Tag: Medicare

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.

CMS Posts 2019 Public Use File

On November 28, 2018, CMS posted the 2019 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in calendar year 2019 for the various levels of ambulance service and mileage. These allowables reflect a 2.3% inflation adjustment over the 2018 rates.

The 2019 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.

Unfortunately, CMS has elected in recent years to release its Public Use Files without state and payment locality headings. As a result, in order to look up the rates in your service area, you would need to know the CMS contract number assigned to your state. This is not something the typical ambulance service would necessarily have on hand. For this reason, the AAA. has created a reformatted version of the CMS Medicare Ambulance Fee Schedule, which includes the state and payment locality headings. Members can access this reformatted fee schedule here.

View Reformatted Fee Schedule

2017 National and State-Specific Medicare Data

The American Ambulance Association is pleased to announce the publication of its 2017 Medicare Payment Data Report. This report is based on the Physician/Supplier Procedure Summary Master File. This report contains information on all Part B and DME claims processed through the Medicare Common Working File and stored in the National Claims History Repository.

The report contains an overview of total Medicare spending nationwide in CY 2017, 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, while the second is limited solely to dialysis transports. Each chart lists total spending by procedure code (i.e., base rates and mileage). For comparison purposes, information is also provided on Medicare spending in CY 2016.

2017 National & State-Specific Medicare Data

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

 

Talking Medicare: CMS Implements Further Dialysis Cuts

Talking Medicare: CMS Implements Further Cuts in Reimbursement for Dialysis Services; Medicare Payment Data Shows Continued Reduction in Overall Spending on Dialysis Transports, but Net Increase in Dialysis Payments in Prior Authorization States

On October 1, 2018, CMS implemented an additional thirteen (13%) cut in reimbursement for non-emergency BLS transports to and from dialysis. This cut in reimbursement was mandated by Section 53108 of the Bipartisan Budget Act of 2018. This on top of a ten (10%) cut in reimbursement for dialysis transports that went into effect on October 1, 2013. As a result, BLS non-emergency ambulance transports to and from dialysis that occur on or after October 1, 2018 will be reimbursed at 77% of the applicable Medicare allowable.

In related news, CMS has released its national payment data for calendar year 2017. This data shows a continued reduction in total Medicare payments for dialysis transports. Medicare paid $477.7 million on dialysis transports in 2017, down from $488.9 million in 2016. This continues a downward trend that has seen total payments decline from a high of more than $750 million in 2013 (see accompanying chart to the right). Not coincidentally, it was in 2013 that our industry saw its first reduction in Medicare’s payments for dialysis transports.

The payment reduction is partially the result of the reduction in the amounts paid for dialysis services. However, it is also reflective of an overall decline in the number of approved dialysis transports. For this, we can look primarily to the impact of a four-year demonstration project that requires prior authorization of dialysis transports in 8 states and the District of Columbia.

As a reminder, the original prior authorization states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress. The chart below shows total spending on dialysis in those states in the years immediately preceding the implementation of the prior authorization project up through 2017, the third year of the demonstration project. While the three states had very different trajectories prior to 2015, each showed a significant decrease in total payments for dialysis under the demonstration project.

However, it is the trajectory of these changes that I want to discuss in this month’s blog. In previous blogs, I discussed the impact of the particular Medicare Administrative Contractor on the outcomes under prior authorization. Specifically, I noted that, while dialysis payments dropped in each state, the decline was far more dramatic in the states administered by Novitas Solutions (NJ, PA) than in the South Carolina, which was administered by Palmetto GBA. This trend continued in the second year of the program, which saw prior authorization expanded into five additional states and the District of Columbia. Those states administered by Novitas (DE, MD) saw far greater declines than the states administered by Palmetto (NC, VA, WV).

Given these declines, the data from the third year is somewhat surprising. The states administered by Palmetto continued to see declines in total dialysis payments, with the only exception being West Virginia. However, in the states administered by Novitas, we saw total dialysis payments increase, particularly in New Jersey, which saw nearly a 33% increase in total dialysis payments.

Three years into the prior authorization program, it is starting to become clear that the two MACs have approached the problem of overutilization of dialysis transports using two different approaches. Palmetto appears to have adopted a slow-and-steady approach, with total payments declining in a consistent manner year after year. By contrast, Novitas adopted more of a “shock the system” approach, where it rejected nearly all dialysis transports in the first year, and has adopted a somewhat more lenient approach in subsequent years.

Key Takeaways

 Last year, I wrote that two years of data under the prior authorization program permitted two conclusions: (1) the implementation of a prior authorization process in a state will undoubtedly result in an overall decrease in the total payments for dialysis within that state and (2) the size of that reduction appears to be highly dependent on the Medicare contractor.

With an additional year of data, I think both conclusions remain valid, although I would revise the second to suggest that the initial reduction has more to do with the Medicare contractor. The evidence from the third year of the program suggests that the trends tend to equalize after the first few years. It is also possible that Novitas felt a more aggressive approach was needed in the first few years to address evidence of widespread dialysis overutilization in the Philadelphia metropolitan area.

This has potential implications beyond the demonstration project, as CMS looks towards a possible national expansion of the program. Among other issues, it suggests that the AAA must continue its efforts to work with CMS and its contractors on developing more uniform standards for coverage of this patient population.

What the AAA is Doing

The AAA continues to work on legislation that would restructure this cut to dialysis transport reimbursement. The AAA strongly supports the NEATSA Act (H.R.6269) introduced by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) that would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports. AAA members and the AAA are working to get a Senate companion bill introduced shortly. The goal of this legislation would be to have the restructured offset go into effect as soon as possible. Thank you to the dozens of AAA members who have already contacted their members of Congress voicing their support for this critical legislation.


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

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.

OIG Report on Overpayments For Non-Emergency Transports

OIG Report – Overpayments For Non-Emergency Ambulance Transports To Non-Covered Destinations

The Office of the Inspector General released its report Medicare Improperly Paid Providers for Non Emergency Ambulance Transports to Destinations Not Covered by Medicare“.

In sum, the OIG reviewed claims that Medicare paid for 2014 – 2016 non-emergency ambulance transports. The review focused on transports to non-covered destinations. OIG found that $8,633,940 was paid by Medicare for non-emergency ambulance transports under codes A0425 (ground mileage), A0426 (ALS non-emergency) and A0428 (BLS non-emergency) during this period of time.

The review was based solely on the claims and not based on a medical review or interviews of providers.

