFR seeks to implement, the Departments have included a prohibition on balance billing for nonemergency ground ambulance transports that occur after a patient has been stabilized in a facility.
The Congress established an Advisory Committee to consider the best way to address balance billing in the context of ground ambulance services, and the Departments should wait to be advised by that group before subjecting nonemergency ground ambulance transports to the broader balancing billing prohibition.
It is important that the Departments hear from as many stakeholders as possible opposing this expansion of the law. To help you develop a comment letter, we provided the following template that we ask you to tailor to your experience and organization. Tailored letters will be of greater value to the Department as they consider the rules. At a minimum, please customize the templated language to insert information about who you are and where you operate.
The must be submitted by September 7, 2021.
Administration Releases First Surprise Billing Interim Final Rule
This content is for AAA members only.
Please either or Join!
EMS Balance Billing Quick Take—July 7, 2021
Webinar July 7, 2021 | 13:00–13:30 ET | Free to AAA Members
Speakers: Kathy Lester, Esq. & Asbel Montes
On July 1, CMS issued a proposed rule on Surprise Billing which applies to those providers and physicians identified in the No Surprises Act. This statute subjected ground ambulance suppliers to an HHS Advisory Committee process prior to any rulemaking addressing these services.
The consultants and staff of the American Ambulance Association are doing a deep dive into the 400+ page rule and evaluating its nuances. We continue to understand from our conversations that ground ambulances are not included and instead are subjected to the Advisory Committee.
The American Ambulance Association will soon provide a summary to members, and will address any confusion with the Administration. Join AAA for a quick take live webinar on July 7 at 13:00 ET to learn more!
AAA Task Force to Address Balance Billing Challenges
This content is for AAA members only.
Please either or Join!
America First Healthcare Executive Order on Surprise Coverage
President Trump’s “An America-First Healthcare Plan” Executive Order on Surprise Billing Policy
by Kathy Lester, J.D., M.P.H.
As the American Ambulance Association (AAA) reported yesterday, President Trump issued an Executive Order (EO) “An America-First Healthcare Plan.” The EO includes several provisions, including related to drug importation generally and for insulin specifically. It also includes statements that indicate if the Congress does not act before the end of the year, the President will have the Department of Health and Human Services (HHS) “take administrative action to prevent a patient from receiving a bill for out-of-pocket expenses that the patient could not have reasonably foreseen.” It does not mention ground ambulances.
In addition to suggesting action if the Congress does not pass legislation, the EO also states that within 180 days, the Secretary will update the Medicare.gov Hospital Compare website to inform beneficiaries of hospital billing quality, including:
- Whether the hospital is in compliance with the Hospital Price Transparency Final Rule;
- Whether, upon discharge, the hospital provides patients with a receipt that includes a list of itemized services received during a hospital stay; and
- How often the hospital pursues legal action against patients, including to garnish wages, to place a lien on a patient’s home, or to withdraw money from a patient’s income tax refund.
The narrative related to balance billing (surprise coverage) reads as follows:
My Administration is transforming the black-box hospital and insurance pricing systems to be transparent about price and quality. Regardless of health-insurance coverage, two‑thirds of adults in America still worry about the threat of unexpected medical bills. This fear is the result of a system under which individuals and employers are unable to see how insurance companies, pharmacy benefit managers, insurance brokers, and providers are or will be paid. One major culprit is the practice of “surprise billing,” in which a patient receives unexpected bills at highly inflated prices from providers who are not part of the patient’s insurance network, even if the patient was treated at a hospital that was part of the patient’s network. Patients can receive these bills despite having no opportunity to select around an out-of-network provider in advance.
On May 9, 2019, I announced four principles to guide congressional efforts to prohibit exorbitant bills resulting from patients’ accidentally or unknowingly receiving services from out-of-network physicians. Unfortunately, the Congress has failed to act, and patients remain vulnerable to surprise billing.
In the absence of congressional action, my Administration has already taken strong and decisive action to make healthcare prices more transparent. On June 24, 2019, I signed Executive Order 13877 (Improving Price and Quality Transparency in American Healthcare to Put Patients First), directing certain agencies — for the first time ever — to make sure patients have access to meaningful price and quality information prior to the delivery of care. Beginning January 1, 2021, hospitals will be required to publish their real price for every service, and publicly display in a consumer-friendly, easy-to-understand format the prices of at least 300 different common services that are able to be shopped for in advance.
We have also taken some concrete steps to eliminate surprise out‑of-network bills. For example, on April 10, 2020, my Administration required providers to certify, as a condition of receiving supplemental COVID-19 funding, that they would not seek to collect out-of-pocket expenses from a patient for treatment related to COVID-19 in an amount greater than what the patient would have otherwise been required to pay for care by an in-network provider. These initiatives have made important progress, although additional efforts are necessary.
