Tag: Maine

Talking Medicare: DOJ Settlement Highlights Importance of Exclusion Testing

Talking Medicare: Recent DOJ Settlement Highlights Importance of Exclusion Testing

On July 17, 2018, the U.S. Attorney for the District of Maine issued a press release on a settlement that had been reached with an ambulance service in Maine. As a result of this settlement, the ambulance service agreed to pay $16,776.74 to resolve allegations that it had submitted false claims to the Medicare and Maine Medicare Programs.

While the Department of Justice’s press release referred to the matter as a civil health care fraud, that headline is somewhat misleading. The ambulance service was not alleged to “up-coded” its claims or to have billed for patients that did not require ambulance transportation. Rather, the ambulance service was accused of using monies paid to it by these federal health care programs to pay the salary and benefits of a woman hired to assist the company’s billing manager. The woman, who was not identified in news reports, had previously been excluded from participation in federal health care programs after surrendering her license as a pharmacy technician after being found to have inappropriately diverted certain controlled substances. The ambulance service apparently failed to conduct an exclusion test on this individual prior to placing her on its payroll. The ambulance service’s side of the story is discussed in greater detail in this article from the local newspaper.

This settlement provides a reminder of the potential liabilities associated with the employment excluded individuals. As the HHS Office of the Inspector General (OIG) noted in its May 2013 Special Advisory Bulletin, the effect of exclusion goes beyond direct patient care. The OIG noted that excluded individuals are prohibited from providing transportation services paid by a federal health care program, using the example of ambulance drivers and ambulance dispatchers. The OIG further indicated that excluded individuals cannot provide administrative and/or management services that are payable by federal health care programs, even if these administrative or management services are not separately billable. In the above-referenced case, the prohibition was applied to the wages and benefits payable to the excluded employee.

Do we need to conduct exclusion testing, and, if so, how frequently?

The OIG recommends that all health care providers conduct exclusion testing prior to an individual’s employment, and then periodically thereafter. However, the OIG takes no formal position on how frequently these periodic exclusion checks should be conducted. The OIG does note, however, that it updates its List of Excluded Individuals and Entities (LEIE) on a monthly basis.

Given the potential risks involved, I think monthly testing of all employees should definitely be considered a best practice. The hope is that this case serves as a cautionary tale for other ambulance providers.

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.

2017 AAA Legislative Awards

Senator Susan Collins Named Legislator of the Year

For Immediate Release

Senator Collins To Receive Highest Legislative Honor from American Ambulance Association

To Be Recognized as AAA Legislator of the Year

Contact
Amanda Riordan
703-610-9018
ariordan@ambulance.org
www.ambulance.org

Washington, D.C. – The American Ambulance Association (AAA) has named Senator Susan Collins of Maine as the AAA Legislator of the Year, in recognition of her strong advocacy for emergency medical services. Senator Collins is invited to receive this honor at the AAA’s annual Stars of Life recognition ceremony on June 13 in Washington, D.C.

The Stars of Life program celebrates the contributions of ambulance professionals who have gone above and beyond the call of duty in service to their communities or the EMS profession. Stars of Life pays tribute to the dedication of these heroes while shining light on the critical role EMS plays in our healthcare infrastructure. This year, 101 EMS professionals will be honored as 2017 Stars of Life. In addition to Senator Collins’s recognition as as Legislator of the Year, twenty-four United States Senators and Representatives will receive Legislative Recognition Awards for their support of ambulance services.

AAA President Mark Postma notes, “Senator Collins has been a tireless advocate for emergency medical services, both in Maine and across our country. The AAA is honored to present her with the distinction of AAA Legislator of the Year.”

Senator Collins is a primary sponsor of the Medicare Ambulance Access, Fraud Prevention and Reform Act which would make permanent the current temporary Medicare ambulance relief. This bill ensures that ambulance service providers across the nation have the resources necessary to provide often life-saving emergency- as well as vital non-emergency medical transportation.

As Chair of the Senate Committee on Homeland Security and Governmental Affairs from 2003 to 2007, Senator Collins ensured both governmental and nongovernmental medical service providers were included in the definition of an emergency responder in the Homeland Security Act. This enabled ambulance service providers as first responders access to critical funding and resources.

