Tag: Medicare

CMS: Revised Repayment Terms for Medicare Accelerated Payments

On October 8, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a Fact Sheet setting forth the repayment terms for advances made under the Medicare Accelerated and Advance Payments Program (AAPP).  These changes were mandated by the passage of the Continuing Appropriations Act, 2021 and Other Extensions Act, which was enacted on October 1, 2020.

Background

On March 28, 2020, CMS expanded the existing Accelerated and Advance Payments Program to provide relief to Medicare providers and suppliers that were experiencing cash flow disruptions as a result of the COVID-19 pandemic, and associated economic lockdowns.  Under the AAPP, Medicare providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments.  These advances are structured as “loans,” and are required to be repaid through the offset of future Medicare payments.

CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act.  CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.

Under the pre-existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds.  The program also called for a 100% offset until all advanced funds had been repaid.

Revised Payment Terms

Under the revised payment terms announced by CMS, providers and suppliers will not be subject to recoupment of their Medicare payments for a period of one year from the date they received their AAPP payment.  Starting on the date that is one year from their receipt of the AAPP payment, repayment will be made out of the provider’s or supplier’s future Medicare payments.  The schedule for such repayments will be as follows:

  • 25% of the provider’s or supplier’s Medicare payments will be offset against the outstanding AAPP balance for the next eleven (5) months; and
  • 50% of the provider’s or supplier’s Medicare payments will be offset against the outstanding AAPP balance for the next six (6) months

To the extent there remains an outstanding AAPP balance after that 17 month period (i.e., 29 months after the date the provider or supplier received its AAPP payment, the provider or supplier will receive a letter setting forth their remaining balance.  The provider or supplier will have 30 days from the date of that letter to repay the AAPP balance in full.  To the extent the AAPP balance is not repaid in full within that 30-day period, interest will begin to accrue on the unpaid balance at a rate of 4%, starting from the date of the letter.

Medicare providers and suppliers are also permitted to repay their accelerated or advance payments at any time by contacting their Medicare Administrative Contractor.

 

2020 Medicare Reference Manual & Medicare Update Webinar

The 2020 Medicare Reference Manual and the 2020 Medicare Update Webinar are both available for purchase. Please see details below!

2020 Medicare Update Webinar

Thursday, April 30, 2020 | 2:00pm EST
Presenter: Brian Werfel, Esq.
$99 for AAA-Members | $198 for Non-Members

Join A.A.A. Medicare Consultant Brian S. Werfel, Esq. for an update on recent changes to Medicare’s coverage of ambulance services. This webinar coincides with the American Ambulance Association’s release of its 2020 Medicare Reference Manual. Brian will discuss recent changes in Medicare policy, including changes to the rules governing the enforcement of fraud and abuse, the appeals process, etc. We will also discuss Medicare’s proposed plan for the ET3 Program, the national expansion of the prior authorization model for scheduled non-emergency transports, and much more.

Of course, we will also discuss Medicare’s coverage of ambulance services during the current COVID-19 process. This will include a frank discussion of the issues related to medical necessity for the transportation of known or suspected COVID-19 patients, the coverage of transports to field hospitals and other alternative destinations, the current status of certain administrative rules like the Medicare patient signature requirement and the Notice of Privacy Practices, etc.

The session will include an extended Q&A period to address any and all questions from attendees. Purchase Webinar► 

*2020 Medicare Reference Manual Sold Separately* 

 

2020 Medicare Reference Manual 

$200 for AAA-Members | $400 for Non-Members
By David Werfel, Esq & Brian Werfel, Esq

The American Ambulance Association’s 2020 Medicare Reference Manual is a must-have for ambulance services that bill Medicare for transports.

CMS Releases Update Guidance on Hospital EMTALA Obligations Related to COVID-19

On March 9, 2020, CMS published a memorandum to State Survey Agency Directors that provides updated guidance on the obligations of hospitals and critical access hospitals (CAHs) under the Emergency Medical Treatment and Labor Act (EMTALA).  This guidance was issued in response to numerous inquiries regarding the EMTALA obligations of these facilities as they struggle to respond to the COVID-19 pandemic.

Under EMTALA, hospitals and CAHs with emergency departments have an obligation to provide an appropriate medical screening examination to any individual that comes into the emergency department seeking examination or treatment of an emergency medical condition.  Hospitals and CAHs are further required to make a determination as to whether the patient actually has an emergency medical condition, and, if so, to provide stabilizing treatment within the hospital’s capabilities, or make appropriate arrangements to transfer the patient to a facility that does have the necessary capabilities.

The hospitals and CAHs had requested guidance on how they can fulfill their basic EMTALA obligations while minimizing the risks of exposure from COVID-19 infected individuals to their staff and other patients in their emergency departments.

Note: in summarizing the CMS guidance document, references to a “hospital” will include both hospitals and CAHs.

Acceptance of Patients Suspected or Confirmed to be Infected with COVID-19

 CMS indicated that hospitals with the capacity and the specialized capabilities needed to provide stabilizing treatments are required to accept transfers from hospitals without the necessary capabilities. CMS indicated that it would take into account the recommendations of the Centers for Disease Control (CDC) in assessing a hospital’s capabilities and capacity.  CMS further indicated that the presence or absence of negative pressure rooms (Airborne Infection Isolation Room (AIIR)) would not be the sole determining factor related to determining when an EMTALA transfer is required.  CMS is advising hospitals to coordinate with their state and local public health officials regarding the appropriate placement of individuals who meet specific COVID-19 assessment criteria, as well as the most current standards for treating patients confirmed to be infected with COVID-19.

CMS is further confirming that hospitals have the ability to set up alternative screening sites on the hospital campus, i.e., the initial medical screening exam does not need to take place in the emergency department.  CMS is confirming that individuals may be redirected to an alternative screening site after being logged into the emergency department.  This redirection can even take place outside the entrance to the emergency department.  Medical screening exams conducted in alternative screening sites must still be conducted by qualifying personnel (i.e., physicians, NPs, Pas, or RNs).

CMS is also indicating that hospitals may set up screening sites at “off-campus, hospital-controlled” sites.  Hospitals and community officials may encourage the public to go to these sites instead of the hospital for screening for influenza-like illnesses.  However, a hospital cannot tell an individual that has already presented at their emergency department to go to an off-site location for their medical screening exam.  Unless the off-campus site is already considered to be a dedicated ED (e.g., a free-standing ED) under EMTALA regulations, the EMTALA regulations would not apply to these off-site screening areas; however, the hospital would be required under its Medicare Conditions of Participation to arrange a referral/transfer to an appropriate hospital if the patient has a need for emergency medical attention. 

 Finally, communities may set up screening clinics at sites not under the control of a hospital.  These sites would not be subject to EMTALA.

EMTALA Obligations when a Screening Suggests Possible COVID-19 Infection

 To the extent a hospital determines, following a medical screening exam that a patient may be a possible COVID-19 case, the hospital is expected to isolate the patient immediately.  CMS indicated that it expects that all hospitals will be able to provide medical screening exams and initiate stabilizing treatment while maintaining isolation requirements.

