Department of Health and Human Services (HHS) Archives - Page 4 of 4

HHS OIG Issues Advisory Opinion on Community Paramedicine

Written by Brian Werfel on March 20, 2019. Posted in Member Advisories, Member-Only, News, Operations, Patient Care, Talking Medicare.

HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions

On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions.

The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions.

Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include the requirement that the patient have CHF and either: (1) be currently admitted as an inpatient at Requestor’s hospital or (2) be a patient of Requestor’s outpatient cardiology department, and who had been admitted as an inpatient at Requestor’s hospital within the previously 30 days. The clinical nurses would identify those patients at higher risk of hospital admission based on a widely used risk assessment tool. The clinical nurses would also determine whether the patient had arranged to receive follow-up care with Requestor’s outpatient CHF center. Patients that do not intend to seek follow-up care with the CHF center, or who have indicated that they intend to seek follow-up care with another health care provider, would not be informed of the current program. Eligible patients would be informed of the current program, and offered the opportunity to participate. The eligibility criteria for the expanded program for COPD patients would operate in a similar manner.

Eligible patients that elect to participate in the current program or the expanded program would receive in-home follow up care for a thirty (30) day period following enrollment. This follow up care would consist of two visits every week from a community paramedic employed by the Requestor. As part of this in-home care, the community paramedic would provide some or all of the following services:

A review of the patient’s medications;
An assessment of the patient’s need for follow-up appointments;
The monitoring of the patient’s compliance with their discharge plan of care and/or disease management;
A home safety inspection; and/or
A physical assessment, which could include checking the patient’s pulse and blood pressure, listening to the patient’s lungs and heart, checking the patient’s cardiac function using an electrocardiogram, checking wounds, drawing blood and running blood tests, and/or administering medications.

The community paramedic would use a clinical protocol to deliver interventions and to assess whether a referral for follow-up care is necessary. To the extent the patient requires care that falls outside the community paramedic’s scope of practice, the community paramedic would direct the patient to follow up with his or her physician. For urgent, but non-life threatening conditions, the community paramedic would initiate contact with the patient’s physician.

The Requestor certified that the community paramedics would be employed by the Requestor on either full-time or part-time basis, and that all costs associated with the community paramedic would be borne by the Requestor or its affiliates. The Requestor further certified that no one involved in the operation of the program would be compensated based on the number of patient’s that enroll in the programs. While one of the states in which the Requestor operates does reimburse for community paramedicine services, Requestor certified that it does not bill Medicaid for services provided under the program.

The question posed to the OIG was whether any aspect of the program violated either the federal anti-kickback statute or the prohibition against the offering of unlawful inducements to beneficiaries.

In analyzing the program, the OIG first determined that the services being offered under the program offer significant benefit to enrolled patients. The OIG specifically cited the fact that one state’s Medicaid program reimbursed for similar services as evidence of this value proposition. For this reason, the OIG concluded that the services constitute “remuneration” to patients. The OIG further concluded that this remuneration could potentially influence a patient’s decision on whether to select Requestor or its affiliates for the provision of federally reimbursable items and services. Therefore, the OIG concluded that the program implicated both the anti-kickback statute and the beneficiary inducement prohibition.

The OIG then analyzed whether the program would qualify for an exception under the so-called “Promoting Access to Care Exception.” This exception applies to remuneration that improves a beneficiary’s ability to access items and services covered by federal health care programs and which otherwise pose a low risk of harm. The OIG determined that while some aspects of the program would likely fall within this exception, other aspects would not. Specifically, the OIG cited the home safety assessment as not materially improving a beneficiary’s access to care.

Having concluded that there was no specific exception that would permit the arrangement, the OIG then analyzed the arrangement under its discretionary authority, ultimately concluding that the program posed little risk of fraud or abuse. In reaching this conclusion, the OIG cited several factors:

The OIG felt that the potential benefits of the program outweighed the potential risks of an improper inducement to beneficiaries. The OIG cited the fact that beneficiaries must have already selected Requestor or its associated clinic as their provider of services before learning about the program. As the OIG indicated “the risk that the remuneration will induce patients to choose Requestor or the Clinic for CHF- or COPD-related services is negligible because patients already have made this selection.” The OIG also noted that the community paramedic will inform beneficiaries of their right to choose a different provider prior to referring the beneficiary to the Requestor or its clinic for services outside the scope of the program.
The OIG noted that, to the extent the program works as intended, it would be unlikely to lead to increased costs to federal health care programs. As noted above, Requestor had certified that it would not bill federal health care programs for the services of the community paramedic.
The program was designed in a way as to minimize the potential for interference with clinical decision-making.
The Requestor certified that it would not advertise or market the program to the public, thereby minimizing the chances of beneficiaries learning about the program prior to selecting Requestor for their CHF- or COPD-related care.
The OIG noted that the program appeared to be reasonably tailored to accomplish the goal of reducing future hospital admissions. For example, the OIG cited the fact that the Requestor limited inclusion in the program to patients deemed to be at a higher-than-normal risk of hospital admission or readmission, and that it made these determinations using a widely used risk assessment tool. The OIG noted that these patients would likely benefit from the continuity of care offered under the program. In addition, the OIG noted that the community paramedics would be in a position to keep the patients’ physicians appraised of their health by documenting all of their activities.

Potential Impact on Mobile Integrated Health and/or Community Paramedicine Programs

OIG advisory opinions are issued directly to the requestor of the opinion. The OIG makes a point of noting that these opinions cannot be relied upon by any other entity or individual. Legal technicalities aside, the OIG’s opinion is extremely helpful to the industry, as it lays out the factors the OIG would consider in analyzing similar arrangements. Thus, the opinion is extremely valuable to ambulance providers and suppliers that current operate, or are considering the operation of, similar mobile integrated health and/or community paramedicine programs.

Release: CMMI Announces Ambulance Innovative Payment Pilot Program

Written by AAA Staff on February 14, 2019. Posted in Advocacy Priorities, Government Affairs, Medicare, Member Advisories, News, Press, Reimbursement.

February 14, 2019

For Immediate Release
Contact Maria Bianchi
American Ambulance Association
202-802-9020
info@ambulance.org

CMMI Announces Ambulance Innovative Payment Pilot Program

Washington, DC – Today, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) announced the launch of the Emergency Triage, Treat and Transport (ET3) Model. During the next five years, this model will test paying ambulance providers and suppliers when they transport beneficiaries to locations other than an emergency department, if the alternative location is more appropriate medically for the patient. It will also test paying for health care services provided by qualified health care professionals or through telehealth at the scene even if the ambulance does not transport the patient.

While there are several important details yet to be released, this model appears to track the recommendations the American Ambulance Association, our members, and other industry partners have been working with CMS to implement.

“Over the last 7 years, the AAA and our members have been working to develop an innovative payment framework to modernize the Medicare ambulance benefit,” said AAA President Aarron Reinert. “We are pleased that CMS is taking this important step and look forward to working closely with Administrator Verma, Director Boehler and their teams on the details of the ideas announced today to ensure the appropriate implementation.”

Representatives of the American Ambulance Association also participated in the CMS announcement of this model today in DC. Senior Department of Health and Human Services (HHS) officials including Secretary Alex Azar, CMS Administrator Seema Verma and CMMI Director Adam Boehler spoke at the event. AAA President-Elect Shawn Baird represented the AAA at the announcement.

While the details of the program are still under development and will be communicated through program guidance, a few general details were provided at the event.

The Emergency Triage, Treat and Transport (ET3) Model, would test two new ambulance payment methods. Under ET3, participating ambulance service providers or suppliers would be able to receive payment for:

treatment in place with a qualified health care practitioner, either on-the-scene or connected using telehealth; and
for unscheduled, emergency transport of Medicare beneficiaries to alternative destinations (such as 24-hour care clinics) other than destinations covered under current regulations (such as hospital EDs).