First elected to the senate in 1996, Senator Collins has earned a national reputation for working across party lines to seek consensus on our nation’s most important issues. Senator Collins has carried out her longstanding commitment to healthcare issues through her work on the Special Committee on Aging as well as the Committee on Health, Education, Labor and Pensions.

In recognition of her ongoing service to the ambulance services of the United States, AAA is proud to call Senator Collins our Legislator of the Year.

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About the American Ambulance Association

Founded in 1979, the AAA represents hundreds of ambulance services across the United States that participate in emergency and nonemergency care and medical transportation. The Association serves as a voice and clearinghouse for ambulance services, and views prehospital care not only as a public service, but also as an essential part of the total public health care system.

AAA Mission Statement

The mission of the American Ambulance Association is to promote health care policies that ensure excellence in the ambulance services industry and provide research, education, and communications programs to enable its members to effectively address the needs of the communities they serve.

ACHA Update – High-risk Pool Amendment

The House Rules Committee met last week to consider a new amendment to the American Health Care Act (AHCA) to establish a federal risk-sharing fund and appropriate $15 billion for a high-risk pool program from 2018 to 2026.

The amendment, which aims to reduce premiums for those with pre-existing conditions, is sponsored by Reps. Gary Palmer (R-AL) and Dave Schweikert (R-AZ), both members of the House Freedom Caucus.

Washington Post: “GOP House leaders say health bill tweak shows progress, but larger divisions remain

The program is reportedly modeled after a successful initiative in the State of Maine. The federal government would run the program initially, but each state will have the ability to take over the high-risk pool after three years.

The amendment represents one area of limited agreement in the broader AHCA debate. Conservative House Members are likely to support it to the extent it shifts authority and funding to the states to help keep premiums down, and moderates are likely to support it because it would add a layer of protection for individuals with pre-existing conditions. It is unclear whether the level of funding appropriated will be sufficient to meet the need, however.

The development is not evidence of a breakthrough, however, and negotiations are far from over. Rather, it is a strategic move by House Republican leaders to signal progress in the Affordable Care Act (ACA) repeal-and-replace debate before lawmakers head home for a two-week congressional recess at the end of this week. It also is unclear whether the amendment will have any impact on the broader areas of disagreement between the House and Senate regarding the timing, substance and process for ACA repeal.

The decision was reportedly made at a meeting the President convened last week with Speaker Paul Ryan (R-WI) and Majority Leader Kevin McCarthy (R-CA). Speaker Ryan indicated that work will continue “in the days and weeks ahead,” suggesting a longer time-frame for any legislative action beyond last week’s vote in the House Rules Committee.

Status of the American Health Care Act

Today, citing “growing pains” of his Republican majority, Speaker Paul Ryan (R-WI), in consultation with President Donald Trump, determined not to proceed with a planned vote on the American Health Care Act (AHCA), which repealed and replaced important elements of the Affordable Care Act (ACA).  The Speaker indicated that the House Republican Caucus “came up short” in the number of votes needed for the bill.  House Republican Leadership had been moving AHCA through the Chamber at a rapid pace.  The bill was officially released on March 6, and had been changed several times to try to appease various conservative and moderate voting blocs within the Republican Caucus.  The Congressional Budget Office (CBO) originally estimated the bill would reduce federal deficits by $337 billion, and subsequently downgraded the deficit reduction to $150 billion based on additional substantive policy changes to the bill.  The CBO estimates the bill would have increased the country’s number of uninsured by about 24 million people.

In negotiating the provisions of AHCA, the House Republican Leadership had faced a constant seesaw, as efforts to appease one ideological bloc upset the other.  Ultimately, throughout the day in advance of the scheduled vote, an increasing number of moderate Republicans, including Appropriations Committee Chairman Rodney Frelinghuysen (R-NJ), announced they would vote against the bill.  As the moderates disappeared, not enough members of the conservative Freedom Caucus decided to support the bill.