Once an individual is admitted to the hospital or the emergency medical condition ends, the hospital has no further obligations under EMTALA.

CMS is further reminding hospitals that the latest screening guidance from the CDC calls for hospitals to contact their State or local public health officials when they have a case of suspected COVID-19.

CMS Grants State of Florida’s 1135 Waiver Request for Coronavirus Response

On March 16, 2020, CMS approved an 1135 Waiver request submitted by the State of Florida. The State had requested the flexibility to waive prior authorization requirements, streamline its Medicaid enrollment process, and allow care to be provided in alternative settings to the extent an existing health care facility needs to be evacuated. The key provisions of the waiver are summarized below:

1. Payments to Out-of-State Providers: Under current CMS coverage guidelines, the Florida Medicaid Program had the authority to reimburse out-of-state providers that were not enrolled in the Florida Medicaid Program provided certain criteria were met. However, this authority was limited to situations involving: (a) a single instance of care furnished over a 180-day period or (b) multiple instances of care furnished to a single Florida Medicaid beneficiary over a 180-day period. Under the waiver, CMS is removing the 180-day restriction for the duration of the emergency.

2. Expedited Enrollments: With respect to providers that are not currently enrolled in the Medicare Program or with another State Medicaid Agency, CMS is waiving the following screening requirements: (a) the payment of the application fee, (b) the fingerprint-based criminal background checks, (c) the required site visits, and (d) the in-state/territorial licensing requirements. Under the waiver, the state would still be required to check enrolling providers against the OIG exclusion list, and confirm that the out-of-state provider is properly licensed in their home state.

3. Cessation of Revalidation Efforts: CMS granted Florida the authority to temporarily cease the revalidation of enrolled in-state Medicaid providers and suppliers who are directly impacted by the emergency.

4. Waiver of Prior Authorization Requirements: CMS has granted Florida the right to waive any prior authorization requirements that are currently part of the State Medicaid Plan. This waiver applies to services provided on or after March 1, 2020, and will continue through the termination of the emergency declaration.

5. Waiver Allowing Evacuating Facilities to Provide Services in Alternative Settings: CMS will allow facilities, including nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric residential treatment facilities, and hospitals to be reimbursed for services rendered during an emergency evacuation to an otherwise unlicensed facility. This waiver will extend for the duration of the declared emergency; however, CMS will require the unlicensed facility to seek licensure with the state after 30 days.

Understanding Medicare, Medicaid, and SCHIP Coverage of Ambulance Services under a Declared National State of Emergency

On March 13, 2020, President Donald J. Trump announced a national state of emergency in response to the COVID-19 pandemic. Previously, HHS Secretary Alex Azar had declared a public health emergency under Section 319 of the Public Health Service Act in response to COVID-19.

This has prompted many AAA members to ask what impact, if any, these declarations have on the coverage of ambulance services under federal health care programs?

The short answer is that these declarations give CMS the authority under Section 1135 of the Social Security Act to waive certain Medicare, Medicaid, and SCHIP Program requirements. This waiver authority includes, but is not necessarily limited to:

• Waiving certain conditions of participation and/or certification requirements;
• Waiving certain pre-approval requirements;
• Waiving the requirements that a provider or supplier be licensed in the state in which they are providing services;
• Waiving EMTALA requirements related to medical screening examinations and transfers; and
• Waiving certain limitations on payments for services provided to Medicare Advantage enrollees by out-of-network providers.

One situation where an 1135 waiver may be of use to an ambulance provider or supplier would be where the ambulance provider or supplier is sending vehicles and crews to a state that is outside its normal service area. The ambulance provider or supplier is unlikely to be licensed by the state in which it is responding. As a result, under normal circumstances, it would be ineligible for payment under federal health care program rules. The 1135 waiver would permit it to submit claims for the services it furnishes in the other state.

Of more immediate significance to the current national emergency, an 1135 waiver may permit hospitals and other institutional health care providers to establish an off-site treatment center for initial screenings of patients. For example, hospitals may establish triage sites in parking lots and other open spaces for the initial intake of patients suspected of being infected with the COVID-19 virus. In theory, this waiver could also extend to drive-thru testing sites to the extent they are operated by the hospital or another health care provider. When a hospital has obtained an 1135 waiver to operate an off-site treatment center, the off-site area becomes a part of the hospital for Medicare payment purposes. Therefore, ambulance transports to an approved off-site treatment area should be submitted to Medicare using the “H” modifier for the destination.

AAA Releases 2020 Medicare Rate Calculator

AAA 2020 Medicare Rate Calculator Now Available!

The American Ambulance Association is pleased to announce the release of its 2020 Medicare Rate Calculator tool. The AAA believes this is a valuable tool that can assist members in budgeting for the coming year. This calculator has been updated to account for recent changes in Medicare policies, including the 2020 Ambulance Inflation Factor (0.9%) and the continuation of the current temporary add-ons.

To access the Rate Calculator, please CLICK HERE.

2020 calculator

40 Under 40: Adam Parker (Sanford Health – Bismarck, ND)

40 Under 40 nominees were selected based on their contributions to the American Ambulance Association, their employer, state ambulance association, other professional associations, and/or the EMS profession.
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Adam Parker
Operations Manager
Sanford Health
Bismarck, ND

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Linked In
Nominated By: Kelly Dollinger (North Dakota EMS Association – Bismarck, ND)

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Biography:

Adam Parker has been involved in North Dakota EMS for over 15 years working for volunteer, private, and hospital-based EMS services. Adam is currently employed by Sanford Health as an Operations Manager overseeing AirMed operations, EMS education and outreach, and a Community Paramedic program. Adam is also a Board Member for the North Dakota EMS Association and serves as Chairman of the Advocacy Committee and Co-chair of the Service Leaders Committee. Adam lives in Bismarck, ND with his wife, Jessica, and two children.

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Reason for Nomination:

As President of the North Dakota EMS Association – I am thrilled to have the opportunity to nominate Adam Parker for consideration in the AAA’s Inaugural Mobile Healthcare 40 Under 40 – due in part to his exceptional and continued rise through the leadership of North Dakota EMS.

Adam’s full-time position is with Sanford Health as the Operations Manager for the Bismarck and Dickinson AirMed bases, as well as the Sanford EMS Department. In his position, Adam oversees the daily and strategic operations for two air medical bases, as well as EMS outreach and education. Adam also spearheaded the creation of the newly developed Community Paramedic program. Currently, Adam supervises over 50 mobile health care professionals including Paramedics, Community Paramedics, Critical Care Paramedics, and Advanced Certified Registered Nurses.

Adam has successfully obtained his Master’s Degree in Business Administration and also completed the Certified Medical Transport Executive course. Adam is always learning and applying what he learns to better himself and the EMS industry.