The program will be national in scope and thus open to all ambulance service suppliers and providers who meet the program requirements, which are still being finalized. The program will be voluntary so providers and suppliers who chose not to participate can continue to be paid under current policy. CMS anticipates releasing applications for the program this summer and an anticipated start date for the program in early 2020.

While seeing the specific details of the program will be crucial, we are very pleased that CMMI is announcing its commitment today to test multiple innovative payment models for ambulance service providers and suppliers. The AAA and our volunteer leaders and members have been working in a collaborative manner with other EMS organizations for the last 5 years to develop an evidence-based, data-driven structural framework to support the adoption of innovative payment models for ambulance emergency and non-emergency services. In 2016, the AAA issued a joint statement with NAEMSP, NAEMSO, and NAEMT outlining this framework. During the last two year, the AAA has worked closely with the Congress, CMS and the CMMI to seek the implementation of this framework. To encourage as broad an adoption as possible, we have focused on achieving these goals through the regulatory process.

The AAA is committed to the development and implementation of innovative payment models. It is critical that they be designed in a manner that will ensure their success. Adoption of the framework along with having the necessary data to establish reimbursement rates that reflect the cost of providing ambulance services will usher in a new era of ambulance services for not only Medicare beneficiaries, but also for all Americans. As part of the effort to modernize the ambulance benefit, ambulance service suppliers should be recognized as providers of health care services and not merely a transportation benefit. The days of merely driving patients to and from other providers are long gone.

We believe that our efforts and those of the Administration will help us achieve this exciting goal. The AAA supports expanding the destination site for 9-1-1 and similar calls, which is currently limited to hospital emergency departments. For some patients, it is more appropriate to take them to other types of facilities, such as rural health clinics, substance or behavioral health facilities, and inpatient psychiatric hospitals. Allowing ambulance services to use state and local protocols to help triage patients to the most appropriate setting will help address the opioid epidemic and better care for patients with behavioral health issues, as well as urgent low acuity medical conditions.

We want to thank the Congress and the groups at CMS and CMMI who began to lay the ground work for the next phase of innovative payment models last winter as well. We also greatly appreciate the efforts of other EMS representatives who worked with the CMMI to help push for the pilot program.

The AAA will continue to advocate for data and evidence-based changes to the Medicare ambulance fee schedule which allow ambulance service providers and suppliers to provide even better medical services to patients.

###

About the American Ambulance Association
The American Ambulance Association, formed in 1979, represents 500 ambulance services across the United States that serve their communities with emergency medical services, interfacility mobile healthcare, and community paramedicine 24/7/365. The Association serves as a voice and clearinghouse for mobile healthcare, and views prehospital care as an essential part of the total public health care system.

Update on HHS OIG Reports on Ambulance Services

Written by Kathy Lester on December 20, 2018. Posted in Member Advisories, Member-Only, News, Reimbursement.

Update on HHS Office of the Inspector General Reports on Ambulance Services

The HHS Office of the Inspector General (OIG) released an update to the Work Plan as the year comes to a close. There are no new projects specific to ambulance services, but the update does provide a summary of three projects that have been completed or are in progress.

Medicare Part B Payments for Ambulance Services Subject to Part A Skilled Nursing Facility Consolidated Billing Requirements (expected release 2019). In this work, the OIG seeking to determine whether ambulance services paid by Medicare Part B were subject to Part A SNF consolidated billing requirements. The OIG will also assess the effectiveness of edits in CMS’s Common Working File to prevent and detect Part B overpayments for ambulance transportation subject to consolidated billing. Prior OIG reports have identified high error rates and significant overpayments for services subject to SNF consolidated billing.
Ambulance Services – Supplier Compliance with Payment Requirements (partially completed; remainder expected release 2019). Prior OIG work has found that Medicare made inappropriate payments for advanced life support emergency transports. The OIG seeks to determine whether Medicare payments for ambulance services were made in accordance with Medicare requirements.

The first report of this project found that Medicare made improper payments of $8.7 million to providers for nonemergency ambulance transports to destinations not covered by Medicare, including the identified ground mileage associated with the transports. The report identified that the majority of the improperly billed claim lines (59 percent) were for transports to diagnostic or therapeutic sites, other than a physician’s office or a hospital, that did not originate from SNFs.

In this report, the OIG recommended that the CMS: (1) direct the Medicare contractors to recover the portion of the $8.7 million in improper payments made to providers for claim lines that are within the claim-reopening period; (2) for the remaining portion of the $8.7 million, which is outside of the Medicare reopening and recovery periods, instruct the Medicare contractors to notify providers of potential improper payments so that those providers can exercise reasonable diligence to investigate and return any identified similar improper payments, and identify and track any returned improper payments; (3) direct the Medicare contractors to review claim lines for nonemergency ambulance transports to destinations not covered by Medicare after the audit period and recover any improper payments identified; and (4) require the Medicare contractors to implement nation-wide prepayment edits to ensure that payments to providers for nonemergency ambulance transports comply with Federal requirements.

The third report is linked to a case study of the closure of the Rosebud Hospital Emergency Department. Rosebud is an Indian Health Service (IHS) hospital that discontinued emergency services. The closure of the Rosebud emergency department (ED) followed a notice of intent by the CMS to terminate Rosebud Hospital from the Medicare program. Representatives of the Rosebud Sioux Tribe raised concerns to OIG about the Rosebud ED closure and linked that closure to several patient deaths that occurred during ambulance transports to other facilities when emergency care was unavailable locally. In response to these concerns, the OIG seeks to examine factors considered and procedures involved in IHS’s decisions to close and later reopen the Rosebud ED. The OIG will also assess IHS’s management, coordination, and communication related to the closure and will identify lessons learned that IHS could apply to similar situations in the future. The report was expected to be published in 2018, but has not as of this date.

The AAA continues to monitor the OIG work plan and engage as appropriate with key officials. Our goal is to provide educational background to address any misunderstandings or incorrect assumptions that may exist.

Federal District Court Judge Strikes Down the ACA

Written by Brian Werfel on December 17, 2018. Posted in Legislative, Member Advisories, News, Reimbursement.

On December 14, 2018, a federal district court judge for the Northern District of Texas issued a ruling striking down the Affordable Care Act (ACA) on the grounds that the Individual Mandate was unconstitutional, and that the rest of the law cannot withstand constitutional scrutiny without the Individual Mandate.

District Court Judge Reed O’Connor’s decision relates to a lawsuit filed earlier this year by 20 states and two individuals. The plaintiffs argued that the Tax Cuts and Jobs Act of 2017 — which amended the Individual Mandate to eliminate the penalty on individuals that failed to purchase qualifying insurance effect January 1, 2019 — rendered the Individual Mandate unconstitutional. The plaintiffs further argued that the Individual Mandate was inseverable from the rest of the ACA, and, therefore, that the entire ACA should be struck down.

The defendants in this case were the United States of America, the U.S. Department of Health and Human Services (HHS), Alex Azar, in his capacity as the Secretary of HHS, and David J. Kautter, in his capacity as the Acting Commissioner of the Internal Revenue Service (IRS). 16 states and the District of Columbia intervened as additional defendants.

In order to properly understand the district court’s ruling, it is necessary to revisit the Supreme Court’s 2012 decision on the constitutionality of the ACA, National Federal of Independent Business v. Sebelius (NFIB). In that case, 26 states, along with several individuals and a business organization challenged the ACA’s Individual Mandate and Medicaid expansion provisions as exceeding Congress’ enumerated powers. In a complicated decision, the majority of Justices ruled that the Individual Mandate was unconstitutional under Congress’ authority to regulate interstate commerce, but that the provision could be salvaged under Congress’ authority to lay and collect taxes. In reaching this conclusion, the majority of Justices focused on the “shared responsibility payment” aspect of the Individual Mandate, which imposed a tax on those individuals that failed to purchase or otherwise obtain qualifying health insurance. The majority of Justices concluded that the shared responsibility payment was a “tax.” It was therefore constitutional under the Congress’ general taxing authority.

