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Tag: Novitas Solutions

Talking Medicare: CMS Implements Further Dialysis Cuts

Written by Brian Werfel on . Posted in Advocacy Priorities, Member-Only, News, Reimbursement, Talking Medicare.

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

Navigating a Post-Prior Authorization World

Written by Brian Werfel on . Posted in Medicare, Member-Only, Talking Medicare.

Talking Medicare: Navigating a Post-Prior Authorization World

Novitas Solutions, Inc. recently announced that it will no longer issue prior authorizations for scheduled, repetitive non-emergency transports, effective December 1, 2017. This announcement was based on Novitas’ expectation that the demonstration project will expire at the end of this calendar year. For ambulance suppliers in the states that currently operate under prior authorization, the focus invariably turns to what that means for their repetitive patient populations?

First a little background. In May 2014, CMS announced the implementation of a three-year prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project was initially limited to the states of New Jersey, Pennsylvania, and South Carolina. These 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. As initially conceived, the prior authorization demonstration project first went into effect on December 15, 2014.

Congress subsequently elected to expand this demonstration project to additional states as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Specifically, Congress mandated that the program be expanded to six additional states (Delaware, Maryland, North Carolina, Virginia, and West Virginia) and the District of Columbia by January 1, 2016, and then potentially to the rest of the nation by January 1, 2017. However, CMS never issued the required report; as a result, the contemplated national expansion never occurred.

Where Do We Go From Here?

If you operate in a state that is not currently operating under prior authorization, the answer to this question is relatively straightforward, i.e., nothing will change.

If, however, operate in a state that is currently subject to prior authorization, this question is a bit trickier. What we do know is that the actual mechanics of submitting claims will revert to the same process you experienced prior to the implementation of prior authorization. You will submit claims for repetitive patients directly to the Medicare Administrative Contractor (MAC), who will likely process them in same manner they process other Medicare claims. In other words, 14 days after the submission of the claim, you will likely receive a remittance notice indicating that the claim has either been paid or denied.

We also know that you will no longer benefit from the protections against post-payment review of these claims. Under the prior authorization model, CMS made clear that it would not audit claims paid based on a valid authorization, except in instances where it could demonstrate that the prior authorization was fraudulently procured.

What We Can Expect from Medicare and its Contractors

What we don’t know is whether the MACs will implement any temporary measures to guard against ongoing over-utilization and/or fraud. To better understand what I mean, put yourself in the position of the MAC. You have empirical evidence (see the chart to the right) that prior authorization has resulted in dramatic reductions in the amount of Medicare dollars paid for dialysis transports. You have further seen little evidence that this reduction in payments has resulted in any serious access to care issues.

The logical conclusion you would draw is that the amounts paid for dialysis prior to the implementation of prior authorization were likely excessive. If so, you might consider some proactive steps to prevent dialysis utilization from increasing back to the levels seen prior to the implementation of prior authorization.
So, it is possible (perhaps even likely) that ambulance suppliers in some of these states may see their MAC elect to implement prepayment reviews for dialysis patients. This could be similar to the process Novitas used for the initial three round trip transports to dialysis.

I also think it is reasonable to expect that the MACs, the Zone Program Integrity Contractors, and the OIG will monitor utilization trends, with an eye towards conducting post-payment reviews on ambulance suppliers that see their dialysis volume increase sharply next year.

Other Potential Impacts

In the previous section, I touched on the steps Medicare and its contractors might take to prevent a return to pre-prior authorization levels of dialysis utilization. In this section, I want to talk about some of the knock-on effects ambulance providers are likely to see.

One of the more interesting changes we saw in the prior authorization regime was a re-balancing of the power dynamic between ambulance suppliers and facilities, i.e., assisted living facilities and skilled nursing homes. Prior to the implementation of prior authorization, that power dynamic was slanted heavily in favor of the facility. By that I mean they could exert tremendous pressure on ambulance suppliers to take marginal patients by ambulance. If you were involved in the industry prior to 2015, you undoubtedly heard an SNF administrator tell you something to the effect of “if your company won’t take the patient by ambulance, I can easily find another company that will.” In competitive markets, that statement was usually accurate.