On top of his busy schedule, Adam serves on the North Dakota EMS Association Board of Directors. Adam serves as the Co-chair of the Service Leader Committee and is currently the Chairperson for the Advocacy Committee. It is in this capacity where Adam has contributed greatly to our EMS Association and the agencies throughout North Dakota. Adam has been instrumental in obtaining Legislative Grant Funding for North Dakota EMS agencies and assisted in developing a formula to determine funding that would allow for as many ambulance services as possible throughout the state. This proved highly contentious, and risked the loss of all state grant funding, but Adam developed a successful strategy and managed the situation extremely well by negotiating with legislators to find a workable agreement. Adam also serves as our State Advocacy Coordinator and Affiliate Advisory Council representative for the NAEMT.

Adam was also instrumental in advancing the Recognition of EMS Personnel Licensure Interstate CompAct (REPLICA) legislation. This bill successfully passed and North Dakota became the 17th State to be recognized as a REPLICA state.

Adam is very knowledgeable in various aspects of state and local politics, policies, and procedures. Adam is the go-to expert on establishing local taxing districts and he advocates heavily for every ambulance service to establish themselves as a political subdivision, since this is the best way to ensure sustainability in rural areas. Adam freely donates time to meet with and assist ambulance services going through this process as it is very complex and daunting for most rural agencies.

Most recently, Adam has taken it upon himself to educate himself on the inner workings of the Medicare cost data collection process and has contacted every ambulance service selected in the state to ensure they understand what they need to do and has helped them organize themselves to collect the necessary information. Despite Adam’s employer not being selected to submit cost data this year, Adam still gives a lot of his time to ensure that rural ambulance services in North Dakota are successful with this important requirement.

Adam is very generous with this time and freely gives out his phone number and encourages anyone to call if they need help – with anything. There is no doubt that Adam would be of the finest selections for the Inaugural Mobile Healthcare 40 Under 40 in recognition of his contributions to the entire state of North Dakota and the mobile healthcare profession.

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View all of the 2020 Mobile Healthcare 40 Under 40 Honorees

2018 National and State-Specific Medicare Data

The American Ambulance Association is pleased to announce the publication of its 2018 Medicare Payment Data Report. This report is based on the “Early Edition” of the 2018 Part B National Summary Data File (previously known as the Bess Report). The report consists of an overview of total Medicare spending nationwide, and then a separate breakdown of Medicare spending in each of the 50 states, the District of Columbia, and the various other U.S. Territories.

For each jurisdiction, the report contains two charts: the first reflects data for all ambulance services, with the second limited to dialysis transports. Each chart is further broken down by HCPCS code. The charts provide information on the total number of allows services and the total Medicare payments for CYs 2017 and 2018. Percentage changes will allow members to view payment trends over the past year.

2018 National & State-Specific Medicare Data

Questions? Contact Brian Werfel at bwerfel@aol.com.

 

Submit Comments on Ambulance Data Collection System

Yesterday, the AAA submitted our comment letter to the proposed rule on changes for FY2020 to the Medicare ambulance fee schedule. The comment letter focused on the section of the proposed rule on the ambulance data collection system. For a copy of the detailed 28-page comment letter, please click here.

Read the AAA Comment Letter

The AAA is very pleased with the approach CMS is taking on data collection which is consistent with the intent of the Congress and the methodology developed and advocated by the AAA. While the AAA comment letter is extremely detailed, our only concern is CMS was not able to test or pilot the sampling methodology and data collection instrument prior to inclusion in the proposed rule. Testing would have allowed CMS to fine-tune the survey and may impact the quality of the first year of data.

Now, it is important that AAA members submit their own letters to demonstrate support for the AAA letter and its key points.

AAA members should go to www.regulations.gov and make three points as follows:

  • Our organization supports the approach CMS is proposing to collect ambulance data and we thank CMS and its contractors.
  • Since CMS was unable to test the sampling methodology and data collection tool, we are concerned about the potential quality of the first year of data. We therefore ask CMS to begin education of ambulance service suppliers and providers and work with the American Ambulance Association to adjust the methodology and tool, if necessary, for future data collections.
  • We fully support the specific comments submitted by the American Ambulance Association as to recommended improvements to the data collection tool.

All you need to do is click on www.regulations.gov and include the above three points. Add your first and last name and click “continue” to then finalize your submission.

The AAA has also developed a sample comment letter you can access by clicking here. Go to www.regulations.gov and instead of adding the three points in the comment back, upload your letter.  Please draft your own customized letter using the letter provided by the AAA as a guideline.

Sample Comment Letter

Comments are due by 5:00 pm on Friday, September 27, so please submit your comment letter today! Please also feel free to forward this email to state ambulance associations and other ambulance service organizations.

The AAA will be submitting a second letter in the next week just on seeking clarification around changes to PCS requirements in the proposed rule but will not be asking members to submit similar comments.

We greatly appreciate the work of CMS and its contractors in developing the ambulance data collection system.

Thank you in advance to all of you who take the time to submit comment letters.

Questions?: Contact Us:

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

New SNF Consolidated Billing Edits: FAQs

On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that it stated would better identify ground ambulance transports that were furnished in connection with an outpatient hospital service that would be bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime.

Unfortunately, the implementation of these new edits has been anything but seamless. Over the past few weeks, I have received numerous phone calls, texts, and emails from AAA members reporting an increase in the number of Medicare claims being denied for SNF Consolidated Billing.

This FAQ will try to explain why you may be seeing these denials.  I will also try to provide some practical solutions that can: (1) reduce the number of claims denied by the edits and (2) help you collect from the SNFs, when necessary.

Please note that, at the present time, there is no perfect solution to this issue, i.e., there is nothing that you can do to completely eliminate these claim denials.  The solutions discussed herein are intended only to minimize the disruption to your operations caused by these denials.  

I am new to Medicare ambulance billing. Can you explain what the SNF Consolidated Billing regime is, and how it operates?

Under the SNF Consolidated Billing regime, SNFs are paid a per diem, case-mix-adjusted amount that is intended to cover all costs incurred on behalf of their residents.  Federal regulations further provide that the SNF’s per diem payment generally the cost of all health care provided during the beneficiary’s Part A stay, whether provided by the SNF directly, or by a third-party.  This also includes the majority of medically necessary ambulance transportation provided during that period.  For these purposes, the “Part A Period” refers to the first 100 days of a qualified SNF stay.

However, medically necessary ambulance transportation is exempted from SNF Consolidated Billing (referred to hereafter as “SNF PPS”) in certain situations.  This includes medically necessary ambulance transportation to and from a Medicare-enrolled dialysis provider (whether free-standing or hospital-based).  Also excluded are ambulance transportations:

  • To an SNF for an initial admission;
  • From the SNF to the patient’s residence for a final discharge (assuming the patient does not return to that SNF on the same day);
  • To and from a hospital for an inpatient admission;
  • To and from a hospital for certain outpatient procedures, including, without limitation, emergency room visits, cardiac catheterizations, CT scans, MRIs, certain types of ambulatory surgery, angiographies (including PEG tube procedures), lymphatic and venous procedures, and radiation therapy.

For a fuller description of the SNF Consolidated Billing Regime, including a discussion of when ambulance services may be separately payable by Medicare Part B, I encourage members to consult the AAA Medicare Reference Manual.

Purchase the 2019 Medicare Reference Manual

Can you explain what prompted CMS to implement these new edits? 