In sum, the Supreme Court ruled that Congress lacked the power to compel individuals to buy qualifying health insurance, but that it could constitutionally impose a tax on those that failed to purchase or otherwise obtain qualifying health insurance.

In the current case, the court was asked to reconsider the Individual Mandate in light of the TCJA, which “zeroed” out of the shared responsibility payment, effective January 1, 2019. The plaintiffs argued that the Individual Mandate could no longer be justified as a valid exercise of Congress’ taxing authority. The federal government and its agents did not necessarily contest the plaintiffs’ argument with respect to the Individual Mandate. By contrast, the intervening states and the District of Columbia argued that the Individual Mandate could continue to be construed as a tax because it continues to satisfy the factors set forth by the Supreme Court in NFIB.

Judge O’Connor sided with the plaintiffs, holding that, because the Individual Mandate would no longer trigger a tax beginning in 2019, the Supreme Court’s ruling on this point in NFIB was no longer applicable. He therefore concluded that the Individual Mandate could no longer be upheld under Congress’ taxing authority. Judge O’Connor then fell back on the Supreme Court’s previous holding that the Individual Mandate, as a stand-alone command, remained unconstitutional under the Interstate Commerce Clause. Judge O’Connor then ruled that the Individual Mandate could not be severed from the rest of the ACA. On this point, the judge cited the express provisions of the ACA, as well as the Supreme Court’s decisions in NFIB and King v. Burwell.

What this decision means

On its face, the decision strikes down the Affordable Care Act in its entirety. However, the ruling is likely to be appealed to the Fifth Circuit Court of Appeals. Most legal experts expect that, regardless of the decision at the Circuit Court, the case is likely to make its way up to the Supreme Court.

Pending the resolution of these appeals, the Administration has adopted a “business as usual” approach. The White House has already indicated that it will not attempt to enforce the ruling during the appeals process. CMS Administrator Seema Verma recently tweeted that the decision will have “no impact to current coverage or coverage in a 2019 plan.”

The American Ambulance Association will continue to monitor this case as it makes its way through the appeals process, and we will notify our members of any new developments.

OIG Releases SemiAnnual Report to Congress

Written by AAA Staff on June 5, 2017. Posted in News, Regulatory.

The Office of the Inspector General of the Department of Health and Human Services (HHS-OIG) recently issued the “Measuring Compliance Program Effectiveness: A Resource Guide“. The Guide was developed by a group of HHS-OIG professionals who wanted to provide a set of metrics by which health care providers can measure the elements of their compliance program. The authors recognize that not all the metrics are applicable to all health care providers but intended to be used as a guide. The Guide was released on March 27.

You can also read the full “Semiannual Report to Congress (October 1, 2016 – March 31, 2017)“.

HHS to Administer $70 million in Funds to Combat Opioid Crisis

Written by AAA Staff on June 1, 2017. Posted in Drugs & Pharma, Emergency Preparedness, Field Resources, News, Patient Care.

The Department of Health and Human Services (HHS) announced $70 million in grants to help communities and health care professionals combat the ongoing opioid crisis that is ravaging communities across the U.S. The majority of the money will be used to help prevent opioid-induced deaths and to provide treatment for people with opioid use disorders, including $28 million allotted for medication-based treatment. More than 33,000 lives were claimed in 2015 due to opioid overdoses.

$41.7 million of the funding is set to expand resources and training for first responders on how to use emergency treatments, such as Narcan, to help reverse and treat overdoses. In many cases, first responders are often the difference between life and death for opioid users who experience an overdose, so it is imperative health care professionals have access to the needed resources and training to help save lives. The additional funding aims to help paramedics, EMTs and other emergency service personnel gain access to much-needed resources.

“The grants we announce today clearly demonstrate our efforts to meet the opioid crisis with every tool at our disposal,” said Substance Abuse and Mental Health Services Administration Acting Deputy Assistant Secretary Kana Enomoto. “The evidence-based training, medication, and behavioral therapies provided here will save lives and help people with addictions start a path toward reaching their potential.”

In addition to the most recent grants, $485 million in grants were awarded in April to treat and prevent opioid abuse.

To read more about the grants, please visit the HHS web site.

ACA Repeal & Reform – What it Means (Part Two)

Written by Kathy Lester on March 20, 2017. Posted in Government Affairs, Member Advisories.

By: Tristan North and Kathy Lester, JD, MPH

This is the second part of a two part Member Advisory by Tristan North and Kathy Lester on ACA Repeal & Reform. Read Part One: ACA Repeal & Reform – What It Means for Ambulance Services (Pt. 1).

The remainder of this alert provides more detail about the House legislation, as well as key bills that have been introduced in the Senate. It also provides background on the process to date.

House Legislation, The American Health Care Act (AHCA)

While three House Committees have referred the ACHA to the full House, over the weekend it became clear that there Speaker Paul Ryan (R-WI) will entertain amendments to the current text. As these agreements become available, we will provide an updated analysis.

The AHCA seeks to redefine the ACA in significant ways. First, it would repeal the penalties related to the individual and employer mandates. It would allow insurance companies to apply a 30 percent late-enrollment surcharge on individual and small group market applicants who have not had coverage in the previous 63 days. It would phase out the Medicaid expansion program, shifting it to a per capita cap model. It would also eliminate many of the taxes implemented under the ACA. It would delay implementation of the “Cadillac Tax” on high cost health plans until 2025. It would repeal the cost sharing subsidies program.

The AHCA would retain certain popular ACA provisions, including allowing children to stay on their parents’ insurance until age 26 and requiring insurers to cover people with pre-existing conditions.

Some additional highlights of the plan include:

Establishing a temporary Patient and State Stability Fund to “lower patient costs and stabilize State markets.” Dollars from the fund could be used to:
- Provide assistance to high-risk individuals who do not have access to health insurance coverage offered through an employer.
- Provide incentives to appropriate entities to enter into arrangements with the State to help stabilize premiums.
- Reduce the cost of providing health insurance coverage in the individual and small group market for otherwise high-cost individuals.
- Promote participation in the individual and small group markets in the State and increasing available health insurance options.
- Promote access to preventive services, dental care services, and mental health and substance use disorder services.
- Provide payments, directly or indirectly, to health care providers for the provision of certain health care services.
- Provide assistance to reduce consumer out-of-pocket costs for individuals enrolled in health insurance coverage in the State.
Eliminates presumptive eligibility determinations for Medicaid.
Decreases mandatory Medicaid income eligibility level from 133 percent of the federal poverty level (FPL) to 100 percent, effective Dec. 31, 2019.
Provides $10 billion total over five years for FMAP payments to non-expansion States that adjust the payment amounts otherwise provided to health care providers for services furnished to Medicaid enrollees.
Increases the basic limit on aggregate health savings account (HSA) contributions to equal the maximum limit on the amount of the annual deductible and out-of-pocket expenses of a high deductible health plan beginning in 2018.
Repeals current actuarial value standards related to the ACA metal levels of coverage, effective for plan years 2020 and beyond.
Eliminates the Disproportionate Share Hospital (DSH) payment cuts.
Repeals Prevention and Public Health Fund funding for FY 2019 and beyond.
Provides $422 million in funding for FY 2017 for the Community Health Center Fund, which makes grants to Federally-Qualified Health Centers (FQHCs).

The Congressional Budget Office (CBO) estimates that the AHCA will reduce the deficit by $337 billion. CBO predicts that by 2018, 14 million more people would join the ranks of the uninsured under the AHCA. This number would reach the 24 million by 2026, when “an estimated 52 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.” CBO also predicts that while there would be an initial 15 to 20 percent increase in premiums in 2018, average premium amounts would drop to 10 percent compared to current law. CBO indicates that Medicaid expenditures would fall by $880 billion over 10 years and 14 million fewer Americans would be enrolled in Medicaid by 2026.