Under the demonstration project, prior authorization or lack thereof traveled with the patient. What that meant is that if your ambulance company submitted a prior authorization request that was denied, that denial would apply to any other ambulance company that might be interested in taking the patient. As a result, the nursing home could no longer hold the threat of going elsewhere with their business over your head.

Prior authorization also affected the standing policies of dialysis centers. Many free-standing dialysis centers have standing policies that they will not assist in transferring the patient to and from the dialysis treatment chair. This meant that patients that could be transported in a wheelchair van, but who required assistance to transfer out of their wheelchair presented a conundrum. There wouldn’t be medical necessity for the ambulance, but there would be no easy way for you to transfer them into the treatment chair without a second crew member (something most wheelchair van services don’t offer). Under prior authorization, it was easier for the ambulance company to push back, since they knew they wouldn’t be paid for the ambulance. As a result, I have heard that dialysis employees in these states had started to assist patients in transferring.

No really, it’s true…

One potential consequence of the prior authorization going away is that it may shift this power dynamic back to the facilities, with all of the negative consequences that are likely to result.

“Okay, I get what you are saying, but what I really want to know is whether I should loosen our standards for accepting a dialysis patient or not?”

Good question. Unfortunately, not one that permits an easy answer. The implementation of prior authorization shifted the cost-benefit analysis associated with transporting dialysis patients. It was likely that you were going to have a smaller number of patients approved and paid, but you could rest easy that you wouldn’t be at risk of having to return that money years later as the result of a Medicare audit.

The expiration of prior authorization shifts the cost-benefit analysis yet again. It is likely that you have tightened up your criteria for who you accept for dialysis transportation as a result of prior authorization. Loosening those criteria would almost certainly result in an increase in your short-term revenues. However, that would be offset, to some degree, by the increased risk of a Medicare audit.

For that reason, the course of action I have been recommending to people is not to dramatically loosen your standards. Instead, I typically ask whether they currently have patients that they believe do require an ambulance, but who were rejected for prior authorization by the MAC. Most providers respond that they do. Put another way, we are trying to identify the patients that you would feel comfortable defending in an audit. That is the additional population I would target for transportation next year.

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: Prior Authorization Spending Update

Written by Brian Werfel on . Posted in Member-Only, News, Reimbursement, Talking Medicare.

Prior Authorization Data Shows Continued Reduction in Overall Spending on Dialysis Transports; Pendulum Swings Back Slightly in New Jersey and Pennsylvania

In May 2014, CMS announced the implementation of a three-year prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project was initially limited to the states of New Jersey, Pennsylvania, and South Carolina. These 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.

Medicare payment data from calendar year 2015 showed the effect of the demonstration project. Total spending on dialysis transports was $559 million that year, down 22% from the year before.  That correlates to a cost savings to the federal government of $158 million. Telling, $137 million (86%) of those savings came from the three states that participated in the demonstration project.

The chart to the right shows total spending on dialysis in those states in the years immediately preceding the implementation of the prior authorization project up through the first year of the project. While the three states had very different trajectories prior to 2015, each showed a significant decrease in payments under the demonstration project.

We now have Medicare payment data for 2016. This blog will focus on the second year of the prior authorization demonstration project. This includes tracking the effects of prior authorization on the five additional states (DE, MD, NC, VA, and WV) and the District of Columbia, which were added to the demonstration project for 2016.

Existing States

In the first year of the demonstration project, both New Jersey and Pennsylvania saw sizeable reductions (85.5% and 83.5%, respectively) in the total spending on dialysis transports. Both states saw dialysis payments rebound in 2016, with New Jersey increasing by 14.7% and Pennsylvania increasing by 3.7%. The financial community uses the phrase “dead cat bounce[1]” to describe a temporary recovery from a prolonged or pronounced decline. It is possible that explains why payments increased for these states in 2016. However, the more likely explanation is that Novitas, the Medicare Administrative Contractor in both states, recognized that the standards it used were overly restrictive during the first year of the project. If so, the increases in 2016 reflect the pendulum swinging back somewhat. If you accept that Novitas has reached an equilibrium point, total spending on dialysis in these states would be roughly 75% below pre-2015 levels.