As disarray in the House Republican Caucus occurred, there appeared to be a similar lack of consensus amongst their Republican colleagues on the Senate side.  While Senate Leadership had planned to move the bill directly to the Senate floor as fast as within a week of receipt from the House, there were a number of Senators from a range of political perspectives with serious concerns about the bill.  On one side of the Republican spectrum, Senators Rand Paul (KY), Mike Lee (UT) and Ted Cruz (TX) had planned to push the limits of what can be included in a reconciliation bill to make it more conservative. Senator Paul had advocated for repealing the ACA in full and dealing with the replacement later on. On the other side, more moderate or “purple state” Members like Senators Susan Collins (ME), Lisa Murkowski (AK), Rob Portman (OH), Cory Gardner (CO) and Dean Heller (NV) raised concerns about insurance affordability and the expedited rollback of Medicaid expansion in the House version of the bill. Other Senators who will likely play a prominent role in any further health reform developments include physician Senator Bill Cassidy (LA), and Senator Tom Cotton (AR), who advocated all along to slow the process down. Republicans can only lose two Senators and still pass any health reform bill, with the vote of Vice President Mike Pence breaking the tie.

As a next step, House and Senate Republican Leadership plan to take more time to develop consensus in any future approach to health reform.  How much time is unclear – but it seems unlikely the bill will be the legislative focus in the short term.  Instead, there will likely be a cooling-off period on health reform legislative activity, since the fundamental disagreements within the caucus are not easily fixed.  There will continue to be significant messaging against ACA from conservatives, and there is the potential that the idea of “repeal and delay” may gain more traction.  Nonetheless, in the short term, the Speaker indicated he would move on to other items on his conference’s agenda – including tax reform.  Keep in mind, however, that since health-related tax provisions are a major component of the tax code, it would not be surprising to see some health issues resurface in tax reform.

The Speaker indicated that he expects the ACA marketplace to get worse – specifically citing rising premium costs.  In his own remarks on the failure to pass AHCA, the President suggested the Democrats will own any rising premiums, and provided a rare moment of optimism for the day when he indicated that a bipartisan health care reform bill may be achievable in the future when that happens.   As the Legislative Branch takes time to develop consensus, more focus will be placed on the Executive Branch.

We expect HHS Secretary Tom Price and White House Budget Director Mick Mulvaney to take an increasingly important role in driving the health agenda.  It is unclear at this point whether the Trump Administration will let ACA drift in the wind, take administrative actions to try to improve the marketplace, or even actively work to derail it further.  A likely bellwether as to the Administration’s intent is how it approaches the pending litigation over cost-sharing reduction (CSR) subsidies.  The House had sued the Obama Administration over the program, which funnels federal dollars to insurers to help keep out-of-pocket costs manageable for lower-income individuals, saying the funding had to be appropriated.  But after the inauguration, the House and Trump Administration sought a stay of the case until May 22 to allow time to resolve the issue.  If the Administration agrees to fold, the subsidies would be cut off, leading to further market instability.  If the House folds, the CSR payments would continue into the indefinite future.

From a health care legislative perspective, 2017 will still be far from a quiet year.  The President has proposed significant changes in the funding levels of important discretionary health programs.  Those budget battles will now move more front and center on the legislative agenda.  Furthermore, there continue to be “must pass” pieces of health care legislation, including CHIP reauthorization, FDA User Fee legislation, and certain Medicare extenders legislation.

House Holds Hearing on Veterans Choice Program

The House VA Committee hearing started at 7:30 p.m., but it was well-attended and lasted until 10 p.m. The witnesses included Senator John McCain (R-AZ), VA Secretary David Shulkin, and representatives of the VA Office of Inspector General and the Government Accountability Office. Senator McCain and Secretary Shulkin were both warmly welcomed by Members of the Committee on a bipartisan basis.

Chairman Roe (R-TN) emphasized the need to act quickly to extend the authorization for the Veterans Choice Program, which expires on August 7. To that end, the House VA Committee is voting today on a bill to eliminate the sunset of the program’s authorization. In addition, the Committee will consider broader legislation later this year to make comprehensive reforms to the Choice Program. He noted that the VA has additional funds available but will not be able to spend them once the authorization expires. A copy of Chairman Roe’s opening statement is available here.

Secretary Shulkin testified in support of extending the Choice Program, and he clarified that the VA was not seeking additional funding – just the authority to spend funds already obligated. He noted that the VA already is being forced to deny Choice Program coverage to veterans whose episodes of care would extend beyond the August 7 expiration date (e.g., pregnancy).