The claims that should not have been paid were to the following destinations:

  • 59% – to diagnostic or therapeutic sites other than a hospital or physician’s office, that did not originate at a SNF.
  • 31% – to a residence or assisted living facility (and not meeting the origin/destination requirement).
  •  6% – to the scene of an acute event.
  •  4% – to a destination code not used for ambulance claims or where no destination modifier was used.
  • <1% – to a physician’s office.

OIG recommended (and CMS agreed) that CMS:

  1. Notify the Medicare Administrative Contractors to recover that portion of the overpayment that is within the 4-year period in which claims can be re-opened.
  2. For the balance of the overpayment that is outside the 4-year period, CMS should provide the information needed for the MACs to notify the providers of the overpayments and have the providers exercise reasonable diligence to investigate and refund improper payments.
  3. Direct the MACs to review the origin/destination requirements for any overpayments following the audit period.
  4. Require the MACs implement edits to ensure they only pay for non-emergency transports that meet the Medicare requirements.

There is a chart in the report that indicates the improper payments for each jurisdiction. It is interesting to note that the overpayments range from a low of $515 (First Coast) to a high of $5,006,696 (Cahaba).

The report can be obtained at: https://go.usa.gov/xU5vf

NEW! AAA PreCon Workshop on Mandatory Cost Data Collection

AAA is excited to announce that this year we will be holding a full day pre-conference workshop at the AAA Annual Conference & Trade Show! Join industry experts Rebecca Williamson, Angie McLain, Asbel Montes, Kathy Lester, Scott Moore, and Brian Werfel to learn what the new cost data collection mandates will require and how you and your service can get ahead of the game and prepare for these changes.

Mandatory Cost Data Collection: When Is It Happening & How to Prepare

September 5, 2018 | 9:00 AM – 4:00 PM | MGM Grand, Las Vegas
$75 for Annual Conference attendees | $250 workshop-only

2018 federal legislation expanded Medicare cost reporting to ambulance services, although with some important differences from other Medicare reporters. Failure to meet these new reporting requirements could lead to significant sanctions including loss of Medicare revenue. In this session, we will review how we got to where we are, what the new mandates will require based on current regulations, and how best to prepare yourself and your service for the phase-in.

Update on Medicare Reimbursement Issues

The AAA would like to take this opportunity to update members on a number of issues related to Medicare reimbursement:

  1. CMS and its contractors have begun adjusting claims for ground ambulance services to reflect the restoration of the temporary add-ons. Section 50203(a) of the Bipartisan Budget Act of 2018 retroactively reinstated the temporary add-ons for ground ambulance services. These add-ons increase the applicable Medicare allowables by 2% in urban areas, 3% in rural areas, and 22.6% in “super rural” areas (over and above the corresponding rural rate), retroactive to January 1, 2018. On a March 7, 2018 Open Door Forum, CMS indicated that it had updated the Medicare Ambulance fee schedule to reflect these higher rates, and that it has provided a Change Request to each of its Medicare Administrative Contractors (MACs). The AAA has confirmed that all MACs have successfully implemented the new rates, and that all are paying current claims at the correct rate. The AAA has further confirmed that MACs have started to adjust 2018 claims paid at the original (lower) rates. Unfortunately, neither CMS nor its MACs have committed to a firm timetable for the completion of all required adjustments; however, a number of MACs have indicated that they anticipate completing all required adjustments by the end of the second quarter of 2018.
  1. Further reduction in Medicare’s payment for non-emergency BLS transports to and from dialysis. The Bipartisan Budget Act of 2018 further required CMS to implement an additional 13% reduction in Medicare’s payment for scheduled, non-emergency BLS transports to and from dialysis. This reduction is on top of the existing 10% payment reduction. Collectively, this means that dialysis transports will be reimbursed at a rate that is 23% less than the rate that would otherwise be applicable to BLS non-emergency transports in your area. The AAA. is reminding members that this additional reduction in payments will go into effect for transports on or after October 1, 2018.
  1. CMS has updated its SNF Consolidated Billing file to resolve the error that resulted in certain ambulance claims being incorrectly denied as being the responsibility of the SNF. Each year, CMS updates the SNF Consolidated Billing file provided to MACs. This file contains several lists of Healthcare Common Procedure Coding System (HCPCS) codes, and provides instructions to the MACs on whether these codes: (i) should be accepted for separate payment under Medicare Part B or (ii) should always be denied for inclusion in the SNF Consolidated Billing system. Ambulance HCPCS codes (A0425, A0426, A0427, etc.) have always been included in the first list, as the issue of whether an ambulance transportation is bundled to the SNF is conditioned on the nature of the services that the patient will receive at the destination. To the extent the service the patient will receive at the destination is bundled, the ambulance services to and from that service will also be bundled, and vice versa. Note: there are two exceptions to this general rule. The first is that ambulance transportation to and from dialysis is specifically exempted from the SNF Consolidated Billing regime, and therefore will always be separately billable to Medicare Part B. The second exception relates to the provision of chemotherapy services furnished on an outpatient basis in a hospital. Chemotherapy services are generally bundled to the SNF; however, several years ago, Congress elected to exempt a number of particularly expensive forms of chemotherapy from the SNF bundle. In these instances, while the SNF is not responsible for the payment of the expensive chemotherapy, the SNF remains responsible for payment of the ambulance transportation to and from the hospital. Because ambulance codes may or may not be bundled to the SNF based on the nature of the transport, they are not automatically denied. Instead, the MACs are supposed to use further edits to identify those situations in which the ambulance transport would be bundled vs. separately payable. Unfortunately, in its 2018 update, CMS inadvertently left the ambulance HCPCS codes off the list of codes that are not automatically denied as being bundled to the SNF.  As a result, ambulance providers have indicated that claims were being denied using remark code “OA109.”  In some cases, claims for dates of service in 2016 or 2017 that were previously paid were being recouped. CMS recognized its error fairly quickly, and updated the SNF Consolidated Billing file in mid-February. All MACs were provided with updated instructions by February 27, 2018. Therefore, the issue has been resolved for current claims. What remains to be resolved is how CMS and its MACs will adjust or reprocess claims that were incorrectly denied. Several MACs have notified providers of the issue, and asked that they refrain from appealing the claims. These MACs are indicating that they will automatically adjust/reprocess affected claims. In other instances, the MACs have asked the providers to make a refund of affected claims that were previously paid, promising to then reprocess the entire claim. The AAA is advising members to carefully track the claims that were affected by this mistake, and to follow the instructions issued by their MAC for ensuring their reprocessing.
  1. CMS has delayed the mailing new ID cards to all Medicare beneficiaries. As part of the Medicare Access and CHIP Reauthorization Act of 2015, Congress mandated that CMS remove a beneficiary’s social security number (SSN) from their Medicare ID card by April 2019. As part of this initiative, CMS will be replacing the SSN-based Health Insurance Claim Number (HICN) with the new Medicare Beneficiary Identifier (MBI). CMS has already started mailing cards with the MBI to newly enrolling Medicare beneficiaries. CMS originally announced that it would be mailing new cards to existing Medicare beneficiaries starting in April 2018, but recently indicated that it would delay the mailing of new cards to existing Medicare beneficiaries until May 2018. From May to June, CMS will mail new cards to existing Medicare beneficiaries residing in Alaska, California, Delaware, Hawaii, Maryland, Oregon, Pennsylvania, Virginia, West Virginia, the District of Columbia, and the U.S. territories of American Samoa, Guam, and the Northern Mariana Islands. The mailing program will then be extended to additional states in 5 “waves” over the coming year. To the extent you provide services in the above-mentioned states, you may want to educate crewmembers and other employees on the differences between the HICN and the MBI. You may want to also consider updating your existing patient databases to include the new identifier. As a reminder, CMS will permit claims to be submitted with either the HICN or the MBI during a transition period running through December 31, 2019.  Effective January 1, 2020, claims must be submitted with a patient’s MBI. This requirement applies regardless of whether the date of service occurred prior to the expiration of the transition period.
  1. Extension of prior authorization project for scheduled, repetitive transports. In December 2017, CMS indicated that it would be extending the prior authorization program for an additional year. This program is currently in place for the states of Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, West Virginia, and the District of Columbia. The extension of the program is limited to those states. CMS has further indicated that it will be making a determination on possible national expansion at some point in the near future. CMS recently released its first interim report on the prior authorization program. As expected, that report indicated that prior authorization has been successful in reducing Medicare expenditures on scheduled, repetitive transports, without any material impact on beneficiary access to and quality of care.