By contrast, South Carolina saw total dialysis spending decrease by an additional 7.9% in 2016, over and above the roughly 25% reduction in 2015. Thus, spending in 2016 was roughly 30% lower than pre-2015 levels.

Expansion to New States

The follow charts track dialysis payments in the five states and the District of Columbia that were first subject to prior authorization in 2016.  The chart on the left shows those states where the prior authorization project is administered by Novitas, while the chart on the right shows those states administered by Palmetto.

The phrase expresses the concept that even a dead cat will bounce if dropped from a tall enough height.

As you can see, both Delaware (72.3%) and Maryland (68.0%) showed sizeable reductions in total dialysis payments. Payments in the District of Columbia actually increased by 30%. However, a closer examination of the numbers shows that the increase was largely the result of an increase in the number of emergency transports to a hospital for dialysis, i.e., claims that fell outside the prior authorization project. Payment for scheduled BLS non-emergency transports fell 82.9% in the District, in line with reductions in the other two states.

The reductions in the Palmetto states was far more moderate, with reductions ranging from 27.8% (North Carolina) to 45.4% (Virginia). West Virginia saw a 36.0% decline.

Key Takeaways

 With two years of experience under the prior authorization demonstration project, I think we can safely come to 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
  1. The size of that reduction appears to be more dependent on the Medicare contractor than on any perceived level of over utilization.

The first conclusion should come as no surprise. Dialysis transports have long been the subject of scrutiny by the federal government. Moreover, the original states were not selected at random; they were selected based on data that suggested they were particularly suspect to over utilization.

The second conclusion is less intuitive. After all, Medicare coverage standards are intended to be national. While you could argue that a sizable reduction was expected for New Jersey and Pennsylvania, as there was evidence of widespread dialysis fraud in the Philadelphia metropolitan area, there was no basis to suspect widespread over utilization in Maryland or the District of Columbia. In fact, the District had only 58 BLS non-emergency dialysis transports in 2015, i.e., the equivalent of a single patient being transported for 2 months. Rather, the 2016 data suggests that Novitas has simply taken a far harder stance on dialysis than Palmetto.

This has potential implications beyond the demonstration project, which is scheduled to expire at the end of this year. As many of you know, the national expansion of prior authorization is part of the House of Representative’s ambulance relief bill (it is not mentioned in the corresponding Senate bill). The data 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.

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

[1] The phrase expresses the concept that even a dead cat will bounce if dropped from a tall enough height.

Novitas – Denials

Written by David Werfel on . Posted in Medicare, Member Advisories, Member-Only.

This advisory is for members who have Novitas as their Medicare Administrative Contractor.

On August 17, 2016, Novitas called me to let me know that they are seeing many ambulance claims denied due solely to the diagnosis codes that are listed on claims. Novitas requires a minimum of two ICD-10 codes, as follows:

  • A primary diagnosis code that describes the patient’s medical condition at the time of transport, AND
  • A secondary diagnosis code that reflects the patient’s need for the ambulance at the time of transport.

The list of primary ICD-10 codes was published by Novitas in their Ambulance Local Coverage Article A54574. While the ICD-10 codes in A54574 are not the only codes that will be accepted, it is highly recommended that you use one of those as your primary code, whenever possible.

Novitas also requires a secondary “diagnosis code”. This list is in their Ambulance Local Coverage Determination (LCD) Policy L35162. That has the four “Z” codes, at least one of which must be used as the secondary diagnosis code:

  • Z74.01 – Bed Confined
  • Z74.3 – needs continuous supervision (includes EKG)
  • Z78.1 – physical restraints (patient safety, danger to self/others)
  • Z99.89 – dependence on enabling machines (includes IV fluids, active airway management)

If the claim does not list a primary AND a secondary code, the claim is automatically denied. While the claim can be corrected and resubmitted for processing, that delays cash flow and adds time and expense for the ambulance supplier. Therefore, please make sure you list an appropriate primary code AND an appropriate secondary code.