Secretary Shulkin also urged Congress to support the VA’s efforts to bring appointment scheduling in-house for care coordination purposes. However, the VA OIG witness noted challenges in records going out to community-based providers and coming back to the VA. The GAO witness also underscored the need for the VA to have better systems in place in order to effectively coordinate care, which will take time to procure and implement. Rep. Brownley (D-CA) echoed that point, calling the VA’s information technology systems a “Model T in a Tesla world.” Rep. Esty (D-CT) also urged improvements in the VA’s information systems and expressed concern that veterans are being improperly billed.

Other Members, including Rep. Wenstrup (R-OH) and Rep. Poliquin (R-ME), raised concerns about continuing delays in the processing of claims and payments to providers. Secretary Shulkin agreed that providers deserve to be paid for their services, noting his own experience as a physician in the private sector. He acknowledged that the VA is not processing enough claims electronically today, and he advised that he plans to pursue options outside the VA for systems procurement going forward.

Many Members also raised serious concerns about treatment of PTSD and mental health conditions for veterans, including Rep. Wenstrup (R-OH), Rep. O’Rourke (D-TX), Rep. Sablan (D-MP), Rep. Banks (R-IN), Rep. Rutherford (R-FL) and Rep. Takano (D-CA). Rep. O’Rourke emphasized that suicide among veterans is the most serious crisis, and Secretary Shulkin agreed that it is his number one priority. The Secretary announced that the VA will begin providing urgent mental health care that also will include individuals other than those service members who were honorably discharged. He added that the VA needs 1,000 more mental health providers, as well as telemental health services, and is looking to expand community partnerships to address suicide.

Rep. Banks noted interest among Indiana veterans in greater access to alternative treatments for PTSD and traumatic brain injury. Secretary Shulkin underscored that he is “most concerned about areas like PTSD, where we do not have effective treatments.” He also advised that the VA has established an “Office of Compassionate Innovation” (separate from the VA’s Center for Innovation), which will focus on finding new approaches to health and physical wellness and explore alternative treatment options for veterans when traditional methods fall short.

Rep. Wenstrup inquired about the VA’s GME and residency programs, as well as its associations with academic institutions. Secretary Shulkin responded that the VA is “doubling down” on partnerships with academic medical institutions.

Chairman Roe concluded his remarks by emphasizing the need to extend the Choice Program authorization soon and to consolidate the VA’s community-based care programs. He also expressed support for the VA’s decision to stop developing its own information technology internally.

2015 Medicare Data Shows Evident of Crackdown on Non-Emergency Transport

2015 Medicare Payment Data Offers Evidence of Nationwide Crackdown on Non-Emergency Ground Ambulance Transportation; Impact Varies Dramatically by Medicare Administrative Contractor

Every year, CMS releases data on aggregate Medicare payments for the preceding year. This file is referred to as the Physician/Supplier Procedure Master File (PSP Master File). This past month, CMS released the 2016 PSP Master File, which contains information on all Part B and DME claims processed through the Medicare Common Working File with 2015 dates of service.

In September’s blog post, I discussed the results of the first year of the prior authorization demonstration project for repetitive, scheduled non-emergency ground ambulance transports. During this first year, the project was limited to three states: New Jersey, Pennsylvania, and South Carolina. The data confirms that these three states saw a dramatic reduction in Medicare’s approved payments for dialysis transports.

This month, I will be discussing the national payment trends for non-emergency ground ambulance transports, and, in particular, Basic Life Support non-emergencies.

In 2015, Medicare paid approximately $990 million for BLS non-emergency transports. This is 13% less than what it paid for BLS non-emergency transports in 2014 ($1.14 billion). Please note that these figures only reflect payments for the base rate; when the payments for the associated mileage are included, the reduction is even more dramatic.