Have any questions about these updates? Contact Brian Werfel at bwerfel@aol.com

Summary of March 2018 Ambulance Open Door Forum

CMS held its latest Open Door Forum on Wednesday, March 7, 2018. As with past Open Door Forums, CMS started the call with the following series of announcements:

Medicare Fee Schedule – CMS indicated that the Bipartisan Budget Act of 2018, enacted on February 9, 2018, contained several provisions that impacted the payment of ambulance claims under the Medicare Ambulance Fee Schedule:

  • Temporary Add-Ons for Ground Ambulance – CMS indicated that Section 50203(a) of the bill extended the temporary add-ons for ground ambulance services for an additional five years, retroactive back to January 1, 2018.  As extended, these add-ons will expire on December 31, 2022.  These add-ons increase Medicare’s allowable for ground ambulance base rates and mileage by 2% in urban areas, 3% in rural areas, and by 22.6% (over the applicable rural rate) for services provided in so-called “super rural” areas.
  • Cost Reporting – CMS indicated that Section 50203(b) of the bill would require ground ambulance providers and suppliers to submit cost data to CMS. CMS noted that the new law requires CMS to develop, no later than December 31, 2019, a data collection system to collect cost, revenue, utilization, and certain other information related to ground ambulance services. The law provides that cost data will be collected using a survey methodology, with a representative sample of ambulance providers and suppliers being asked to submit cost data in any given year.  Finally, CMS noted that, starting on January 1, 2022, providers or suppliers that fail to submit the requested cost data would be subject to a 10% reduction in their Medicare payments, unless otherwise exempted on the basis of significant hardship.
  • Additional Reduction in Medicare Payment for Dialysis Transports – Section 53108 of the bill provides that the Medicare allowable for non-emergency, basic life support transports to and from dialysis will be subject to a further 13% reduction.  This reduction would go into effect for dialysis transports with dates of service on or after October 1, 2018. This would be on top of the existing 10% reduction in Medicare’s payment for dialysis transports, for a total reduction of 23%.

Temporary Enrollment Moratorium – CMS indicated that the temporary moratorium on the enrollment of new ground non-emergency ambulance providers in Texas was lifted on September 1, 2017. CMS further indicated that the enrollment moratorium was extended for the states of New Jersey and Pennsylvania for an additional six months on January 29, 2018. CMS will need to make a determination on or before July 29, 2018 on whether to lift the moratorium or extent it for an additional six months in that state.

Following the announcements, CMS moved into a brief Question & Answer period.  Most of the questions were not answered on the call; instead, CMS took the contact information of the person asking the question, and indicated that they would respond directly to them at a later date.  However, the following questions were answered:

  1. CMS indicated that a Change Request had been sent to all Medicare Administrative Contractors (MACs) informing them of the new, adjusted fee schedule amounts. CMS further indicated that this Change Request, which it indicated was confidential, provided further instructions to the MACs on when and how to adjust claims initially paid at the original 2018 rates.
  1. CMS confirmed that the adjusted rates are retroactive to January 1, 2018. Accordingly, CMS indicated that claims paid at the original 2018 rates will be adjusted by the MACs at some future date.
  1. CMS indicated that it recently released its First Interim Evaluation Report on the Medicare Prior Authorization Model for repetitive, non-emergency ground ambulance transports. CMS further indicated that it was still reviewing this report, and that no decision has yet been made on the extension of this model within the existing 9 states and the District of Columbia and/or the expansion of the model to additional states.

Have questions? Please write to the Werfels at bwerfel@aol.com.

AAA Releases Updated 2018 Medicare Rate Calculator

CMS Posts Updated 2018 Public Use File; OIG Guidance on Waiver of Small Cost-Sharing Balances Updated AAA 2018 Medicare Rate Calculator Now Available!

The Centers for Medicare and Medicaid Services (CMS) has posted an updated version of the 2018 Medicare Ambulance Fee Schedule Public Use Files (PUF). These files contain the Medicare allowed base rate reimbursement amounts for the various levels of ambulance service and mileage rates. These files reflect the restoration, retroactive to January 1, 2018, of the temporary add-ons for ground ambulance services (2% for urban transports, 3% for rural transports, and the “super-rural” bonus) pursuant to the Bipartisan Budget Act of 2018, which was enacted on February 9, 2018.