In 2017, the HHS Office of the Inspector General conducted an investigation of ground ambulance claims that were furnished to Medicare beneficiaries during the first 100 days of a skilled nursing home (SNF) stay. The OIG’s investigation consisted of a review of all SNF beneficiary days from July 1, 2014 through June 30, 2016 to determine whether the beneficiary day contained a ground ambulance claim line. The OIG excluded beneficiary days where the only ambulance claim line related to: (1) certain emergency or intensive outpatient hospital services or (2) dialysis services, as such ambulance transportation would be excluded from SNF Consolidated Billing.

The OIG determined that there were 58,006 qualifying beneficiary days during this period, corresponding to $25.3 million in Medicare payments to ambulance suppliers. The OIG then selected a random sample of 100 beneficiary days for review.  The OIG determined that 78 of these 100 beneficiary days contained an overpayment for the associated ambulance claims, as the services the beneficiary received did not suspend or end their SNF resident status, nor was the transport for dialysis. The OIG determined that ambulance providers were overpaid a total of $41,456 for these ambulance transports.  The OIG further determined that beneficiaries (or their secondary insurances) incurred an additional $10,723 in incorrect coinsurance and deductibles. Based on the results of its review, the OIG estimates that Medicare made a total of $19.9 million in Part B overpayments to ambulance suppliers for transports that should have been bundled to the SNFs under SNF Consolidated Billing regime.  The OIG estimated that beneficiaries (and their secondary insurances) incurred an additional $5.2 million in coinsurance and deductibles related to these incorrect payments.

The OIG concluded that the existing edits were inadequate to identify ambulance claims for services associated with hospital outpatient services that did not suspend or end the beneficiary’s SNF resident status, and which were not related to dialysis. The OIG recommended that CMS implement additional edits to identify such ambulance claims.

The OIG’s report prompted CMS to issue Transmittal 2176 in November 2018.  This transmittal instructed the CWF Maintainer and the Medicare Administrative Contractors (MACs) to implement a new series of edits, effective April 1, 2019.

Can you provide a simple overview of how these new CWF edits operate?

Before we turn to the new edits, I think it is important to understand that CMS has had long-standing edits to identify outpatient hospital services that should be bundled to the SNF under SNF PPS.  These edits work by comparing the Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes on the outpatient hospital claim to applicable lists of excluded codes.  To the extent the HCPCS or CPT code appears on the applicable list of excluded codes, the outpatient hospital claim will bypass the edit for SNF PPS, and be separately payable by the MAC.  To the extent the HCPCS or CPT code on the outpatient hospital claim does not appear on the applicable list of excluded codes, the claim will be denied as the responsibility of the SNF.  The new CWF edits for ambulance claims simply extend the existing process one step further, i.e., they compare the ambulance claim to the associated hospital claim.

Conceptually, the new edits “staple” the ambulance claim to the outpatient hospital claim, with our coverage piggybacked on whether the outpatient hospital claim is determined to be bundled or unbundled.

How would I identify a claim that is denied for SNF Consolidated Billing?

Typically, the denial will be evidenced by a Claim Adjustment Reason Code on the Medicare Remittance Advice.  The denial will typically appear as an “OA-190” code, with the following additional explanation: “Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.  The “OA” stands for “Other Adjustment,” and is intended to notify you that the SNF is the correct payer.  Note: in some instances, the denial may appear as “CO-190” on the remittance advice.  However, the effect of the denial is the same, i.e., they are indicating that the SNF is financially responsible for payment.

Frequently, the denial will be accompanied by Remittance Advice Remark Code “N106,” which indicates “Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF.  You must request payment from the SNF rather than the patient for this service.”

I have heard you refer to the new CWF edits as over-inclusive.  What do you mean by that?

When CMS elects to implement a new edit to the CWF, it has to make some decisions on how to structure the edit.  Two typical decisions that must be made are:

  1. Will the edit be conditional based on the submission of other Medicare claims? And
  2. Is the edit designed to be under- or over-inclusive?

For these purposes, a conditional edit is one where the coverage or lack of coverage depends, in part, on the claims submitted by other health care providers that furnished services to the same beneficiary (typically on the same date).  As you are probably aware, the Medicare rules for all Part B payments prohibit payment whenever the service has been paid for, directly or indirectly, under Medicare Part A.  Thus, all edits for hospital and SNF bundling are conditioned, in part, on the patient’s Part A inpatient status at the time of transport.

By contrast, an unconditional edit is one that operates the same regardless of other types of claims for the same patient.  For example, with respect to ambulance claims, the MACs medical necessity edits are unconditional, i.e., they apply to all ambulance claims, regardless of the patient’s inpatient status at a Part A facility.  The edits for origin/destination modifiers are another example of an edit that is typically unconditional.

In addition, CMS has to decide whether to make an edit under- or over-inclusive.  This is because no edit can be perfectly tailored to be applied to all qualifying claims, but no non-qualifying claims.  An “underinclusive” edit is one that is designed to identify the majority – – but not all – – of the claims that should be denied based on the edit criteria.  By contrast, an “overinclusive” edit is one that would deny not only all of the qualifying claims, but also some non-qualifying claims.

In many instances related to EMS coverage, the underlying facts and circumstances of the transport are ultimately what determines the coverage.  It is frequently difficult – – if not impossible – – to fully describe these circumstances with enough specificity on the electronic claim for CMS to perfectly apply its edits.  For that reason, CMS has historically elected to design its ambulance edits to be underinclusive.

Unfortunately, the new SNF edits are both conditional AND overinclusive.  To further complicate matters, they are not only conditioned on the claim of a single Part A provider, but two separate Part A providers, i.e., in order for the new edits to work properly, CMS is reliant upon information from both the SNF and the hospital to properly apply its new edits.

I recently received a denial for an emergency transport from an SNF to the hospital for an emergency room visit.  I thought emergency ambulance transports were excluded from SNF PPS?

They are. The denial was likely the result of your claim being submitted prior to Medicare’s receipt of the associated outpatient hospital claim.

As noted above, the new edits are both conditional and overinclusive.  In this context, they are designed to deny the ambulance claim UNLESS there is a hospital outpatient claim for that same patient with the same date of service.  If there is no hospital outpatient claim on file when your ambulance claim hits the system, the edit indicates that the MAC should deny your claim for SNF PPS.

OK, that makes some sense.  Does that mean I have to appeal the denial?

In theory, no.  The instructions in Transmittal 2176 make clear that the CWF should “adjust” the ambulance claim upon receipt of the associated hospital claim.  For these purposes, that adjustment should take the form of re-processing the ambulance claim through the edits to compare it to the associated hospital claim, and to bypass the new CWF edits if the hospital claim contains an excluded code.

However, there is no timeframe for how quickly these adjustments should take place.  Most ambulance providers are reporting that they are seeing few, if any claims, being reprocessed.

I submitted several claims without knowing the patient was in the Part A Period of an SNF stay.  These claims were initially paid, but a few days later, I received a recoupment request from the MAC indicating that the claim was the responsibility of the SNF under SNF PPS. 