In actual terms, this means Medicare Administrative Contractors (MACs) approved nearly 1 million fewer BLS non-emergency transports in 2015 (5.86 million) than they approved in 2014 (6.81 million). Roughly 75% of this reduction can be directly attributed to the prior authorization program in the three states listed above. Note: the reduction in approved dialysis transports in New Jersey accounts for nearly half of the national decline). However, that leaves nearly 250,000 fewer approved transports in the remaining 47 states. This reduction was not the result of fewer claims being submitted in 2015; the number of submitted claims was actually higher in 2015 than 2014. Rather, the data shows that this reduction is the result of the MACs actively denying many more claims than in year’s past.

I believe these reductions are the direct result of a step-up in the enforcement activities of the MACs, which I also believe has the tacit, if not outright, approval of CMS.

To test this thesis, I looked at the state-by-state data to see if any trends could be found. What I found was that 28 states saw increases in the total number of approved BLS non-emergency transports in 2015, with 19 states seeing decreases. However, on its face, that number is somewhat deceiving. The states that saw increases tended: (1) to see either relatively small increases or (2) had relatively low utilization rates to begin with. The states that saw decreases tended to be larger states with higher utilization rates, and those decreases tended to be larger in percentage terms. For instance, California saw a 21.5% decrease in the number of approved BLS non-emergency transports. Ohio saw an 11.7% decrease.

Digging deeper, it becomes clear that a state’s overall change in payments for BLS non-emergencies is almost perfectly correlated with its change in payments for dialysis transports. In other words, to the extent the state saw an overall reduction in payments for BLS non-emergencies, that reduction – – in nearly all cases – – was the result of the total payments for dialysis decreasing by more than any offsetting increase in the total payments for non-dialysis transports.

These relative changes in dialysis were also highly correlated with the MAC that administers Medicare claims in that state. To the extent your state saw a reduction in dialysis payments, it is highly likely that neighboring states administered by the same MAC saw similar reductions in payments. The following charts will help illustrate this point:

2016-11-29-werfel-non-emergency-crackdown-chart-1As you can see, all three states within Cahaba’s jurisdiction saw a net increase in the total payments for dialysis. While the increases themselves were quite minor in Alabama and Tennessee, Georgia saw an 11.8% increase in total payments for dialysis. Similarly, both Florida and Puerto Rico saw significant increases in the approved payments for dialysis.

By contrast, every state in National Government Services’ (NGS’) jurisdiction with more than 1,000 paid dialysis transports in 2015 saw a net reduction in the total payments for dialysis. These reductions ranged from a relatively minor reduction of 1.17% in New York to a nearly two-thirds (64.58%) reduction in Minnesota.

2016-11-29-werfel-non-emergency-crackdown-chart-2This trend was present in all remaining jurisdictions, although the results were more mixed. For example, with the exception of South Carolina, the three remaining states administered by Palmetto all saw increases. Likewise, the majority of states administered by WPS saw decreases. This included Indiana, which has a sizeable dialysis population. Among WPS states, only Missouri saw a small (3.90%) increase.

California saw a 31.76% decrease in its payments for dialysis. The only other Noridian states with more than 1,000 paid dialysis trips were Hawaii and Washington, which both saw increases.

Novitas presents a more complicated picture, with several large states, such as Texas, seeing double-digit increases in payments for dialysis, while other large states saw sizeable decreases.

All in all, the data suggests that CMS and its contractors continue to pay close attention to the non-emergency side of our business, particularly BLS non-emergency transports. These transports have been under scrutiny for many years, as reports from the Office of Inspector General, the Government Accountability Office and other federal agencies have flagged this portion of our industry as being particularly prone to overutilization (and, in some cases, outright fraud).  However, this heightened scrutiny is not being uniformly applied across-the-board. The data suggests that certain MACs have been far more aggressive in targeting these sorts of trips across their entire jurisdictions, while others seem content to target specific (typically large) states within their jurisdictions. This could serve as a template for how MACs will approach prior authorization in their jurisdictions.

‘Praemonitus, Praemunitus’     

Latin Proverb, loosely translated to “forewarned is forearmed.”

 

 

Senator Scott Receives 2015 AAA Legislative Recognition Award

Pictured is Senator Tim Scott (R-SC) receiving a 2015 AAA Legislative Recognition Award from Greg Shore of AAA member Medshore Ambulance Service in Andersen, South Carolina. Included in the picture is Senator Susan Collins (R-ME) who is one of the lead sponsors of the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 377, H.R. 745).