Not all hospitals allow for surprise bills. But many do. Unfortunately, surprise billing has become sufficiently pervasive that the fear of receiving a surprise bill may dissuade patients from seeking appropriate care. And research suggests a correlation between hospitals that frequently allow surprise billing and increases in hospital admissions and imaging procedures, putting patients at risk of receiving unnecessary services, which can lead to physical harm and threatens the long-term financial sustainability of Medicare.
Efforts to limit surprise billing and increase the number of providers participating in the same insurance network as the hospital in which they work would correspondingly streamline the ability of patients to receive care and reduce time spent on billing disputes.
The AAA will continue to advocate for the resources necessary to sustain life-saving mobile healthcare.
House Committees Consider Balance Billing Proposals
This past Tuesday and Wednesday, respectively, the House Ways & Means and Education & Labor Committees marked up their proposals on balance or “surprise” billing. As we reported on Monday of this week, the Ways & Means Committee proposal, the Consumer Protections Against Surprise Medical Bills Act (H.R. 5826), did not include a provision on ground ambulance services. The House Education & Labor proposal, The Ban Surprise Billing Act (H.R. 5800), however, included a provision to create a federal advisory committee to recommend restrictions on the ability of ground ambulance service providers and suppliers to balance bill.
The Ways & Means Committee reported out H.R 5826 favorably by voice vote. While the Education & Labor Committee also reported out H.R. 5800 favorably, the vote was 30 to 13 as a block of its Committee members preferred the approach of the Ways & Means proposal on how to address balance billing for other providers. It is now up to House leadership to determine next steps on how the chamber will approach a final package on balance billing.
While H.R. 5800 as reported out by the Education & Labor Committee still includes the provision on ground ambulance services, Chairman Scott (D-VA) and Ranking Member Foxx (R-NC) prior to mark up had removed the most problematic language in the bill. As introduced, H.R. 5800 would have given the Department of Health and Human Services the authority to issue regulations to restrict balance billing based on the findings of the advisory committee. This would have eliminated federal lawmakers from being able to evaluate the recommendations prior to the changes being implemented. The language was removed in the chairman’s mark of the bill, and thus the Congress would now have an opportunity to debate and craft legislation on the recommendations.
The AAA along with the International Association of Fire Chiefs (IAFC), International Association of Firefighters (IAFF) and National Association of EMTs (NAEMT) had advocated against the ground ambulance provision. We thank Chairman Scott, Ranking Member Foxx and members of the Committee for listening to our concerns and removing the regulation authority language.
Only one of the four pieces of legislation on balance billing reported out by congressional committees includes a provision on ground ambulance services. We will continue to advocate to preserve the ability of local governments to determine the rates and standards for their EMS systems and against the inclusion of a ground ambulance provision in a final package on balance billing.
We will keep you apprised of new developments on the issue.
Balance Billing Update
This content is for AAA members only.
Please either or Join!
Update on AAA Legislative Priorities
The American Ambulance Association has been working hard to accomplish the legislative goals of the membership in the 116th Congress. The AAA would like to take this opportunity to provide an update on what we have accomplished thus far in the 116th Congress.
Balance/Surprise Billing
Balance/surprise billing is a hot button issue that recently came into the spotlight at the start of the 116th Congress. With the President’s announcement calling for Congress to pass legislation that would end surprise billing for patients, there has been an increase in Congressional action on the issue including introduced legislation, discussion drafts and hearings in all committees of jurisdiction. The AAA has been working tirelessly with the Congressional committees of jurisdiction to educate Members and staff on the unique characteristics of EMS systems and that it would be inappropriate to apply the same restrictions on balanced billing to ground ambulance services.
The AAA has formed a working group comprised of AAA member volunteers that have worked on policy and messaging on balance billing. The working group has submitted comments to the Energy and Commerce Committee and Senate HELP committees advocating that the ambulance industry is unique from other stakeholders, and as such, should be looked at differently. Ambulance service providers and suppliers are required by law to treat and transport all patients, regardless of their ability to pay and are heavily regulated at the local level. The AAA has been working to communicate these factors that place the ambulance industry in a different situation than many other stakeholders.
Public Safety Officers Death Benefit (PSOB)
The Public Safety Officers Death Benefit (PSOB), a one-time benefit paid to families of first responders killed in the line of duty, is an issue that the AAA has passionately advocated for over many years. In the 116th Congress, the AAA has secured introduction of legislation in the House of Representatives, H.R. 2887, the Emergency Medical Service Providers Protection Act. H.R. 2887 would extend the PSOB to first responders employed by private for-profit EMS agencies. The AAA was able to secure several commitments from Members of Congress to cosponsor the legislation during Stars of Life meetings in Washington, DC. In addition to taking action to move H.R. 2887 through the legislative process, the AAA will be engaging in an outreach campaign in the next few weeks.