 

Novitas Issues Guidance for Ambulance Providers, Facilities and Beneficiaries Regarding Expansion of Prior Authorization Project for Repetitive Patients

Written by Brian Werfel on . Posted in Medicare, Member Advisories, Member-Only, Regional Workshops.

September 17, 2015

Novitas Solutions, Inc. (Novitas) recently issued a series of guidance documents on the expansion of the prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project is currently operating in the states of New Jersey, Pennsylvania, and South Carolina.

The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. Law 114-10), enacted on April 16, 2015, requires that this program be expanded into the remaining states of MAC Regions L (Delaware, Maryland, and the District of Columbia) and M (North Carolina, Virginia, and West Virginia), effective January 1, 2016. The program will be further expanded to cover all remaining states starting on January 1, 2017.

Novitas is the Medicare Administrative Contractor for MAC Region L, and therefore will be responsible for implementing this program in Delaware, Maryland and the District of Columbia. These guidance documents are intended to educate ambulance services, health care professionals and facilities, and beneficiaries located in these states on the programs requirements.

Guidance Document for Ambulance Services

On August 17, 2015, Novitas issued a “Dear Ambulance Company” letter that provides guidance to ambulance companies on how the program will operate. As noted in the letter, participation is voluntary.

However, ambulance services that elect not to seek prior authorization for repetitive patients (defined as a patient that is transported by non-emergency ambulance for the same service either: (1) three or more times in a 10-day period or (2) once a week for three straight weeks) will find that claims for these patients will be subject to a prepayment review. For this reason, it is anticipated that most ambulance services will elect to seek prior authorization for their repetitive patient population.

The letter further summarizes the documentation requirements needed to request prior authorization for a patient. These include the submission of a prior authorization cover sheet (which can be found on Novitas’ website), a valid Physician Certification Statement (PCS) signed by the beneficiary’s attending physician within sixty (60) days of the requested first transport date, and all other medical records supporting medical necessity.

Novitas will review the submitted documentation and issue either a prior authorization covering all transports within a set date range, or a rejection. To the extent an application is rejected, the provider will be entitled to resubmit the application with additional documentation to support medical necessity.

Guidance Document for Health Care Professionals and Facilities

On August 24, 2015, Novitas issued a “Dear Healthcare Provider/Facility” letter that provides guidance to physicians, healthcare practitioners, and facilities on how the prior authorization project will operate. This letter includes bolded language that indicates that these individuals and facilities must provide certain records to the transporting ambulance service and/or the beneficiary. The letter specifically includes a statement that “[a]ttending physicians must provide a physician certification statement (PCS) and medical records that support medical necessity.” Members may want to download copies of this letter for distribution to physicians and facilities from which they may need to obtain PCS forms and other medical records.

Guidance Document for Beneficiaries

On August 20, 2015, Novitas issued a “Dear Medicare Beneficiary” letter that is intended to educate Medicare beneficiaries on the operation of the prior authorization project. The letter indicates that the pre-approval process is intended to allow the beneficiary to know whether his or her transports will be covered by Medicare prior to the provision of services. The letter indicates that either the beneficiary or the ambulance service can obtain a prior authorization, but notes that the ambulance provider will typically be the one submitting requests. Members may want to download copies of this letter for distribution to beneficiaries and their families.

AAA to hold Prior Authorization Workshop on October 2, 2015

The AAA will be holding a one-day workshop devoted exclusively to the prior authorization program. The workshop will take place on October 2, 2015 at the AAA Headquarters located in McLean, Virginia. This workshop will feature representatives from both Novitas and Palmetto (the MAC for Region M), who will be able to provide additional details on how the project will operate in their areas. Dr. William Rogers from the Centers for Medicare and Medicaid Services will also be in attendance to offer CMS’ perspective on this new program. This is a wonderful opportunity for CEOs and senior ambulance executives in the affected states to hear first-hand how this project will impact their ambulance services.

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