The American Medical Association (AMA), AARP, the American Hospital Association (AHA), the Federation of American Hospitals, the Association of American Medical Colleges, the American Nurses Association, the American College of Physicians oppose the AHCA. Other organizations have expressed serious concern, including the American Health Care Association (nursing homes) and the American Academy of Family Physicians. America’s Health Insurance Plans (AHIP) has expressed concerns, but is open to compromise.

Senate ACA Reform Legislation

It is more difficult to anticipate how the Senate will react to the House legislation. However, it is likely that Senate Republicans will support at least some of the following reform ideas:

HSAs could be paired with health insurance plans that have high deductibles and low premiums. Republicans favor HSAs because they generally shift a greater amount of financial responsibility to the beneficiary. HSA could be designed to include tax-free contributions, growth of savings, and medical expense withdrawals.

High-risk pools. While policies to address the problem of the risk pools could take many forms, there have been focused efforts to remove individuals with pre-existing conditions from the general pool of health insurance to lower the premiums for the young and healthy. Some States have attempted to implement high-risk pools in the past; however, previous iterations have been expensive.

Medicaid reform. Republicans remain concerned about the expense of the Medicaid program and have suggested per-capita grants, which would allocate a set amount of money per enrollee in the state.

Tax credits for health insurance. Republicans prefers to use tax credits to help people buy insurance rather than keep the ACA’s subsidies. Several proposals have been discussed, including age-adjusted credits or credits based on number of family members.

While there may be an effort to amend the House’s AHCA, there is at least one Senate bill that has earned some attention. Sens. Bill Cassidy (R-LA) and Susan Collins (R-ME) introduced “The Patient Freedom Act” earlier this year. It would replace the current Exchange structure and allow States to select from one of three alternatives for providing coverage to its citizens.

First, States could re-implement the ACA coverage they have been relying upon, if the think it is working for them. States could continue to receive federal premium tax credits, cost-sharing subsidies, and Medicaid dollars, to the extent that such subsidies do not exceed a certain limit. Second, States could enact a new market-based system that would retain popular ACA provisions, such as protecting those with pre-existing conditions. They could continue to receive funding equal to 95 percent of federal premium tax credits and cost-sharing subsidies, as well as the federal match for Medicaid expansion. States could choose to receive funds in the form of per beneficiary grants or advanced refundable tax credits, but in both cases, funds would be deposited in a Roth Health Savings Account (HSA), meaning the money would go directly to the patient. Third, States could decide not to take any federal assistance and design and oversee the insurance market without federal intervention.

This legislation also seeks to curb high costs medical expenses and includes a broad provision seeks to ensuring access to emergency services without excessive charges for out-of-network services. AAA and our members are working to explain the unique nature of ambulance services to avoid this provision inappropriately being applied to ground ambulance services.

It is likely that other proposals will arise in the Senate and that the Senate Finance Committee will develop a proposal that could amend the AHCA or take a different path. We will provide you with more information as the proposals develop.

Process for Repeal and Reform

Republicans intend to address repeal and replace through three actions. First, the Congress passed the 2017 Budget Reconciliation legislation to repeal key structural pieces of the ACA. The second set of actions are being undertaken by the Trump Administration, which is making changes to the ACA through the administrative or regulatory process. Third, congressional Republicans are now in the process of moving a second piece of legislation later in the year that would address the specifics of the replace.

With passage of the FY2017 Budget Resolution (S.Con.Res. 3), Congressional Republicans took the first step to repealing the ACA. On January 12, the Senate voted 51 to 48 in favor of a FY2017 Budget, which included the budget framework for repealing the ACA. The House followed suit on January 13 by a vote of 227 to 198. While not binding or needing the signature of the President, the passage of the FY2017 Budget provides authority to the House and Senate committees of jurisdiction to move forward on the provisions of a FY2017 Budget Reconciliation package. The Reconciliation package is binding and would be sent to President Trump for his signature. This would actually repeal the ACA.

Congressional Republicans are using the budget reconciliation process, as it only requires a simple majority in the Senate to pass. Senate Democrats can therefore not filibuster the package unlike most legislation that requires 60 votes to end debate. This is the same process Democrats used back in 2010 to pass portions of the ACA.

During the week of March 6, the House Energy & Commerce and Ways & Means Committee passed their respective sections of repeal in replace as part of the FY2017 Budget Reconciliation package which has been named the American Health Care Act (AHCA). On March 16, the House Budget Committee combined the sections and approved the package. The House Rules Committee is expected to meet on the rules debate by Wednesday with the full House expected to consider the bill on March 23. Passage of the bill is likely but not certain as some more conservative as well as more moderate members of the Republican Caucus are expected to join with possibly all Democrats in opposition to the bill. Several more moderate as well as conservative Republican Senators have also voiced concerns leaving in doubt whether the bill can pass the Senate.

Repealing the ACA is actually much easier than passing a second piece of legislation later to address the specifics of the replacement. Much of the ACA replacement package is subject to a point of order and can’t be included in a Budget Reconciliation bill because such a package can only be used for provisions that increase or reduce the budget. So Republicans will need the support of eight Senate Democrats to pass a second replacement package. All this will ensure a very intense next few months or longer as repeal and replacement moves forward.

Administrative Actions

As noted, another critical piece of the three-step process of repealing and replacing/refining the ACA comes from the Trump Administration. One of President Trump’s first actions after being sworn in as the 45^th President of the United States was to issue an Executive Order to federal agencies to “waive, defer, grant exemptions from, or delay the implementation of any provision or requirement [of the Affordable Care Act]…that would impose a fiscal burden on any State, or a cost, fee, tax, penalty, or regulatory burden on an individual.” The Executive Order also directs agencies to provide relief to the states, as well as “waive” regulations or costs on “makers of medical devices, products, or medications.”

Although the Executive Order does not legally halt any of the policies from continuing in its current state, such as the individual mandate or the medical device excise tax, it does give a clear signal from the new Trump Administration on its intent to dismantle the ACA quickly, without waiting for Congress. The Order does confirm that the new Administration will follow the Administrative Procedure Act, which requires federal agencies to go through a formal rulemaking process to implement major changes.

Soon after, the Administration released one of its first proposed rules, entitled “Marketplace Stabilization.” Overall, the rule proposes a series of modifications to the Marketplaces that align with requests made by issuers in an attempt to keep them in the Marketplaces. (Please see the March 1, 2017, Member Advisory for more details about this proposed rule)

More recently, Secretary of the Department of Health and Human Services (HHS) Tom Price and Centers for Medicare and Medicaid Services (CMS) Seema Verma sent a letter to State Governors describing their plans for the Medicaid Program (Please see the March 17 Member Advisory for more details about this letter).

There are several other ways that the Secretary and Administrator can dismantle the ACA without Congressional intervention. These include:

Stopping enforcing the individual mandate. In coordination with Treasury Department, the Secretary could limit or stop the collection of the penalty for those without health insurance.

Modifying hardship waivers. The Secretary has significant discretion in defining what constitutes “hardship” when granting exemption to the individual mandate penalty and could expand this definition to grant more exemptions.

Limiting or eliminating women’s preventive services. The Secretary could expand the Hobby Lobby exemption available to religious organizations, nonprofits, and closely-held for-profit corporations; exclude contraception from the list of women’s preventive services; or entirely eliminate coverage of women’s preventive services.

Narrowing regulations on EHBs. The ACA establishes 10 EHB categories, but the Secretary has the authority to issue regulations that would permit insurers to more narrowly define what it means to cover the categories. Similarly, the Secretary could adjust revise or eliminate the requirements related to defining EHBs by referencing benchmark plans.

Restricting special enrollment periods. The Secretary could establish additional requirements for those trying to sign up outside of the open enrollment period, such as requiring more documentation.

Approving different 1115 waivers for Medicaid. As evidenced in the recent letter to State Governors, the Secretary and Administrator have already signaled that they are likely to approve different Medicaid waivers than were provided during the Obama Administration.