Dialysis Off-Set Restructuring
The AAA has worked toward reintroduction of legislation to restructure the offset that was passed into law in the Bipartisan Budget Act of 2018 (H.R. 1892) in the 115th Congress. This offset included a total cut of 23% to the Medicare reimbursement for basic life support (BLS) non-emergency transports performed by all ambulance service suppliers and providers to and from dialysis centers. This cut served as an offset to the 5-year extension of Medicare add on payments that our industry worked hard to get extended.
The AAA has secured introduction of legislation in both the House and Senate. H.R. 3021 was introduced by Representatives LaHood (R-IL) and Sewell (D-AL) and S. 228 by Senators Cassidy (R-LA) and Jones (D-AL). If passed, this legislation would change the cut that is currently in place so that it applies specifically to companies conducting over 50% ESRD non-emergency transports. Those ambulance services with over 50% ESRD transports would get a cut of 29.5%, while those doing less would receive a 15.5% cut. The AAA will continue to work toward movement and passage of this legislation that would better distribute the reduction to those providers which do almost exclusively non-emergency dialysis transports and thus have a lower cost of providing services.
Medicare Priorities Bill
The AAA has crafted legislation that is specifically aimed at addressing major Medicare ambulance industry issues. The issues that will be included in future legislation include making Medicare ambulance add-ons permanent, implementing a prior-authorization program across the nation, allowing for transportation to alternative destinations, reducing regulatory burdens, and providing relief through maintaining many zip codes as rural following the next census. The AAA is working to get this Medicare priorities legislation introduced in the coming months so that we can get to work on solving these Medicare issues that impact our industry as a whole.
VA Legislation
Another priority that that the AAA has been diligently working toward getting introduced is Veterans Affairs (VA) legislation. The Veterans Reimbursement for Emergency Ambulance Services Act (VREASA) introduced by Congressman Tipton (R-CO) would provide veterans with reimbursement for emergency ambulance services when a Prudent Layperson would have a reasonable expectation that a delay in seeking immediate medical attention will jeopardize the life or health of the veteran. This legislation was introduced as a result of the VA consistently requiring all medical records be provided, including the records of treatment after the emergency service has taken place. Should those records show that it was not a life threatening emergency or a false alarm, the claim for reimbursement is being denied. The VA legislation would mandate that the VA apply the “prudent layperson” definition of emergency to determine coverage of ambulance claims.
The AAA is also working toward addressing two other issues with the VA to enforce more prompt payment by the VA and treating the VA as the first payor, similar to Medicare, as it is determined whether there is a different primary payor. The AAA has been working with Senators Collins and Tester on language help solve this ongoing and serious reimbursement issue.
In our next update, we will be reporting on the progress the AAA has made this year on regulatory issues.
Questions? Contact Us
If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.
Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025
Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027
Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026
Thank you for your continued membership and support
Member Update on Balance Billing
This morning Ruth Hazdovac and Aidan Camas of AAA staff and Kathy Lester, Esq, Healthcare Consultant to the AAA attended a briefing held by the House Energy & Commerce Committee on the issue of surprise/balance billing. At the briefing, staff for Chairman Frank Pallone (D-NJ) and Ranking Member Greg Walden (R-OR) announced that they would be releasing a bipartisan discussion draft, the No Surprises Act, which would “protect consumers from surprise medical bills and increase transparency in our health care system.”
As of now, ground and air ambulances are NOT included in the discussion draft. However, the committee is asking for comments on ground and air ambulance and recommendations on how to provide relief to the consumer in this area. The AAA has a Balance Billing Work Group that is hard at work developing a policy recommendation that will work for our members.
The House Ways and Means Health Subcommittee Chairman Lloyd Doggett also announced today that the Health Subcommittee will hold a hearing next week entitled “Hearing on Protecting Patients from Surprise Medical Bills.” AAA Staff will be at the briefing and provide a timely update to membership on any developments.
The AAA team will be submitting comments and policy recommendations based off the work of the Balance Billing Work Group to both the Energy & Commerce and Ways & Means Committee to ensure that the views of our members are well represented. We will also be reaching out to AAA members in the states of key policymakers on the Committees to submit comments, as well. The AAA will also provide members with key talking points in the event they are contact by their Members of Congress or their staff.
Questions? Contact Us
If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.
Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025
Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027
Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026
Thank you for your continued membership and support.
AAA 2016 State Balanced Billing & Direct Pay Survey Results Released
Just Released!
The AAA is providing its members with the results of two important surveys conducted of state laws impacting ambulance services. The first chart entitled “2016 State Balance Billing Survey” shows whether a state restricts balancing billing of patients. The second entitled “2016 State Direct Pay Survey” lists whether a state has a law requiring an insurer to send payment directly to a non-contracted ambulance service or a law allowing the insurer do send payment to the patient. We thank AAA Medicare Consultant Brian Werfel for compiling the data and members of the AAA Medicare Regulatory Committee and the AAA membership to which Brian reached out for their assistance.