2018 Fee Schedule

Accuracy of Rates and AAA Fee Calculator

The American Ambulance Association has reviewed the rates in this file and confirmed that the rates are accurate. The AAA has also revised its Medicare Ambulance Rate Calculator to reflect the five-year extension of the ambulance add-ons as well as other policy changes including the two-year extension (2026 and 2027) of the 2% Medicare provider cut under sequestration and the additional 13% (23% total) cut to BLS nonemergency transports to and from dialysis centers. The additional dialysis transport cut takes effect on October 1, and as a modifier, is not included in the Public Use File.

Download the 2018 Rate Calculator

Reformatted Version of PUF

Unfortunately, CMS has elected in recent years to release its Public Use Files without state and payment locality headings. As a result, in order to look up the rates in your service area, you would need to know the CMS contract number assigned to your state. This is not something ambulance services would necessarily know off-hand. For this reason, the AAA has created a reformatted version of the CMS Medicare Ambulance Fee Schedule, which includes the state and payment locality headings. Members can access this reformatted fee schedule on the AAA website.

CMS has yet to announce a timetable for adjusting claims that were paid at the original fee schedule amounts. It is anticipated that CMS will make an announcement on this timetable in the next few weeks.

Coinsurance

One issue that frequently arises in these situations is how ambulance providers and suppliers should treat the additional coinsurance amounts that are generated when CMS and its contractors adjust claims from the original allowed amounts to the now higher allowed amounts. These additional coinsurance amounts are typically quite small. Ambulance providers and suppliers may determine that the costs associated with trying to collect these small amounts would likely exceed the amounts they could reasonably hope to collect. The question is whether writing off these small balances could be construed as a routine waiver of cost-sharing amounts, a practice prohibited under Medicare’s rules.

In 2010, the HHS Office of the Inspector General (OIG) issued guidance on this issue. Specifically, the OIG indicated that it would not seek to impose administrative sanctions on Medicare providers and suppliers that waive these amounts provided the following conditions are met:

• The waiver is limited to the increased cost-sharing amounts generated upon adjustment of claims previously paid at the lower allowable, i.e., it does not apply to cost-sharing amounts associated with claims paid at the increased allowables;
• The waiver is limited to the small balances created by the adjustment of claims, i.e., it does not apply to the cost-sharing amounts originally imposed on the beneficiary when the claim was paid at the lower amounts;
• The waiver must be offered uniformly to all affected beneficiaries;
• The waiver must not be advertised; and
• The waiver must not be conditioned on the beneficiary’s receipt of any items, suppliers, or services.

Assuming the above-referenced conditions are met, ambulance providers and supplier can safely write-off these small balances. Please note that the OIG is not indicating that ambulance providers and suppliers must write-off these amounts. Rather, the OIG is simply indicating that this is an option available to health care providers and suppliers impacted by retroactive adjustment of claims.

Download the 2018 Rate Calculator

2018 Fee Schedule

New Medicare Card Project CMS ODF Follow Up

CMS’s Office of Information Technology (OIT) held its special Open Door Forum on the New Medicare Card Project on Tuesday, February 6 at 2:00 PM Eastern.

Following the CMS call, AAA AAA Medicare Consultant, Brian Werfel, Esq.; and AAA Medicare Regulatory Committee Chair, Rebecca Williamson hosted a debrief and Q & A.

Slides from today’s presentation are now available: View the Slides

VA Issues Rule Expanding Coverage of Ambulance Services

Veterans Administration Issues Interim Final Rule Expanding
Coverage of Ambulance Services under Millennium Bill

On January 9, 2018, the Department of Veterans Affairs issued an interim final rule that would amend its policy for payment of Millennium Bill claims. The Millennium Bill authorizes the Veterans Administration (VA) to pay for emergency care provided to veterans in non-VA facilities — including emergency ambulance transportation — provided the veteran has no other health insurance that would cover the costs of such emergency care. These changes were necessitated, in part, by a recent decision of the U.S. Court of Appeals for Veterans’ Appeals (Staab v. McDonald, 28 Vet. App. 50, 2016).

The two major changes being made by the interim final rule are: (1) the expansion of payment eligibility to include veterans who received partial payment or reimbursement from a health plan for their non-VA emergency care and (2) the expansion of payment eligibility for emergency transportation associated with a veteran’s receipt of emergency treatment in a non-VA facility.

These changes went into effect on January 9, 2018.

Relevant Background

38 U.S.C. §1725 authorizes the VA to reimburse veterans for the costs of emergency treatment for non-service connected conditions furnished in a non-VA facility, provided certain criteria were met. One requirement was that the veteran be personally liable for the costs of that emergency treatment. As originally enacted in 1999, the statute indicated that the veteran would be personally liable if the veteran: (1) has no entitlement to care or services under a health-plan contract and/or (2) the veteran had no contractual or legal recourse against a third party that would, in part or in whole, extinguish such liability. The VA historically interpreted its payment obligations under the Millennium Bill to be limited to situations where the veteran had no entitlement to coverage under their health insurance or any other contractual or legal recourse against a third party.

The Expansion of Veteran Eligibility for Reimbursement Act of 2010 amended the requirements related to non-health insurance payments to remove the phrase “in part”. As a result, the VA revised its regulations to permit it to make a payment under the Millennium Bill in situations where automobile or other forms of non-health insurance made a partial payment, and where the veteran remained liable for the balance of the health care provider’s bill. However, there was no corresponding change made to the provisions related to health insurance contracts. As a result, the VA continued to view partial payment by a health plan as a bar to payment by the VA.

In Staab, the Court of Appeals adopted a more lenient interpretation of the statute, i.e., a more restrictive view of the VA’s statutory bar on reimbursement. Specifically, the Court held that the reimbursement bar would only apply when the payment from the health plan fully extinguished the veteran’s liability. The practical effect was to place health insurance plans on equal footing with other forms of insurance. The Court remanded the case back to the lower court for further proceedings.

The VA subsequently appealed the Court of Appeals decision. However, on June 14, 2017, Veterans Affairs Secretary David Shulkin announced that the Department would drop its appeal.  Reversing course, Secretary Shulkin indicated that the VA had drafted regulations to implement the expanded Millennium Bill coverage. Those regulations form the basis of this interim final rule.

Provisions of Interim Final Rule

Partial Payment from Health Insurance Plan

The VA revised its regulations at 38 C.F.R. §17.1002(f) to indicate that the VA will make payment under the Millennium Bill to the extent the veteran otherwise qualifies for coverage to the extent that the veteran “does not have coverage under a health-plan contract that would fully extinguish the medical liability for the emergency treatment.” The VA retained the reimbursement bar for situations where the veteran would have been covered under a health plan had the veteran or the provider failed to comply with the requirements of that health plan, e.g., by failing to submit a timely claim. This change will apply to: (1) all claims pending with the VA as of April 8, 2016 or (2) submitted after that date.