We will keep you posted of new developments on repeal and replace of the Affordable Care Act.

HHS Letter to Governors on Medicaid Changes

Written by Mark Postma on March 17, 2017. Posted in Government Affairs, Medicaid, Member Advisories, Regulatory, Reimbursement.

On Monday evening, the Senate confirmed Seema Verma, MPH, as the new Administrator of the Centers for Medicare and Medicaid Services (CMS). She has a strong background in Medicaid, and prior to her appointment worked as a consultant to several States seeking Medicaid waivers.

One of her first acts was to issue a letter to governors with Secretary Tom Price, MD, regarding the Medicaid program. The letter highlights several initiatives on which they are focusing with regard to Medicaid. Perhaps of most importance to the ambulance community is the section on “Aligning Medicaid and Private Insurance Policies for Non-Disabled Adults.” In this section, the Secretary and Administrator suggest that States:

may consider creating greater alignment between Medicaid’s design and benefit structure with common features of commercial health insurance, to help working age, non-pregnant, non-disabled adults prepare for private coverage. These state-led reforms could include, as allowed by law: …waivers of non-emergency transportation benefit requirements.

While it may be meaningful that the reference does not include “medical,” before transport, it is critically important that the AAA work to protect Medicaid beneficiary access to medically necessary non-emergency medical transports. Thus, the Medicare Regulatory Committee is developing a letter and considering additional engagement with CMS to clarify that the reference is to programs related to providing beneficiaries with the cost of taxis, buses, or other transportation options, but not to medically necessary non-emergency ambulance transports.

It is important that AAA members speak out on this issue with their governors and State Medicaid officials. The AAA has developed draft talking points to assist with these contacts as well.

Thank you for your attention to this critical issue.

Mark Postma
President, American Ambulance Association
Representing EMS in America

Thank you to AAA Consultant Kathy Lester, JD, of Lester Health Law for the analysis of this issue.

Senate Confirms Seema Verma as CMS Administrator

Written by AAA Staff on March 15, 2017. Posted in Government Affairs, News, Regulatory.

On Monday, the Senate voted 55-43 to confirm the nomination of Seema Verma to be the new Administrator of the Centers for Medicare and Medicaid Services. Ms. Verma was involved in designing Indiana’s Medicaid expansion.

Seema Verma, MPH – Biography

Senate confirms Seema Verma to head Medicare and Medicaid

Ms. Verma will be working alongside HHS Secretary Price to help implement President Trump’s healthcare agenda.

Tom Price Confirmed as HHS Secretary

Written by AAA Staff on February 13, 2017. Posted in Government Affairs, Member Advisories, News, Regulatory.

The Senate voted 52-47 Friday to confirm Rep. Tom Price (R-GA) as Health and Human Services secretary. Democrats held the Senate floor for the full 30 hours permitted to them, raising concerns about Price’s trades in health stocks and his opposition to the Affordable Care Act.

New HHS Secretary, Tom Price

A retired orthopedic surgeon, Price will oversee the administration’s efforts to repeal and replace or repair the Affordable Care Act. Rep. Price was previously the Chairman of the House Budget Committee.

Tom Price: Everything You Need to Know About the New Health Secretary
Tom Price Is Sworn In as Health Secretary Amid Senate Disunity

In related news, the Senate Finance Committee has scheduled a hearing on February 16 to consider the nomination of Seema Verma as Administrator of the Centers for Medicare and Medicaid Services (CMS).

Rep. Tom Price Selected as HHS Secretary, Verma for CMS Admin

Written by AAA Staff on November 29, 2016. Posted in Government Affairs, Member-Only, News.

Rep. Tom Price, M.D., Named HHS Secretary

President-Elect Trump has nominated Dr. Tom Price for the position of Secretary of the Department of Health and Human Services. Rep. Tom Price has served as the Congressman for the Sixth District of Georgia since 2005. He is currently the Chairman of the House Budget Committee.

Chairman Price received his B.A. and M.D. from the University of Michigan. He was first elected to Congress in 2004 and has served as on the Ways & Means committee and as Budget Committee chairman. Chairman Price opposes expanding the Affordable Care Act, voted for MACRA, supports expanded use of Health Savings Accounts, and providing age-adjusted tax credits.

Akin Gump has put together a detailed summary of legislation introduced by Rep. Price’s to repeal and replace the Affordable Care Act (H.R. 2300, the Empowering Patients First Act).

5 Things To Know About Rep. Tom Price’s Health Care Ideas

Seema Verma, Named CMS Administrator

The President-Elect has also nominated Seema Verma for the position of CMS Administrator. Currently, she is the founder and CEO of a health policy consulting firm in Indiana. She is a close advisor to Vice President-Elect Pence and worked as a policy advisor for Governor Pence, focusing on Medicaid and public health.

Prior to consulting, Ms. Verma served as Vice President of Planning for the Health & Hospital Corporation of Marion County and as a Director with the Association of State and Territorial Health Officials (ASTHO) in Washington D.C. She received her Master’s degree in Public Health with concentration in health policy and management from Johns Hopkins University and her Bachelor’s degree in Life Sciences from the University of Maryland.

Trump Picks Seema Verma To Run Medicare And Medicaid

The AAA will keep you posted as we learn more about the plans and potential policies of Chairman Price and Ms. Verma.

Indian Health Service Issues Final Rule on Payments to Non-Contracted Providers

Written by Brian Werfel on May 18, 2016. Posted in Government Affairs, Medicare, Member Advisories, Talking Medicare.

On March 21, 2016, the Indian Health Service (IHS), an agency with the Department of Health and Human Services, issued a final rule with comment period titled “Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medicare Charges Associated with Non-Hospital-Based Care.” This final rule will change the way the Indian Health Service pays for Purchased/Referred Care (PRC), formerly known as Contract Health Services (CHS). The provisions of this final rule will become effective on May 20, 2016.

Under current regulations, payment for PRC services is based on rates established by arms-length negotiations between the physician or other health care provider (including ambulance providers and suppliers) and the IHS, Tribe, Tribal Organization or urban Indian organizations (collectively referred to hereinafter as I/T/U programs). In the absence of an agreement, the health care provider is generally paid its full billed charges.

Provisions of Final Rule

The final rule amends the regulations at 42 C.F.R. 136.1 e. seq. to provide that payment for PRC services will now be based on Medicare payment methodologies. Specifically, payments would generally be set at the lowest of: (1) the amount provided for such service under the applicable Medicare fee schedule or Medicare waiver, (2) the amount negotiated with a specific provider or its agent, or the amount negotiated by a repricing agent, if applicable, or (3) the rate for such service paid by the health care provider’s or supplier’s “Most Favored Customer” (MFC). For these purposes, IHS has indicated that the MFC rate will be evidenced by commercial price lists or paid invoices and other related pricing and discount data.

While the previous paragraph sets forth the general rate-setting regime, a number of important exceptions will apply. First, any negotiated rate between the parties must be equal to or better than the provider’s or supplier’s MFC rate. The AAA is interpreting this requirement to require the provider or supplier to offer better (i.e. lower pricing) to the I/T/U program than it offers to any nongovernmental entities, including insurance plans. However, IHS indicated that this restriction would not apply to the extent the I/T/U program determines that the negotiated rate is otherwise fair and reasonable, and is otherwise in the best interests of the I/T/U (as determined by the I/T/U). Second, in the event that no agreement exists, and the Medicare Fee Schedule amount is greater than the provider’s or supplier’s MFC rate (i.e. the provider or supplier has voluntarily elected to accept a rate lower than the corresponding Medicare allowable from at least one nongovernmental entity), then the rate may not exceed the MFC rate, but may be lower than the MFC rate.

The final rule can be viewed in its entirety here.

Member Advisory: Follow Up Regarding Recent OIG Report on Questionable Billing Practices for Ambulance Suppliers

Written by Brian Werfel on October 1, 2015. Posted in Government Affairs, Member Advisories, Member-Only, Regulatory.