As noted above, the edits were designed to deny claims to the extent CMS was unable to determine whether they should be bundled to the SNF, i.e., to deny if the associated hospital claim was not already in the system.  Therefore, in theory, it should be impossible for the ambulance provider to receive a payment and then a recoupment for SNF PPS.

I suspect the situation described above is one where the ambulance claim is submitted prior to CMS’ receipt of the associated SNF claim for the patient.  As noted above, in order for the edits to work properly, both the associated hospital and SNF claims must be in the system.  While CMS clearly contemplated the possibility that the ambulance claim might be submitted prior to the associated hospital claim, they do not appear to have considered the possibility that the ambulance claim might beat the associated SNF claim into the system.

When that happens, there is nothing in the CWF to indicate that the patient was in a Part A SNF Stay.  As a result, the claim bypasses these new edits entirely, and frequently ends up being paid by the MAC.  I suspect what happens next is that the SNF claim hits the system, and triggers CMS to automatically recoup the payment for the ambulance claim.

What should happen at that point is the ambulance claim should then be run through the new edits.  If the hospital claim is already in the system, the ambulance claim gets “stapled” to that claim, and then either passes the edit or gets denied based on the information on the hospital claim.  If the hospital claim is not in the system, the ambulance provider gets the “interim” denial discussed above, and the claim should be further adjusted if and when the hospital claim is submitted.

However, at this point, it is entirely possible that these claims are not being put through the edit.  The AAA has asked CMS to look into whether the new edits are working as intended in these situations.

This sounds like a complete mess:  

Not really a question, but you are not wrong.

This sounds extremely complicated.  Is there anything I can do to reduce the possibility that my claims get denied?

I think it is important to distinguish between: (1) denials that are correct based on the HCPCS or CPT codes on the associated hospital claim and (2) denials that are based solely on the timing of your claim, i.e., denials based on your claim being submitted prior to the submission of the associated hospital claim.  For these purposes, I will refer to the latter category as “interim denials.”

At the onset, I think all members should recognize that there is nothing you can do to eliminate denials for claims that are properly bundled to the SNF based on the HCPCS or CPT codes on the associated hospital claim.

For numerous reasons, I think the proper focus should be on reducing the interim denials.  First and foremost, the difficulty with an interim denial is that you don’t know whether that denial will ultimately prove to be correct, or whether the claim will ultimately be reprocessed and paid by the MAC.  Second, even if the claim will be reprocessed, there currently appears to be a significant delay in “when” that reprocessing takes place.  Finally, without knowing whether the claim will be reprocessed (and whether that reprocessing will result in a payment), you can’t know whether you should be billing the SNF.

What information would be helpful in reducing these interim denials?

You would need to know the following data points prior to the submission of your claim:

  1. Whether the patient was in a Part A SNF Stay on the date of transport?
  2. What was the specific procedure/service the patient received at the hospital?

If you knew with certainty that the patient was not in the Part A Period of their SNF stay, you would know that the new edits would be inapplicable to your claim, and you could submit it to Medicare as part of your normal billing workflow.

If you also knew the specific procedure/service the patient received at the hospital, you would also be in a position to know whether the service was the financial responsibility of the SNF, assuming the patient was in the Part A Period.  When you know the claim is the financial responsibility of the SNF, you could then immediately invoice the claim to the SNF.  If your arrangement with the SNF requires you to first obtain a Medicare denial, you would also have the option of submitting the claim and getting the proper OA-190 denial, and then invoicing the SNF. Note: in these situations, you would receive the oA-190 denial regardless of whether your claim was submitted prior to the hospital claim.

By contrast, when you know the patient is in the Part A Period AND the procedure/service is one that would be excluded from SNF PPS, you can avoid the interim denial by ensuring that your claim is not submitted until after the associated hospital claim. In other words, this is a situation where holding your claim for a reasonable period of time might be beneficial.

We currently ask the SNF to provide information on the patient’s Part A status.  However, they frequently tell us that they don’t know, or that we are not entitled to this information.  What can we do?

First, they are absolutely permitted to share this information with you.  Both you and the SNF are “covered entities” under the HIPAA Privacy Rule.  In this instance, information on the patient’s Part A status would be helpful to you in managing your payment practices.  The regulations at 45 C.F.R. 164.506(c)(3) permit one covered entity to share protected health information with another covered entity for the payment activities of that entity.

However, it is important to note that, while the SNF may share that information with you, the Privacy Rule does not require them to provide you with this information absent a written authorization from the patient.

This information is critical to navigating the new edits.  If you haven’t been asking for it up until this point, I would strongly encourage you to consider having a discussion with the local SNFs to explain why you will be asking for this information in the future.  You may also want to consider developing a specific form that they must complete (similar to the PCS form) that would provide this information.

We have asked for this information in the past, and are typically told that if we continue to ask, the SNF will consider using our competitor, who doesn’t ask too many questions. 

I understand.  I would try to explain to the SNF that the reason you are asking for this information is to be able to make an intelligent determination on whether the transport is likely to the be financial responsibility of the SNF.  This information allows you to avoid denials in certain instances where they would otherwise not be responsible.  If they don’t provide you with this information, the foreseeable consequence is that you will end up getting interim denials from Medicare, which may leave you no choice but to bill the SNF for the transport.

I feel bad for the person that asked the previous question.  Fortunately for me, we are the only ambulance provider in the area, so the threat of going to a competitor rings a bit hollow.  Do I have any additional options to get this information?

You do.  I would try to insert language into your agreements with the SNFs that obligate them to provide you with this information.  You could also try to insert language that makes them financially responsible whenever they fail to provide this information.

We don’t have agreements with the local SNFs.  Do we need an agreement?

One of the foreseeable consequences of this new edit is that it will increase the frequency with which you bill the SNFs.  One of the most common complaints I hear is that SNFs refuse to pay their bills.  In most instances, the problem is that the ambulance service lacks a written agreement with the SNF, and, as a result, they frequently end up in disputes about when the SNF is responsible.  A written agreement that clearly spells out when the SNF is responsible can not only minimize the potential for misunderstandings, but also afford you greater remedies when the SNF refuses to pay.

With respect to the new edits, what should that agreement say?

You should consult with your local attorney regarding the applicable language.  However, conceptually, you want to include language that indicates that a Medicare denial is conclusive evidence that the SNF is financially responsible.  This provision could then go on to provide that, in the event Medicare should reprocess and pay a particular claim, then you would refund the SNF’s payment.

What can I do to help the AAA in minimizing the administrative burden associated with these new edits?

The AAA is currently conducting a survey of members to help get a sense of the magnitude of the issues created by these new edits. If you would like to participate in the survey, you can click here.

Take the Survey

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

Update on AAA Legislative Priorities

The American Ambulance Association has been working hard to accomplish the legislative goals of the membership in the 116th Congress. The AAA would like to take this opportunity to provide an update on what we have accomplished thus far in the 116th Congress.