Expansion of Payment Authority for Emergency Transportation

The VA historically viewed emergency ambulance transportation to the non-VA facility as part of the overall emergency treatment of the veteran. As a result, the VA believed that a health plan’s payment for the hospital care, in whole or in part, triggered its reimbursement bar. One common situation that impacts ambulance suppliers involves veterans that have Medicare Part A benefits (which cover the costs of their hospital care), but where the veteran has elected to forego paying for Medicare Part B.  In these situations, Medicare would pay for the hospital care. The VA took the position that this triggered the reimbursement bar, and therefore prevented it from making payment for the emergency ambulance transportation.

Because the interim final rule expands Millennium Bill coverage to include situations where a health plan makes a partial payment, the VA found it necessary to amend its regulations governing the payment of ambulance claims. Specifically, the VA amended its regulations at 38 C.F.R. 17.1003 to provide that ambulance providers will now be eligible for payment provided the following conditions are met:

  1. Payment for emergency care provided at the non-VA facility is authorized or would have been authorized had:
  2. The veteran’s personal liability for the emergency treatment was not fully extinguished by payment by the health plan or other third-party; or
  3. Death not occurred before emergency treatment (at the hospital) could be provided);
  4. The veteran is financially liable to the ambulance provider;
  5. The veteran does not have coverage under a health insurance plan that would fully extinguish the medical liability for the emergency transport (and further provided that the veteran or the provider has timely filed a claim with the health plan);
  6. If the emergency transportation is the result of an accident or work-related injury, the veteran must have reasonably exhausted his remedies against a third-party payor (e.g., auto insurance policy or workers’ compensation policy); and
  7. The veteran remains liable for all copayments and deductibles.
Effect of Coinsurance and Deductibles

The A.A.A. has confirmed that the VA does not consider the coinsurance or deductible obligations imposed by a veteran’s health plan for the purposes of determining whether the veteran’s liability has been fully extinguished by the health plan’s payment.

Therefore, in situations where the veteran has health care coverage, payment by the VA is likely to be limited to situations where the ambulance provider is permitted under state and local laws to bill patients for the difference between their billed charges and the amounts allowed by the health insurer, i.e., those areas that currently permit balance billing. This would also mean that the VA would be unlikely to have any payment responsibility in situations where Medicare has made payment on the ambulance claim (although it leaves open the possibility that the VA may be responsible for non-covered Medicare services such as excess mileage).

Amount of Payment

 When the VA pays under this expanded Millennium Bill authority, its payment will be based on the following methodology:

  1. When the veteran has no coverage under a health plan or other third-party payor, the VA will pay the lesser of: (a) the amount for which the veteran is personally liable or (b) 70% of the applicable Medicare allowable;
  2. When partial payment is made by a health plan or other third party payer, the VA will pay the difference between: (a) the amount the VA would have paid under the preceding bullet point (typically 70% of the Medicare allowable) or (b) the amount paid (or payable) by the health plan or other third-party payor; provided that amount is greater than zero;
  3. If the calculation in the preceding bullet point would not result in the VA making a payment (i.e., because the resulting amount would be less than zero), the VA will pay the lesser of: (a) the veteran’s personal liability after the third-party payment (excluding deductibles and copayments) and (b) 70% of the applicable Medicare allowable;
  4. In the absence of a corresponding allowable, the VA will be the lesser of: (a) the amount for which the veteran is personally liable or (b) the amount calculated by the VA Fee Schedule in 38 C.F.R. 17.56(a)(2)(i)(B).

Payment from the VA is generally considered to be payment-in-full, and extinguishes the veteran’s remaining liability to the provider for unpaid amounts. Note: the veteran would remain liable for unpaid co-payments and deductibles. If the provider does not wish to accept the VA’s payment, it has 30 days from its receipt of such payment to reject and refund the payment.


Have any Medicare questions? Contact Brian at bwerfel@aol.com

CMS Extends Moratorium on Non-Emergency Ground Services

CMS Extends Temporary Moratorium on Non-Emergency Ground
Ambulance Services in New Jersey and Pennsylvania

On January 30, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a notice in the Federal Register extending the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey and Pennsylvania. The extended moratoria will run through July 29, 2018.

Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse. On July 31, 2013, CMS used this new authority to impose a moratorium on the enrollment of new ambulance providers in Houston, Texas and the surrounding counties. On February 4, 2014, CMS imposed a second moratorium on newly enrolling ambulance providers in the Philadelphia metropolitan areas. These moratoriums were subsequently extended on August 1, 2014, February 2, 2015, July 28, 2015, and February 2, 2016.

On August 3, 2016, CMS announced changes to the moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that: (1) the enrollment moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier and (2) the enrollment moratoria on non-emergency ambulance services would be expanded to cover the entire states of New Jersey, Pennsylvania, and Texas. At the same time, CMS announced the creation of a new “waiver” program that would permit the enrollment of new non-emergency ambulance providers in these states under certain circumstances. The revised moratorium on newly enrolling non-emergency ground ambulance providers was subsequently extended on January 9, 2017 and July 28, 2017.

On September 1, 2017, CMS issued a notice on its website indicating that it had elected to lift the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017. CMS indicated that this decision was made to assist in the disaster response to Hurricane Harvey.  CMS published formal notice of the lifting of this moratorium on November 3, 2017.

On or before July 29, 2018, CMS will need to make a determination on whether to extend or lift the enrollment moratorium.


Have any Medicare questions? Contact Brian at bwerfel@aol.com

CMS ODF and Follow Up Call Cancelled

UPDATE: The CMS Open Door Forum and Follow Up Q&A Call have been postponed until further notice.

CMS’s Office of Information Technology (OIT) will hold a special Open Door Forum on the New Medicare Card Project on Tuesday, January 23 at 2:00 PM Eastern. If you plan to attend, please dial in at least 15 minutes before the call.

Following the CMS call, AAA Senior Vice President of Government Affairs, Tristan North, will moderate a Q&A call for members. To answer your questions, AAA Medicare Consultant, Brian Werfel, Esq.; AAA Medicare Regulatory Committee Chair, Rebecca Williamson; and AAA Medicare Regulatory Vice-Chair, Angie (Lehman) McLain will be on the line.