HHS OIG Analysis Part 2 of 2 – Read Part One of the Analysis

October 1, 2015

Yesterday, the American Ambulance Association summarized a report from the Department of Health and Human Services Office of the Inspector General (OIG) on certain questionable billing practices by ambulance suppliers.

In this report, the OIG indicated that 1 in 5 ambulance providers had engaged in one or more of the following “questionable billing” practices”:

Billing for a transport without a Medicare service being provided at either the origin
Billing for excessive mileage for urban transports
Billing for a high number of transports per beneficiary
Billing using compromised beneficiary ID numbers
Billing for an inappropriate or unlikely transport level
Billing for a beneficiary that is being shared among multiple ambulance suppliers
Billing for transports to/from a partial hospitalization program

In this member advisory, I want to devote additional attention to the questionable billing practice the OIG referred to as “inappropriate or unlikely transport levels”.

The OIG identified 268 out of the 15,614 ambulance suppliers reviewed (2%) that had questionable billing based on the percentage of claims submitted with inappropriate or unlikely combinations of transport levels and destinations. The OIG summarized its findings as follows:

“We identified two types of transports billed with inappropriate combinations of destinations and transport levels. First, we identified emergency transports that suppliers indicated were to a destination other than a hospital or the site of a transfer between ground and air transports. We also identified specialty care transports that suppliers indicated were to or from destinations other than hospitals, SNFs, or transfer sites.”

The OIG went on to state that a high percentage of an ambulance supplier’s transports with inappropriate or unlikely transport levels (given the destination) could be indicative of “upcoding”. The OIG identified 268 ambulance suppliers that had particularly high numbers of claims submitted with unlikely or inappropriate transport levels/destinations combinations. These ambulance suppliers submitted 3% or more of their claims with these suspect combinations, compared to less than 1% for most ambulance suppliers. The OIG identified 19 companies that used a suspect combination on more than 25% of their claims.

Since the publication of the OIG’s report, the AAA has received numerous inquiries from members asking for guidance on how they can identify whether their company is at risk for submitting claims with these suspect combinations. Unfortunately, there is no easy answer to that question. However, based on my experience, I can offer the following general guidelines:

Define the types of claims that would potentially be problematic. The OIG identified two distinct categories of suspect combinations. The first involves emergency transports. The OIG indicated that a claim would presumably not qualify for payment of an emergency base rate to the extent the patient was being transported to somewhere other than a hospital or an intercept site (i.e., the “I” modifier). In other words, the OIG is looking at claims billed for an emergency base rate (HCPCS Codes A0427 or A0429) with a destination modifier that is either an “R” (Residence), “N” (Skilled Nursing Facility), “E” (Other Custodial Facility), “J” (Free-Standing Dialysis Facility). The second category involved specialty care transports (SCT). To qualify as SCT, a transport must be “interfacility”, which CMS has defined to be transports between hospitals (including hospital-based dialysis facilities), skilled nursing facilities, or any combination thereof. Therefore, the OIG would consider a claim to be suspect if the origin or destination modifier was an “R”, “N”, “E”, or “J”.
Investigate the claim submission edits within your billing system. Having defined the types of claims that the OIG would consider suspect, I suggest that you investigate the claims submission edits within your billing system. Specifically, you want to see whether there is anything currently in place that would make it impossible for you to submit a claim with any of these suspect combinations. For example, would your billing system prevent you from submitting the following claim: A0427 HR? This may require you to attempt to submit test claims with each possible combination to see whether your billing software would reject any or all of these combinations.
To the extent these claim submission edits are not already in place, you should investigate whether your billing software permits you to create them. Assuming your billing system does not currently have edits in place to prevent the submission of claims with these suspect combinations, you want to investigate whether these types of edits can be added. Many billing software products have optional submission edits that you can enable for certain payers. Other products may permit you to create specialized edits for these purposes. You may want to contact your billing vendor to ask whether there is any way to put these edits in place for your Medicare claims. Assuming your software has the capability of putting these edits in place, it almost certainly makes sense to do so, in order to eliminate the possibility of submitting claims with these suspect combinations going forward.

The suggestions listed in paragraphs #1 and #2 above address the issue of whether it was possible for your company to have inadvertently submitted claims with any of these suspect combinations. Even if you determine that it was theoretically possible for you to have submitted claims with any of these suspect combinations, it does not necessarily follow that any such claims were actually submitted. Most ambulance companies have numerous controls in place to guard against inadvertent mistakes in the coding/billing of claims. For example, while many billing software products permit an ambulance coder to duplicate an earlier transport for the patient, many companies elect not to use this functionality, preferring instead to code each claim from scratch. This removes one possible mechanism by which these types of inadvertent errors can occur. Moreover, even if it a claim was submitted with a suspect combination, it does not necessarily follow that the claim was paid by Medicare. Your Medicare contractor may have its own edits in place to deny claims submitted with these suspect combinations. Finally, even if a claim was accidentally submitted with a suspect combination and paid by the Medicare contractor, it is possible that you may have caught the error at the time you posted Medicare’s payment. Assuming that you properly refunded the incorrect payment at that time, there is no need for further concern.

Conclusion

Ambulance supplier should attempt to determine whether their billing software was designed in such a way as to prevent these suspect combinations from being submitted to Medicare. To the extent you are confident that it is impossible for these claims to be submitted to Medicare, there is nothing further that needs to be done.

To the extent an ambulance supplier determines that their current billing software edits do not make it impossible for such claims to be submitted to Medicare, they should determine whether the necessary edits could be implemented on a go forward basis. The ambulance supplier will also need to make an organizational determination on whether to investigate its past claims universe. This determination should be made in consultation with the company’s legal advisers. Your legal advisers will also guide you on the steps that should be taken if you discover that you remain paid for any claims with any of these suspect combinations.

Member Advisory: OIG Issues Report on Questionable Billing Practices for Ambulance Suppliers

Written by Brian Werfel on September 30, 2015. Posted in Government Affairs, Member Advisories, Member-Only, Regulatory.

HHS OIG Analysis Part 1 of 2 – Read Part Two of the Analysis

On September 29, 2015, the Department of Health and Human Services Office of the Inspector General (OIG) issued a report titled “Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports” (OEI-09-12-00351). The report, conducted by the Office of Evaluation and Inspections (OEI), looked at claims data for 7.3 million ambulance transports furnished during the first half of 2012. The OIG reviewed this claims data to determine whether claims were billed appropriately to the Medicare program.

Summary of the OIG’s Findings

The OIG determined that Medicare paid $24.2 million in the first half of 2012 for ambulance transports that did not meet certain program requirements for payment. The OIG identified an additional $30.2 million paid for transports for which the beneficiary did not receive Medicare services at either the pick-up or drop-location, or anywhere else. Finally, the OIG determined that 1 in 5 ambulance suppliers met certain criteria that indicated they may have engaged in questionable billing practices. According to the OIG, more than half of all questionable transports were provided to beneficiaries residing in 4 metropolitan areas.

Detailed OIG Findings

Medicare paid $24.2 million for ambulance transports that did not meet certain Medicare requirements justifying payment. This included transports to a non-covered destination, as well as transports to a covered destination but where the level of service was inappropriate.

The OIG determined that Medicare paid $17.4 million for ambulance transports to non-covered destinations. This amount also include return trips following treatment at the non-covered destination. These transports represented 0.6% of all Medicare payments during the first half of 2012.

The OIG indicated that transports to a physician’s office were the most common type of non-covered destination. Payments for transports to and from a physician’s office accounted for $8.7 million in improper payments. Medicare also paid $5.8 million for transports of beneficiaries to and from community mental health centers or psychiatric facilities (other than duly-licensed psychiatric hospitals). Other transports to non-covered destinations included independent laboratories, diagnostic or therapeutic sites (i.e., “D” modifiers), non-SNF nursing facilities, long-term care and hospice facilities.