Balance/Surprise Billing

Balance/surprise billing is a hot button issue that recently came into the spotlight at the start of the 116th Congress. With the President’s announcement calling for Congress to pass legislation that would end surprise billing for patients, there has been an increase in Congressional action on the issue including introduced legislation, discussion drafts and hearings in all committees of jurisdiction. The AAA has been working tirelessly with the Congressional committees of jurisdiction to educate Members and staff on the unique characteristics of EMS systems and that it would be inappropriate to apply the same restrictions on balanced billing to ground ambulance services.

The AAA has formed a working group comprised of AAA member volunteers that have worked on policy and messaging on balance billing. The working group has submitted comments to the Energy and Commerce Committee and Senate HELP committees advocating that the ambulance industry is unique from other stakeholders, and as such, should be looked at differently. Ambulance service providers and suppliers are required by law to treat and transport all patients, regardless of their ability to pay and are heavily regulated at the local level. The AAA has been working to communicate these factors that place the ambulance industry in a different situation than many other stakeholders.

Public Safety Officers Death Benefit (PSOB)

The Public Safety Officers Death Benefit (PSOB), a one-time benefit paid to families of first responders killed in the line of duty, is an issue that the AAA has passionately advocated for over many years. In the 116th Congress, the AAA has secured introduction of legislation in the House of Representatives, H.R. 2887, the Emergency Medical Service Providers Protection Act. H.R. 2887 would extend the PSOB to first responders employed by private for-profit EMS agencies. The AAA was able to secure several commitments from Members of Congress to cosponsor the legislation during Stars of Life meetings in Washington, DC. In addition to taking action to move H.R. 2887 through the legislative process, the AAA will be engaging in an outreach campaign in the next few weeks.

Dialysis Off-Set Restructuring

The AAA has worked toward reintroduction of legislation to restructure the offset that was passed into law in the Bipartisan Budget Act of 2018 (H.R. 1892) in the 115th Congress. This offset included a total cut of 23% to the Medicare reimbursement for basic life support (BLS) non-emergency transports performed by all ambulance service suppliers and providers to and from dialysis centers. This cut served as an offset to the 5-year extension of Medicare add on payments that our industry worked hard to get extended.

The AAA has secured introduction of legislation in both the House and Senate. H.R. 3021 was introduced by Representatives LaHood (R-IL) and Sewell (D-AL) and S. 228 by Senators Cassidy (R-LA) and Jones (D-AL). If passed, this legislation would change the cut that is currently in place so that it applies specifically to companies conducting over 50% ESRD non-emergency transports. Those ambulance services with over 50% ESRD transports would get a cut of 29.5%, while those doing less would receive a 15.5% cut. The AAA will continue to work toward movement and passage of this legislation that would better distribute the reduction to those providers which do almost exclusively non-emergency dialysis transports and thus have a lower cost of providing services.

Medicare Priorities Bill

The AAA has crafted legislation that is specifically aimed at addressing major Medicare ambulance industry issues. The issues that will be included in future legislation include making Medicare ambulance add-ons permanent, implementing a prior-authorization program across the nation, allowing for transportation to alternative destinations, reducing regulatory burdens, and providing relief through maintaining many zip codes as rural following the next census. The AAA is working to get this Medicare priorities legislation introduced in the coming months so that we can get to work on solving these Medicare issues that impact our industry as a whole.

VA Legislation

Another priority that that the AAA has been diligently working toward getting introduced is Veterans Affairs (VA) legislation. The Veterans Reimbursement for Emergency Ambulance Services Act (VREASA) introduced by Congressman Tipton (R-CO) would provide veterans with reimbursement for emergency ambulance services when a Prudent Layperson would have a reasonable expectation that a delay in seeking immediate medical attention will jeopardize the life or health of the veteran. This legislation was introduced as a result of the VA consistently requiring all medical records be provided, including the records of treatment after the emergency service has taken place. Should those records show that it was not a life threatening emergency or a false alarm, the claim for reimbursement is being denied. The VA legislation would mandate that the VA apply the “prudent layperson” definition of emergency to determine coverage of ambulance claims.

The AAA is also working toward addressing two other issues with the VA to enforce more prompt payment by the VA and treating the VA as the first payor, similar to Medicare, as it is determined whether there is a different primary payor. The AAA has been working with Senators Collins and Tester on language help solve this ongoing and serious reimbursement issue.

In our next update, we will be reporting on the progress the AAA has made this year on regulatory issues.

Questions? Contact Us

If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support

New SNF PPS Edits Highlight the Importance of Facility Agreements

On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that are intended to better identify ground ambulance transports that are furnished in connection with an outpatient hospital service that is properly bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime.

These edits work by comparing the ambulance claim to the associated outpatient hospital claim.  Hospital claims were already subject to CWF edits designed to identify outpatient hospital services that should be bundled to the SNF.  These hospital edits operate by referencing a list of Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes that correspond to outpatient hospital services that are expressly excluded from SNF Consolidated Billing.  Hospital claims for outpatient services that are submitted with one of these excluded codes bypass the existing CWF edits, and are then sent to the appropriate Medicare Administrative Contractor for further editing and payment.  Hospital claims submitted without one of these codes are denied for SNF Consolidated Billing.

The new ambulance edits will extend these process one step further.  The ambulance claim will be associated with the outpatient hospital claim on the same date.  To the extent that hospital claim is bundled under SNF Consolidated Billing, the associated ambulance claim will also be bundled.  To the extent the hospital claim is unbundled, the associated ambulance claim will be unbundled.

In order for these new edits to work properly, there must be an outpatient hospital in Medicare’s claim history. If the ambulance claim beats the hospital claim into the system, the ambulance claim will be rejected. If and when an outpatient hospital claim with the same date of service enters Medicare’s system, the initial rejection of the ambulance claim will be overturned, and the ambulance claim will be reprocessed using the same edits.

It is important to note that the new edits were designed to reject the ambulance claim as a bundled service unless the hospital claim indicates that it should not be bundled.  In other words, these edits are designed to be “over inclusive.”  This over-inclusiveness creates the potential for ambulance denials in situations that, on their face, would not appear to be bundled.

A few examples will help illustrate this point. Imagine a situation where the patient elects, for whatever reason, to pay out-of-pocket for their hospital care (in a situation where that care would not be bundled to the SNF), and, as a result, the hospital does not submit a bill to Medicare for its services.  Based on how the new edits are designed, your ambulance claim for the transport to that excluded service will be rejected based on the lack of a hospital claim. Or maybe the patient has both Medicare and the V.A., and has elected to have the V.A. be the primary payer for their required hospital care.  Again, there would likely be no outpatient hospital claim submitted to Medicare on that date of service, resulting in the rejection of your ambulance claim.

I can see your point, but those examples are pretty far-fetched.  How big an issue is this really?

I agree those examples are pretty far-fetched.  However, there are other situations that create the same problem.  For example, what about an emergent response to transport an SNF patient to the hospital for necessary emergency services?  Imagine if you are called to respond late at night (e.g., 11:30 p.m.) tonight.  Now imagine that, by the time you get to the patient, load them into the vehicle, and transport them to the ED, it has crossed over midnight into the next day.