 

Add-Ons Update & Impact of Partial Government Shutdown

Call To Action:  Ambulance Add-Ons Update &
Impact of Partial Government Shutdown

Congress is heading toward a possible partial shutdown of the federal government without taking action on our expired Medicare add-on payments. While the AAA and other industry stakeholders have pressed hard for Congress to immediately pass a five-year extension of the ambulance add-ons, our message is not being heard loud enough amongst all the other noise. We need you to contact your members of Congress today in support of extending the 2% urban, 3% rural and 22.6% super rural increases!

Write to Your Member of Congress

Last night, the House of Representatives mostly along party lines passed a Continuing Resolution to fund the federal government through February 16. The fate of the bill in the Senate is uncertain. If Congress does not pass by midnight tonight a measure extending funding for the federal government, there will be a partial government shutdown.

The AAA had pushed for Congress to attach a Medicare provider extender package including a five-year extension of the ambulance add-ons to the Continuing Resolution.  Since the extender package was not included in the Resolution, we are pressing Congress to consider a separate extenders only package including the five-year ambulance extension or attach the package to another moving legislative vehicle.  We are also pushing Congress to at the very least pass a short-term extension retroactive to January 1 until a Medicare extender package can move.

It is critical that we get the Medicare ambulance add-ons reinstated as soon as possible.
So please write your members of Congress today!

In the meantime, here are answers to questions about whether you should continue to hold claims and what a partial government shutdown would mean for Medicare and Medicaid payments.

Should my organization still hold Medicare claims?

CMS has not formally stated whether it is holding claims beyond the requirement for contractors to not pay claims until two weeks after receiving them.  AAA members may want to consider holding claims until the issue is resolved, assuming their financial position permits.  Holding claims would potentially allow members to avoid the need to have claims subsequently adjusted at a later date.

Will CMS pay claims during a partial government shutdown?

Yes. CMS has issued the following:  CMS would continue key Federal Exchange activities, such as open enrollment eligibility verification, using Federal Exchange user fee carryover. In the short term, the Medicare Program will continue largely without disruption during a lapse in appropriations. Additionally, other non-discretionary activities including Health Care Fraud and Abuse Control, and Center for Medicare & Medicaid Innovation activities would continue. States will have sufficient funding for Medicaid through the second quarter, due to the continuation of authority under the CR for appropriated entitlements, and CMS will maintain the staff necessary to make payments to eligible states from remaining Children’s Health Insurance Program (CHIP) carryover balances.

Should I Hold My Medicare Claims?

The Great Medicare Debate: Should I Hold My Medicare Claims?

By: Brian S. Werfel, Esq. and Rebecca Williamson, Chair, AAA Medicare Regulatory Committee

Ambulance suppliers face an important decision at the start of every calendar year on whether to hold their Medicare claims for the first few weeks of the calendar year.

This decision historically revolved around the patient’s Medicare Part B deductible ($183 in 2018).  The argument in favor of holding claims was that a brief claims hold would allow time for the patient’s deductible to be satisfied by another health care provider, thereby relieving the ambulance supplier of the time and expense involved in billing the patient (or their secondary insurance) for the deductible.  Ambulance suppliers that hold claims believe that this ultimately results in higher collections.  The argument against holding claims is that any increase in overall collections is likely to be minimal, and that the resulting disruption to the company’s cash flow more than offsets any potential benefits from those higher collections.

This year, the debate is complicated by the events surrounding the expiration of the temporary add-ons for urban, rural, and super-rural ground ambulance transports on December 31, 2017.  These temporary add-ons increased the Medicare allowables by 2%, 3%, and 22.6%, respectively.  Congress failed to act upon these temporary add-ons prior to its adjournment.  However, there remains strong bipartisan support for reinstating these add-ons – – and Medicare extenders for other types of Medicare providers – – early in the 2018 Legislative Calendar.  The AAA’s political consultants believe these Medicare extenders will likely be included in the next government funding legislation, which must be passed by January 19, 2018.

Assuming our temporary add-ons are reinstated, they are likely to be made retroactive to January 1, 2018.  This would require CMS to retroactively adjust claims previously paid at the current (lower) rate.  This may also require secondary payers, including State Medicaid Programs, to retroactively adjust their payment amounts to reflect increased cost-sharing amounts.  There is precedent for these sort of retroactive adjustments.  Most recently, the Affordable Care Act, which was enacted on March 23, 2010, provided for a reinstatement of these same temporary add-ons, retroactive to January 1, 2010.

In this inaugural edition of the Great Medicare Debate, AAA Medicare Regulatory Committee Chair Rebecca Williamson and AAA Medicare Consultant Brian S. Werfel, Esq. debate the merits of holding claims pending a resolution of the add-on issue vs. submitting claims.

Ambulance suppliers would likely benefit from holding their claims for some period of time pending clarity on the status of our temporary add-ons.


Rebecca Williamson, Chair of the AAA’s Medicare Regulatory Committee:

According to CMS, 73% of all ambulance service suppliers bill less than 1,000 Medicare covered transports per year. Additionally, 54% of ambulance suppliers bill less than 250 Medicare covered transports per year. Assuming an average claim amount of $400.00 per call (base rate plus mileage), an ambulance supplier with 1,000 Medicare covered transports per year could collect approximately $320,000.00 per year in a best case scenario ($400,000.00 X 80%). This leaves the service with copays of $80,000.00 to be collected from patients. By adding $183.00 as a deductible for each of these 1,000 patients, the collection from Medicare decreases to only $173,600.00. This means the service now must collect an additional $43,400.00 . In other words, if the patient has not met the deductible, the deductible is applied first and a $400.00 allowable becomes a $217.00 allowable. Medicare now pays 80% of $217.00 which is $173.60. Multiplied by 1,000 claims, Medicare pays a total of $173,600.00 and the balance owed to the supplier is the deducible of $183,000.00 and copayments of $43,400.00.

By holding claims for a brief period, usually thirty days, ambulance services increase the likelihood that another provider, often a hospital, will file claims with Medicare first, meaning collecting patients’ deductibles becomes the facilities’ responsibility.

Of course these numbers are only examples and many factors affect the actual billing and collection process. Some Medicare beneficiaries will promptly pay the deductible, many will have secondary payers or insurances, and a certain percentage will be dually eligible for Medicare and Medicaid, all of which results in higher collection ratios for the ambulance service. However, in plain terms, collecting $320,000.00 versus $173,600.00  can make a very real difference in the viability of a small service.  Each service should look carefully at its own payer mix, patient statistics, and demographics to determine individual service projections.