The OIG determined that Medicare paid $7 million for transports with inappropriate combinations of the level of service billed and the type of destination. This included $4.3 million in payments for specialty care transports (SCT) where either the origin or destination was something other than a hospital, SNF, or intercept site. The majority of these inappropriate SCT transports involved transports between the patient’s SNF or residence and a free-standing dialysis facility. The OIG also determined that Medicare paid $2.7 million for emergency transports where the destination was not a hospital.

Medicare paid $30.2 million for ambulance transports for which the beneficiary did not receive Medicare services at any origin or destination.

The OIG identified $30.2 million in payments for ambulance transports where the beneficiary did not appear to receive any Medicare services at either the origin or destination within 1 day of the date of transport. To account for the possibility that the ambulance supplier may have submitted a claim with the wrong origin or destination, the OIG only flagged a claim as questionable if its records determined that the beneficiary did not receive Medicare services at any other facility type within 1 day of the transport. The OIG stated its belief that, since there was no record of the beneficiary receiving Medicare services at or close to the date of transport, the OIG believed that it was likely that Medicare inappropriately paid for the ambulance transports. The OIG did note the possibility that these transports occurred during an inpatient hospital or SNF stay, and therefore may have been the responsibility of the inpatient facility. These transports represented 1.1% of all Medicare payments during the first half of 2012.

The OIG determined that 1 in 5 ambulance suppliers had questionable billing

As part of the methodology used for this report, the OIG developed a set of 7 measure that it believed could be evidence of questionable billing practices. These seven measures were:

No Medicare service provided at either the origin or destination – The OIG believes that a high percentage of an ambulance supplier’s for which the beneficiary did not receive Medicare services at either the origin or destination could be indicative of either: (a) billing for transports to non-covered destinations or (b) billing for transports that were not provided.
Excessive mileage for urban transports – The OIG believes that high average mileage for transports within an urban area could be indicative of either: (a) billing for more miles than the ambulance supplier actually drove or (b) billing for mileage beyond the nearest appropriate facility.
High number of transports per beneficiary – The OIG believes that a high average of per-beneficiary transports could be indicative of billing for transports that were not medically necessary.
Compromised Beneficiary Number – The OIG believes that a high percentage of an ambulance supplier’s transports provided to beneficiary with compromised beneficiary ID numbers could be indicative of billing for transports that were not medically necessary, or which were not provided.
Inappropriate or unlikely transport level – The OIG believes that a high percentage of an ambulance supplier’s transports with inappropriate or unlikely transport levels (given the destination) could be indicative of “upcoding”.
Beneficiary sharing – The OIG believes that when multiple ambulance suppliers all provide dialysis transports to the same beneficiary that it could be evidence of the misuse of a beneficiary’s ID number, or it could be evidence that the beneficiary is shopping his or her ID number for kickbacks.
Transports to or from partial hospitalization programs – The OIG believes that transports to and from a partial hospitalization program (PHP) is unlikely to be medically necessary because beneficiary’s that meet Medicare’s coverage requirements for PHP services generally do not qualify for ambulance transportation.

The OIG indicated that 21% of ambulance suppliers met one of the seven measures it developed for identifying questionable billing practices. 17% of ambulance suppliers met only 1 of the 7 measures, while 4% met 2-4 of these measures. No ambulance suppliers met more than 4 of these measures.

The OIG identified 2,038 out of the 15,614 ambulance suppliers reviewed (13%) that had questionable billing based on the percentage of their transports where the beneficiary did not receive Medicare services at either the origin or destination. The OIG flagged an ambulance supplier’s billing as questionable if 3% or more of its transports involved situations where no Medicare service was billed at the destination. 46 ambulance suppliers had 95% or more of their transports involve situations where the beneficiary did not receive Medicare services at either the origin or destination. By contrast, the median for all ambulance suppliers was zero transports where the beneficiary did not receive services at either the origin or destination.

The OIG identified 642 out of the 15,614 ambulance suppliers reviewed (4%) that had questionable billing based on the average mileage they billed for beneficiaries residing in urban areas. The OIG indicated that the typical ambulance supplier average 10 miles for an urban transport. By contrast, the average mileage for the 642 suppliers identified by the OIG was 34 miles. The OIG identified 48 suppliers with an average urban mileage of more than 100 miles.

The OIG identified 533 out of the 15,614 ambulance suppliers reviewed (3%) that had questionable billing based on the average number of transports per beneficiary. Beneficiaries transported by the typical ambulance supplier that provided dialysis transports received an average of 4 ambulance transports during the first 6 months of 2012. Beneficiaries transported by the 533 suppliers identified by the OIG received an average of 21 transports during the first half of 2012.

The OIG identified 358 out of the 15,614 ambulance suppliers reviewed (2%) that had questionable billing based on the percentage of their transports that were associated with compromised beneficiary ID numbers. In studying this measure, the OIG excluded ambulance suppliers that did not bill for any transports involving the use of compromised beneficiary ID numbers. Among those suppliers that billed any transports that involved the use of a compromised ID number, only 1% of the typical supplier’s involved the compromised ID numbers. The 358 suppliers identified by the OIG used a compromised ID number for at least 7% of their claims. 31 suppliers used a compromised ID number for more than 95% of their submitted claims.

The OIG identified 268 out of the 15,614 ambulance suppliers reviewed (2%) that had questionable billing based on the percentage of claims submitted with unlikely or inappropriate transport levels and destinations. For the typical supplier that billed any claims with an inappropriate combination of transport level and destination, these claims accounted for less than 1% of all claims submitted in the first half of 2012. For the 268 suppliers identified by the OIG, these claims accounted for more than 3% of all claims submitted in the first half of 2012. The OIG identified 19 suppliers that used an inappropriate or unlikely combination on at least 25% of the claims they submitted during the first half of 2012.

Finally, the OIG noted that the ambulance suppliers that tested “positive” for any of the questionable billing practices it identified were disproportionately likely to provide BLS non-emergency transports (including dialysis). The OIG noted that BLS non-emergency transports accounted for only 36% of transports billed by providers that did not meet any of its questionable billing measures, while BLS non-emergency transports accounted for 65% of all claims submitted by those suppliers it identified as having at least one questionable billing practice.

More than half of questionable ambulance transports were provided to beneficiaries residing in 4 metropolitan areas

The OIG determined that questionable billing was concentrated in the metropolitan areas of Houston, Los Angeles, New York, and Philadelphia. These 4 areas accounted for 18% of all ambulance transports during the first half of 2012, but 52% of all questionable transports. Collectively, these areas accounted for $104 million of the $207 million in Medicare payments for “questionable” ambulance transports during the first half of 2012.

The OIG also determined that, on average, ambulance suppliers that provided transports to beneficiaries in these 4 metropolitan areas transported more Medicare beneficiaries and received more in Medicare payments than suppliers in other metropolitan areas. For example, the average ambulance supplier in Los Angeles received a total of $105,696 in Medicare payments, compared with an average of $16,137 in Medicare payments per supplier in other metropolitan areas. The numbers in NY ($85,606), Philadelphia ($56,667), and Houston ($34,951) were also far in excess of the national average.