What date of service is going to be on the hospital’s claim?  Almost certainly, the hospital will use tomorrow’s date.  As a result, when your claim hits Medicare’s system, there will not be an associated hospital claim, which will result in your claim being rejected as the responsibility of the SNF.  In this situation, Medicare’s edit has worked as intended, but the result is the denial of a claim that should be separately payable by Medicare Part B.

Okay, I can see how this might be annoying,
but I can appeal the claim and likely win on appeal, right? 

Yes and no.  The problem is that you are not likely to win on either of the first two levels of appeal, as they are likely going to rely upon the information in the CWF.  I can see you possibly winning your appeal at the ALJ level…5 to 7 years from now.

In other words, the appeals process is unlikely to provide an acceptable resolution.  Instead, I think the majority of ambulance providers are going to look to the SNFs to make good in these situations.  Of course, the SNFs are likely going to disclaim liability, arguing (correctly) that ambulance transportation to an ED is an excluded service.

This is where the agreement with the SNF comes into play.  One key purpose of contracts is to allocate known risks between the parties.  In this instance, the “risk” that needs to be addressed is the possibility that Medicare might incorrectly reject your claim thinking it is bundled to the SNF.  I would argue that this risk should be absorbed by the SNF.  The transport to the ED should have suspended the patient’s SNF stay, which would have allowed you to receive a separate payment from Medicare.  However, the fact that your claim was rejected is proof positive that the CWF does not reflect the suspension of the patient’s SNF stay.  Indirectly, it also serves as proof that the SNF received a per diem payment for the patient on that date.  To me, the fact that they accepted the per diem payment means they accepted the risk of a bundled ambulance service on that date.  I would also argue that it was their failure to properly suspend the patient’s SNF stay that set in motion your denial.  Either way, I would be looking to the SNF for payment.

Based on my experience, the typical agreement with an SNF does not address this situation.  Frequently, these agreements do not even address the specifics of SNF Consolidated Billing.  Instead, I tend to see general language indicating that the ambulance provider will bill the SNF when payment responsibility lies with the SNF under an applicable federal or state health care program.  I doubt that language is going to convince an SNF to take financial responsibility for the situation discussed above.

The good news is that your existing agreements can easily be revised to address this situation.  The language I would recommend is something along the lines of:

“The parties acknowledge and agree that a denial from Medicare for SNF consolidated billing shall constitute conclusive evidence that a transportation service is the financial responsibility of the facility.” 

In sum, the new SNF Consolidated Billing edits are going to increase the frequency with which we are forced to look to the SNFs for payment.  In most instances, it will be a situation where the SNF is legally responsible under SNF Consolidated Billing.  However, there will also be situations where the over-inclusive nature of the edits results in the claim being incorrectly denied as the SNF’s responsibility.  The question becomes how you want to handle these incorrect denials.  Do you want to appeal and hope CMS reverses its decision?  Or do you want to hold the SNF responsible?  If you want to hold the SNF responsible, you will likely need to revise your agreements with the SNFs.

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

Update on New SNF Edits

CMS Set to Implement New Common Working File Edits to Identify Ambulance Services Provided in Connection with Outpatient Hospital Services that should be bundled to the SNF under Consolidated Billing.

In a Member Advisory issued last week, the AAA provided an update on a series of new Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019. 

In our discussion of the implementation specifics, we attempted to answer the question of what would happen when an ambulance claim is submitted prior to the receipt of the associated hospital outpatient claim, and where the associated hospital claim eventually hit Medicare’s system. Specifically, we indicated as follows:

“The Transmittal contains further instructions that the CWF be updated to identify previously rejected ambulance claims upon receipt of an associated hospital claim for the same date of service that contains an Exempted Code.  Once identified, the Shared System Maintainer (SSM) is supposed to adjust the previously rejected or denied ambulance claim.  At this point, the nature of that “adjustment” is unclear, i.e., it is unknown whether the SSM will automatically reprocess the ambulance claim for payment.  The AAA is seeking additional clarification from CMS on this important point.”

On March 15, 2019, CMS responded to our request for clarification. Specifically, CMS indicated that it has instructed the SSM and/or its Medicare Administrative Contractor (MAC) to automatically reprocess claims that were rejected for lack of an associated hospital outpatient claim.

Upon reprocessing, the claims will pass the edits to the extent the associated hospital claim contains a HCPCS or CPT code that indicates that the hospital outpatient service was excluded from SNF Consolidated Billing. Such claims would then be forwarded to the MAC for further editing, and either paid or denied. By contrast, when the associated hospital outpatient claim contains HCPCS or CPT codes that suggest the hospital services should be bundled to the SNF, the claim will be reprocessed and denied by the MAC with a remittance advice code indicating that the SNF is financially responsible.

AAA Webinar on New SNF Consolidated Billing Edits

March 27, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Esq.
$99 for Members | $198 for Non-Members

Join AAA Medicare Consultant Brian Werfel, Esq., to go over the new SNF Consolidated Billing edits that go into effect April 1, 2019. These edits are being implemented by CMS in response to 2017 investigation by the HHS Office of the Inspector General that determined that CMS lacked the appropriate claims processing edits to properly identify ambulance transports provided in connection with hospital outpatient services that are not expressly excluded from SNF PPS. The implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on what to do with these claims moving forward. Sign up today to make sure your service is ready!

Register for the Webinar

CMS SNF Edits Go Into Effect – April 1, 2019

CMS Set to Implement New Common Working File Edits to Identify Ambulance Services Provided in Connection with Outpatient Hospital Services that should be bundled to the SNF under Consolidated Billing

On November 2, 2018, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 2176 (Change Request 10955), which would establish a new series of Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019. 

Why these edits are necessary?

In 2017, the HHS Office of the Inspector General conducted an investigation of ground ambulance claims that were furnished to Medicare beneficiaries during the first 100 days of a skilled nursing home (SNF) stay. Under the SNF Consolidated Billing regime, SNFs are paid a per diem, case-mix-adjusted amount that is intended to cover all costs incurred on behalf of their residents.  Federal regulations further provide that, with limited exceptions, the SNF’s per diem payment includes medically necessary ambulance transportation provided during the beneficiary’s Part A stay. The OIG’s report was issued in February 2019.

The OIG conducted a review of all SNF beneficiary days from July 1, 2014 through June 30, 2016 to determine whether the beneficiary day contained a ground ambulance claim line. The OIG excluded beneficiary days where the only ambulance claim line related to: (1) certain emergency or intensive outpatient hospital services or (2) dialysis services, as such ambulance transportation would be excluded from SNF Consolidated Billing. The OIG determined that there were 58,006 qualifying beneficiary days during this period, corresponding to $25.3 million in Medicare payments to ambulance suppliers.

The OIG then selected a random sample of 100 beneficiary days for review. The OIG determined that 78 of these 100 beneficiary days contained an overpayment for the associated ambulance claims, as the services the beneficiary received did not suspend or end their SNF resident status, nor was the transport for dialysis. The OIG determined that ambulance providers were overpaid a total of $41,456 for these ambulance transports. The OIG further determined that beneficiaries (or their secondary insurances) incurred an additional $10,723 in incorrect coinsurance and deductibles.