Another good reason to hold claims, this year in particular, is the almost certainty of Congress reinstating the extenders. For those of us who have been in this industry for a long time, the expiration of the add-ons this year is a painful reminder of 2010  when the extenders expired and were not reinstated until March 23, 2010. It wasn’t until July 2010 that CMS even began the process of correcting previously processed claims , and by January 2011 many claims were still outstanding and had not been completely reprocessed. Also by that time, which could have been as long as a year after the date of service, many secondary payers were either unwilling or unable to retroactively correct the reprocessed claims. Some Medicaid states, such as Oklahoma, simply did not have the manpower or ability to even attempt it.

The administrative burden imposed on ambulance suppliers by having claims retroactively reprocessed by CMS, then reprocessed again by secondary payers – potentially incorrectly, if at all – along with the many manual adjustments required in-house, make it even more attractive to advocate and advise holding claims for as long as financially feasible. Of course not every service has the cash reserve to be able to do this, and I would generally not advise holding claims for as long as it may take for Congress to reinstate the extenders and for CMS to implement the correction  for services who cannot afford to, but for those who can, not only will they almost certainly increase the amount of payments collected, they will decrease overhead administrative costs.

I am very optimistic that Congress will include the ambulance extenders in legislation as well as being optimistic that it will be sooner rather than later. I know others disagree, but the higher likelihood of it happening versus not, make this a good bet to take. 

Ambulance suppliers should disregard the status of the temporary add-ons when making their decision on whether to hold claims for some period of time


By: Brian S. Werfel, Esq.:

Rebecca makes a strong argument about the benefits of holding claims.  Moreover, I have long advocated in favor of holding claims for the patient’s deductible.  For these reasons, I would understand if ambulance suppliers elect to hold claims for the patient deductible.  However, I would question the wisdom of holding claims pending further clarity on the status of the temporary add-ons.

My argument against holding claims for that reason boils down to a single word: uncertainty.  In this context, I am referring to four specific types of uncertainty:

  1. Uncertainty over whether the temporary add-ons will be extended.
  2. To the extent legislation is passed extending the temporary add-ons, uncertainty as to whether the higher rates will be made retroactive to January 1, 2018.
  3. To the extent legislation is passed extending the temporary add-ons, uncertainty as to how quickly CMS will implement the revised rates for new claims and adjust claims paid at the original, lower rates.
  4. Uncertainty over how the various secondary payers will handle their adjustments.

With respect to the extension of the add-ons, I agree that they are likely to be included with other Medicare adjusters in the budget resolution that must pass before January 19, 2018.  Likewise, at this point, there is no reason to think that these add-ons will not be made retroactive to January 1, 2018.  However, there are no guarantees.  It is possible that the Republicans and Democrats fail to reach agreement on the larger budgetary issues, including the status of the so-called “Dreamers”, and a government shutdown results.

My larger concern relates to how quickly CMS revises its fee schedule, and implements instructions to its contractors.  As Scott noted above, the last time we faced this issue was in 2010.  The Affordable Care Act was signed into law on March 23, 2010.  However, CMS didn’t issue a transmittal to its contractors until May 21, 2010, and even then, didn’t instruct its contractors to start paying the higher rates until July 6, 2010.

In other words, if you elected to hold claims to avoid having them paid and then reprocessed, you would have needed to hold claims for more than 6 months.

To me, the strongest argument for holding claims is not how Medicare would handle the adjustment.  I recognize the administrative burden created by having to post and then re-post the same claim once it was adjusted.  However, I trust that CMS will eventually get it right (emphasis on eventually).

I have far less confidence in how the secondary payers, including State Medicaid Programs, will handle the adjustments.  When this happened in 2010, we had numerous reports from A.A.A. members of secondary payers incorrectly processing the adjustment.  For example, some State Medicaid Programs didn’t simply issue a supplemental check for the higher copayment.  Instead, the Medicaid Program took back its initial payment, and then reprocessed the claim in its entirety.  Unfortunately, in some instances, the Medicaid rates changed in the interim, and Medicaid then repaid a lower amount.  In other instances, they failed to repay the patient’s deductible.  Similar issues were noted with commercial secondary payers, Medicaid managed care organizations, etc.

In sum, if your company has historically held claims during the first few weeks of the year for the patient’s deductible, I see no reason to discontinue that practice.  If, however, you historically submitted claims without regard to the patient’s deductible, I see little benefit to holding claims pending action by Congress on our add-ons.


Have any Medicare questions? Contact Brian at bwerfel@aol.com

AAA Spearheads Medicare Provider Extension Letter

AAA Spearheads Medicare Provider Letter
Supporting Add-ons Extension

The AAA spearheaded a letter by a coalition of Medicare providers urging congressional leaders to pass a Medicare provider extender package by January 19. This is part of the AAA’s ongoing efforts to ensure that the Medicare ambulance add-ons are extended as soon as possible.

Many thanks to John Jonas and the team at Akin Gump for taking the lead on reaching out to other Medicare provider organizations. The AAA was able to secure the support of twenty organizations on the letter and the letter has been to congressional leaders as well as all congressional offices.

Read the Letter

The organizations that singed on to the letter are:

American Ambulance Association (AAA)
American Health Care Association (AHCA)
American Medical Rehabilitation Providers Association (AMRPA)
American Physical Therapy Association (APTA)
American Occupational Therapy Association (AOTA)
Association of Critical Care Transport (ACCT)
Brain Injury Association of America
Christopher & Dana Reeve Foundation
Emergency Department Practice Management Association
Falling Forward Foundation
Focus on Therapeutic Outcomes, Inc. (FOTO)
National Association for Home Care & Hospice
National Association for the Support of Long Term Care (NASL)
National Association of Emergency Medical Service Physicians
National Center for Assisted Living
National Rural Health Association (NRHA)
Partnership for Quality Home Healthcare
Private Practice Section of the American Physical Therapy Association
Texas Association for Home Care and Hospice
United Spinal Association

While we believe we may be approaching the endzone on the extender renewals, we must continue to push Congress to do what is right for EMS. Now, more than ever, we need you to add your voice to those of AAA, state-level ambulance associations, and thousands of your peers. Please take a moment today to send Congress your message of support for the Medicare ambulance add-ons—it takes just two clicks. Write a letter now

 

Alert: Medicare Increases Will Expire For Now: What You Need to Know

While the Congress succeeded in passing the Republican tax bill and keeping the federal government open with a short-term continuing resolution that included a temporary extension for the State Children’s Health Insurance Program (CHIP), it did not act upon the several Medicare extenders that expire on December 31, 2017. This extenders package includes the ambulance add-ons for urban, rural, and super-rural areas, as well as a moratorium on therapy caps, extenders for hospitals, and several other extenders important to other Medicare providers.