OIG’s Recommendations

In this report, the OIG makes a number of recommendations to CMS to reduce the number of inappropriate payments and questionable billing practices. These recommendations include:

Expanding the temporary moratoria on new enrollments to additional metropolitan area. The OIG is recommending that CMS consider whether the existing moratoria (in place in Houston and Philadelphia) should be expanded to NY and Los Angeles.CMS concurred with this recommendation, and stated that it will continue to monitor these geographic areas, and will impose additional temporary moratoria if warranted.
Require ambulance suppliers to include the National Provider Identifier (NPI) of the certifying physician on non-emergency claims that require a certification. The OIG is recommending that when a physician certification is required (e.g., for dialysis transports), that the physician’s NPI be listed on the claim. The OIG notes that the NPI of the ordering physician is already required for laboratory and DME claims. The OIG also recommended that the physician’s NPI be listed on PCS forms.CMS concurred with the recommendation, and indicated that it will explore the best way to implement this recommendation.
Implement new claims processing edits, or improve existing edits, to prevent inappropriate payments for ambulance transports. The OIG is recommending that CMS update its edits to prevent payment: (a) for transports to non-covered destinations and (b) for transports with inappropriate combinations of the destination and the level of service billed (e.g., emergency transports to a patient’s residence).CMS partially concurred with the recommendation, but indicated that it wanted to review the data on the claims identified by the OIG in the report before taking any actions.
Increase CMS’ monitoring of ambulance billing. The OIG is recommending that CMS continue to monitor the billing of ambulance claims using the measures of questionable billing that the OIG developed.CMS appeared to concur with the recommendation, indicating that it would continue its current monitoring. However, the OIG indicated that its recommendation was not to continue monitoring at the current levels, but rather to increase the monitoring of ambulance claims.
Determine the appropriateness of the claims billed by the ambulance suppliers identified in this report and take appropriate action. The OIG indicated that it would be providing CMS with a separate memorandum that lists the claims it identified that did not meet Medicare billing requirements. The OIG was suggesting that CMS or its contractors should take a closer look at these providers, for example by reviewing medical records or performing unannounced site visits to determine whether additional actions are appropriate.CMS partially concurred with the recommendation, but indicated that it wanted to review the data on the claims identified by the OIG in the report before taking any actions.

Member Advisory: OIG Issues Report on Questionable Billing Practices for Ambulance Suppliers

Written by Brian Werfel on September 30, 2015. Posted in Government Affairs, Member Advisories, Member-Only, Regulatory.

HHS OIG Analysis Part 1 of 2 – Read Part Two of the Analysis

Summary of the OIG’s Findings

Detailed OIG Findings

Medicare paid $30.2 million for ambulance transports for which the beneficiary did not receive Medicare services at any origin or destination.

The OIG determined that 1 in 5 ambulance suppliers had questionable billing

As part of the methodology used for this report, the OIG developed a set of 7 measure that it believed could be evidence of questionable billing practices. These seven measures were:

No Medicare service provided at either the origin or destination – The OIG believes that a high percentage of an ambulance supplier’s for which the beneficiary did not receive Medicare services at either the origin or destination could be indicative of either: (a) billing for transports to non-covered destinations or (b) billing for transports that were not provided.
Excessive mileage for urban transports – The OIG believes that high average mileage for transports within an urban area could be indicative of either: (a) billing for more miles than the ambulance supplier actually drove or (b) billing for mileage beyond the nearest appropriate facility.
High number of transports per beneficiary – The OIG believes that a high average of per-beneficiary transports could be indicative of billing for transports that were not medically necessary.
Compromised Beneficiary Number – The OIG believes that a high percentage of an ambulance supplier’s transports provided to beneficiary with compromised beneficiary ID numbers could be indicative of billing for transports that were not medically necessary, or which were not provided.
Inappropriate or unlikely transport level – The OIG believes that a high percentage of an ambulance supplier’s transports with inappropriate or unlikely transport levels (given the destination) could be indicative of “upcoding”.
Beneficiary sharing – The OIG believes that when multiple ambulance suppliers all provide dialysis transports to the same beneficiary that it could be evidence of the misuse of a beneficiary’s ID number, or it could be evidence that the beneficiary is shopping his or her ID number for kickbacks.
Transports to or from partial hospitalization programs – The OIG believes that transports to and from a partial hospitalization program (PHP) is unlikely to be medically necessary because beneficiary’s that meet Medicare’s coverage requirements for PHP services generally do not qualify for ambulance transportation.

More than half of questionable ambulance transports were provided to beneficiaries residing in 4 metropolitan areas

OIG’s Recommendations

In this report, the OIG makes a number of recommendations to CMS to reduce the number of inappropriate payments and questionable billing practices. These recommendations include:

Expanding the temporary moratoria on new enrollments to additional metropolitan area. The OIG is recommending that CMS consider whether the existing moratoria (in place in Houston and Philadelphia) should be expanded to NY and Los Angeles.CMS concurred with this recommendation, and stated that it will continue to monitor these geographic areas, and will impose additional temporary moratoria if warranted.
Require ambulance suppliers to include the National Provider Identifier (NPI) of the certifying physician on non-emergency claims that require a certification. The OIG is recommending that when a physician certification is required (e.g., for dialysis transports), that the physician’s NPI be listed on the claim. The OIG notes that the NPI of the ordering physician is already required for laboratory and DME claims. The OIG also recommended that the physician’s NPI be listed on PCS forms.CMS concurred with the recommendation, and indicated that it will explore the best way to implement this recommendation.
Implement new claims processing edits, or improve existing edits, to prevent inappropriate payments for ambulance transports. The OIG is recommending that CMS update its edits to prevent payment: (a) for transports to non-covered destinations and (b) for transports with inappropriate combinations of the destination and the level of service billed (e.g., emergency transports to a patient’s residence).CMS partially concurred with the recommendation, but indicated that it wanted to review the data on the claims identified by the OIG in the report before taking any actions.
Increase CMS’ monitoring of ambulance billing. The OIG is recommending that CMS continue to monitor the billing of ambulance claims using the measures of questionable billing that the OIG developed.CMS appeared to concur with the recommendation, indicating that it would continue its current monitoring. However, the OIG indicated that its recommendation was not to continue monitoring at the current levels, but rather to increase the monitoring of ambulance claims.
Determine the appropriateness of the claims billed by the ambulance suppliers identified in this report and take appropriate action. The OIG indicated that it would be providing CMS with a separate memorandum that lists the claims it identified that did not meet Medicare billing requirements. The OIG was suggesting that CMS or its contractors should take a closer look at these providers, for example by reviewing medical records or performing unannounced site visits to determine whether additional actions are appropriate.CMS partially concurred with the recommendation, but indicated that it wanted to review the data on the claims identified by the OIG in the report before taking any actions.

Tag: Department of Health and Human Services (HHS)

HHS OIG Issues Advisory Opinion on Community Paramedicine

HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions

Potential Impact on Mobile Integrated Health and/or Community Paramedicine Programs

Release: CMMI Announces Ambulance Innovative Payment Pilot Program

CMMI Announces Ambulance Innovative Payment Pilot Program

Update on HHS OIG Reports on Ambulance Services

Update on HHS Office of the Inspector General Reports on Ambulance Services

Federal District Court Judge Strikes Down the ACA

What this decision means

OIG Releases SemiAnnual Report to Congress

HHS to Administer $70 million in Funds to Combat Opioid Crisis

ACA Repeal & Reform – What it Means (Part Two)

By: Tristan North and Kathy Lester, JD, MPH

House Legislation, The American Health Care Act (AHCA)

Senate ACA Reform Legislation

Process for Repeal and Reform

Administrative Actions

HHS Letter to Governors on Medicaid Changes

Senate Confirms Seema Verma as CMS Administrator

Tom Price Confirmed as HHS Secretary

Rep. Tom Price Selected as HHS Secretary, Verma for CMS Admin

Rep. Tom Price, M.D., Named HHS Secretary

Seema Verma, Named CMS Administrator

Indian Health Service Issues Final Rule on Payments to Non-Contracted Providers

Member Advisory: Follow Up Regarding Recent OIG Report on Questionable Billing Practices for Ambulance Suppliers

Conclusion

Member Advisory: OIG Issues Report on Questionable Billing Practices for Ambulance Suppliers

Summary of the OIG’s Findings

Detailed OIG Findings

OIG’s Recommendations

Member Advisory: OIG Issues Report on Questionable Billing Practices for Ambulance Suppliers

Summary of the OIG’s Findings

Detailed OIG Findings

OIG’s Recommendations

Stay In Touch!

Customer Service

Media Inquiries