Based on the results of its review, the OIG estimates that Medicare made a total of $19.9 million in Part B overpayments to ambulance suppliers for transports that should have been bundled to the SNFs under SNF Consolidated Billing regime. The OIG estimated that beneficiaries (and their secondary insurances) incurred an additional $5.2 million in coinsurance and deductibles related to these incorrect payments.

The OIG concluded that the existing edits were inadequate to identify ambulance claims for services associated with hospital outpatient services that did not suspend or end the beneficiary’s SNF resident status, and which were not related to dialysis. The OIG recommended that CMS implement additional edits to identify such ambulance claims.

Overview of new claims processing edits

In response to the OIG’s report, CMS issued Transmittal 2176, which implements a new series of claims processing edits to identify ambulance claims associated with outpatient hospital services that should be bundled to the SNF. As noted above, these edits will go into effect on April 1, 2019.

These new claims processing edits are somewhat complicated. In order to properly understand how these claims edits will work, it is helpful to understand that CMS already has claims processing edits in place to identify hospital outpatient claims that should be bundled to the SNF. These CWF edits operate by referencing a list of Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes that correspond to outpatient hospital services that are expressly excluded from SNF Consolidated Billing. Hospital claims for outpatient services that are submitted with one of these excluded codes bypass the existing CWF edits, and are then sent to the appropriate Medicare Administrative Contractor for further editing and payment. Hospital claims submitted without one of these codes are denied for SNF Consolidated Billing. For convenience, the list of HCPCS and CPT codes excluded from SNF Consolidated Billing is hereinafter referred to as the “Exempted Codes.”

The new edits for ambulance claims will compare Part B ambulance claims to the associated outpatient hospital claim to see whether or not that hospital claim is excluded from SNF Consolidated Billing.

Specifics related to new claims processing edits

Under these new edits, the CWF will reject an incoming ambulance claim whenever the beneficiary is determined to be in an SNF Part A stay if either:

  1. There is no associated outpatient hospital claims for the same date of service on file; or
  2. There is an associated outpatient hospital claim for the same date of service on file (paid or denied), but where that outpatient hospital claim does not contain at least one Exempted Code.

When an incoming ambulance claim is rejected by the CWF, it will be sent to the applicable Medicare Administrative Contractor and rejected (Part A Ambulance Providers) or denied (Part B Ambulance Suppliers) using the applicable Claim Adjustment Reason Code/Remittance Advice Remark Code for SNF Consolidated Billing.  In other words, the ambulance claim will be denied with an indication that youshould bill the SNF.

The Transmittal contains further instructions that the CWF be updated to identify previously rejected ambulance claims upon receipt of an associated hospital claim for the same date of service that contains an Exempted Code. Once identified, the Shared System Maintainer (SSM) is supposed to adjust the previously rejected or denied ambulance claim. At this point, the nature of that “adjustment” is unclear, i.e., it is unknown whether the SSM will automatically reprocess the ambulance claim for payment. The AAA is seeking additional clarification from CMS on this important point.

Potential concerns for ambulance providers and suppliers

Based on the current experience of hospital providers, the AAA is cautiously optimistic that the new edits can be implemented in a way that proper identifies ambulance transports associated with hospital outpatient claims that should be bundled to the SNF vs. those that correctly remain separately payable by Medicare Part B.

However, the AAA has some concerns with the manner in which CMS intends to apply these edits.  Ambulance providers and suppliers are typically in a position to submit their claims earlier than the corresponding hospital, many of which submit claims on a biweekly or monthly cycle.  This creates a potential timing issue. This timing issue arises because the edits will reject any ambulance claim that is submitted without an associated hospital claim on file.  In other words, even if the hospital outpatient service is properly excluded from SNF Consolidated Billing, the ambulance claim will still be rejected if it beats the hospital claim into the system. The hope is that CMS will subsequently reprocess the ambulance claim once the hospital claim hits the system. However, at this point in time, it is unclear whether these claims will be automatically reprocessed, or whether ambulance providers and suppliers will be forced to appeal these claims for payment.

One option available to ambulance providers and suppliers would be to hold these claims for a period of time, in order to allow the hospitals to submit their claims. By waiting for the hospital to submit its claim, you can ensure that your claims will not be denied solely due to the timing issue. This should eliminate the disruption associated with separately payable claims being rejected and then subsequently reprocessed and/or appealed. It would also give you a degree of certainty when billing the SNF for claims that are denied for SNF Consolidated Billing. However, holding claims carries an obvious downside, i.e., it will disrupt your normal cash flow.

To summarize, the implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on whether to hold claims to minimize the potential for problems, or to continue their existing submission practices and deal with any issues as they arise.

AAA webinar on new SNF Consolidated Billing edits

March 27, 2019 | 2:00 PM Eastern
Speakers: Brian Werfel, Esq.
$99 for Members | $198 for Non-Members

Join AAA Medicare Consultant Brian Werfel, Esq., to go over the new SNF Consolidated Billing edits that go into effect April 1, 2019. These edits are being implemented by CMS in response to 2017 investigation by the HHS Office of the Inspector General that determined that CMS lacked the appropriate claims processing edits to properly identify ambulance transports provided in connection with hospital outpatient services that are not expressly excluded from SNF PPS. The implementation of these new edits will force ambulance providers and suppliers to rethink their current claims submission processes for SNF residents. Ambulance providers and suppliers will need to make a decision on what to do with these claims moving forward. Sign up today to make sure your service is ready!

Register for the Webinar

AAA Releases 2019 Medicare Rate Calculator

AAA 2019 Medicare Rate Calculator Now Available!

The American Ambulance Association is pleased to announce the release of its 2019 Medicare Rate Calculator tool. The AAA believes this is a valuable tool that can assist members in budgeting for the coming year. This calculator has been updated to account for recent changes in Medicare policies, including the 2019 Ambulance Inflation Factor (2.3%) and continuation of the current temporary add-ons.

To access the Rate Calculator, please CLICK HERE.

Download the 2019 Rate Calculator

Update on Government Shutdown and Sequestration

As the government shutdown drags on the negative impacts continue to grow. If the shutdown continues through January 24, 2019, which is looking likely at this point, current law will require the Trump Administration to cut about $839 million from non-exempt federal benefit programs to avoid increasing the deficit. This is a result of the “PAYGO” (pay as you go) law which requires spending increases or tax cuts to be offset with cuts to programs or additional revenue to avoid increasing the deficit. As the largest nonexempt benefit program, it is likely that Medicare would experience the worst of these cuts through sequestration.

While the Trump Administration has not yet issued a sequestration order, there is a distinct possibility that one could be issued if the shutdown continues much longer. A sequestration order would mean an additional across the board cut to all Medicare providers, including ambulance services. Ambulance service providers are still feeling the impact of the 2% sequestration cut that has been in effect the past few years. Any new cuts would likely start out being targeted at administrative tasks which could slow payments to providers. Temporary cuts would be expensive for the administration to facilitate and is made more challenging by the fact that many important staff members are currently furloughed. There are also some at the Office of Budget and Management (OMB) who believe that these cuts could not actually be administered until the government is reopen.

The AAA will keep members informed of any new developments.