Despite the fact that the Congress left town, there is still strong bipartisan support for reinstating these extenders – including the ambulance extenders – early in January 2018. The most likely time frame will be for the extenders to be added to the next government funding legislation, which must be passed by January 19.

First, do not panic. As you may have already heard, CMS is telling providers and suppliers that the add-ons will expire at the end of the month. Technically that is true. The Agency is simply stating the obvious; but no one should imply from such statements that the Congress will not fix them or not make them retroactive. Historically, CMS has followed this pattern of indicating the add-ons have expired until legislation extending the add-ons has passed both chambers of Congress and the President has signed the bill into law.  CMS will make similar statements relative to the other Medicare extenders as well.

Second, prepare. To the extent you are able to do so, you may hold your claims. Medicare requires providers to files claims no later than 12 months after the date when the services were provided. (See Medicare: File a Claim; see also section 6404 of the Affordable Care Act). While this may not work for all claims, holding claims will reduce the number that would have to be reprocessed once the add-ons become law. If CMS believes at some point the legislation will pass, it may also break with its own precedent and indicate that has asked the contractors to hold claims for a short period of time as well. It did this in 2014 when it discovered errors in a final fee schedule rule. Once the claims are processed, so long as the add-ons have been extended by law, the add-on dollars will appear in the reimbursement amounts sent to providers and suppliers.

Third, retroactivity can be expensive, but CMS can mitigate the costs. CMS did this most recently in May of 2017. Then, CMS announced that it would implement the retroactive extension of a transitional payment for durable medical equipment suppliers by having the contractors automatically reprocess claims from the period when the transitional payment was made retroactive. This approach reduced the burden on providers and suppliers by eliminating the need to resubmit claims.

Despite the fact that there are ways to mitigate the problem, the American Ambulance Association (AAA) remains deeply concerned that the Congress did not extend the add-ons before they left for the holidays. We understand that for ambulance services across the country receiving timely payments from Medicare can be the difference between being able to make payroll or not. Having the dollars from the add-ons is also crucial to ensuring adequate cash flow. Therefore, while we advise you to think through your options and take the steps that best meet your needs and the needs of your employees, patients, partners, and businesses, we also ask that you reach out to the Congress and let them know how important it is to get the add-ons extended as early in January as possible. Make your voice heard by going to the AAA’s grassroots page. There you can send an email or reach out through social media to your Members of Congress.  We need everyone, including your employees, patients, and others who support high quality ambulance services, to reach out today.

Write to Your Members of Congress

The AAA will continue our direct efforts on Capitol Hill to make sure these add-ons are extended and overly burdensome new requirements are not placed on ambulance services. With your help, we can get the add-ons extended. For more information please visit https://ambulance.org/advocacy/.

Summary of December 2017 Ambulance Open Door Forum

On December 14, 2017, CMS held its latest Open Door Forum. As usual, it started with a few announcements, as follows:

  1. Ambulance Inflation Factor – CMS announced that it had published Transmittal 3893 on October 27, 2017, which sets forth the Ambulance Inflation Factor (AIF) for calendar year 2018. In that Transmittal, CMS indicated that the CY 2018 AIF would be 1.1%. This is based on an increase in the CPI-U of 1.6%, and a multi-factor productivity adjustment of 0.5%.
  1. Expiration of Temporary Adjustments – CMS indicated that the current temporary adjustments for urban (2%), rural (3%) and super rural ground ambulance transports are set to expire on December 31, 2017. CMS also indicated that they were aware of proposed legislation that would extend these adjustments for 2018 and beyond, but that they have yet to be enacted into law.
  1. CY 2018 Public Use File – CMS indicated that the Public Use File on its website has been updated to include Medicare allowables for 2018. CMS made a point of noting that the 2018 rates do not include the temporary adjustments, as they are set to expire on December 31, 2017.
  1. Prior Authorization Demonstration Project – CMS indicated that it had decided to extend the Prior Authorization Demonstration Project for schedule, non-emergency ground ambulance transportation of repetitive patients for another year. The extension is limited to the 8 states (DE, MD, NJ, NC, PA, SC, VA, and WV) and the District of Columbia in which the program was in effect in 2017.  CMS further indicated that the extension would be effective for dates of service on or after December 5, 2018.  As a result, claims for dates of service between December 2 and December 4 would not be subject to prepayment review if a prior authorization was not received; however, ambulance providers in these states would be permitted to request prior authorization for those dates. CMS further indicated that it had developed a “streamlined” process to allow for prior authorization of transports in situations where the patient was approved for transport, but where the duration of the authorization was shortened from the normal 60-day period to account for the program’s scheduled expiration on December 1, 2017. An example would be an authorization that was granted for transports starting on November 1, 2017. The provider was likely given authorization for only a 30-day period. The streamlined process would allow them to submit a request to allow that 30-day authorization to be extended to a fully 60 days. CMS indicated that the streamlined process would not require the submission of medical records to establish medical necessity for the ambulance.

As with previous forums, CMS then fielded questions from the audience. The majority of these questions focused on the prior authorization process. As with previous ODFs, CMS declined to answer most of the questions on the call, instead asking the provider to submit their questions to CMS via email.

CMS did answer the following questions on the call:

  1. CMS was asked when it anticipated issuing its report on the effectiveness of the Prior Authorization Demonstration Program.  CMS responded that it expected to issue that report during the first quarter of 2018.
  2. CMS was asked when it expected to expand the Prior Authorization Demonstration Program to additional states and/or the nation as a whole.  CMS responded that it was still evaluating the effectiveness of the program.  Therefore, CMS indicated that no decision on national expansion had been made at this time.

Have questions? Please write to the Werfels at bwerfel@aol.com.

AAA Releases 2018 Medicare Rate Calculator

AAA 2018 Medicare Rate Calculator Now Available!

The American Ambulance Association is pleased to announce the release of its 2018 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 2018 Ambulance Inflation Factor (1.1%) and continuation of the current temporary add-ons.

To access the Rate Calculator, please CLICK HERE.

To access the Fee Schedule, please CLICK HERE.

(Please note: the 2018 Fee Schedule does not include the temporary Medicare add-ons that are set to expire on 12/31/2017. The AAA is working hard to get these add-ons extended. Please write your members of Congress today to show your support!)

Download the 2018 Rate Calculator

2018 Fee Schedule