New SNF Consolidated Billing Edits: FAQs

On April 1, 2019, CMS implemented a new series of Common Working File (CWF) edits that it stated would better identify ground ambulance transports that were furnished in connection with an outpatient hospital service that would be bundled to the skilled nursing facility (SNF) under the SNF Consolidated Billing regime. Unfortunately, the implementation of these new edits has been anything but seamless. Over the past few weeks, I have received numerous phone calls, texts, and emails from AAA members reporting an increase in the number of Medicare claims being denied for SNF Consolidated Billing. This FAQ will try to explain why you may be seeing these denials.  I will also try to provide some practical solutions that can: (1) reduce the number of claims denied by the edits and (2) help you collect from the SNFs, when necessary. Please note that, at the present time, there is no perfect solution to this issue, i.e., there is nothing that you can do to completely eliminate these claim denials.  The solutions discussed herein are intended only to minimize the disruption to your operations caused by these denials.   I am new to Medicare ambulance billing. Can you explain what the SNF Consolidated Billing...

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HHS OIG Issues Advisory Opinion on Community Paramedicine

HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions. The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions. Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include...

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CMS SNF Edits Go Into Effect – April 1, 2019

CMS Set to Implement New Common Working File Edits to Identify Ambulance Services Provided in Connection with Outpatient Hospital Services that should be bundled to the SNF under Consolidated Billing On November 2, 2018, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 2176 (Change Request 10955), which would establish a new series of Common Working File (CWF) edits intended to identify ambulance transports furnished in connection with outpatient hospital services that are properly bundled to the skilled nursing facility under the SNF Consolidated Billing regime. These new edits are set to go into effect on April 1, 2019.  Why these edits are necessary? In 2017, the HHS Office of the Inspector General conducted an investigation of ground ambulance claims that were furnished to Medicare beneficiaries during the first 100 days of a skilled nursing home (SNF) stay. Under the SNF Consolidated Billing regime, SNFs are paid a per diem, case-mix-adjusted amount that is intended to cover all costs incurred on behalf of their residents.  Federal regulations further provide that, with limited exceptions, the SNF’s per diem payment includes medically necessary ambulance transportation provided during the beneficiary’s Part A stay. The OIG’s report was issued in February 2019. The OIG...

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Update on HHS OIG Reports on Ambulance Services

Update on HHS Office of the Inspector General Reports on Ambulance Services The HHS Office of the Inspector General (OIG) released an update to the Work Plan as the year comes to a close.  There are no new projects specific to ambulance services, but the update does provide a summary of three projects that have been completed or are in progress. Medicare Part B Payments for Ambulance Services Subject to Part A Skilled Nursing Facility Consolidated Billing Requirements (expected release 2019). In this work, the OIG  seeking to determine whether ambulance services paid by Medicare Part B were subject to Part A SNF consolidated billing requirements. The OIG will also assess the effectiveness of edits in CMS’s Common Working File to prevent and detect Part B overpayments for ambulance transportation subject to consolidated billing. Prior OIG reports have identified high error rates and significant overpayments for services subject to SNF consolidated billing. Ambulance Services – Supplier Compliance with Payment Requirements (partially completed; remainder expected release 2019). Prior OIG work has found that Medicare made inappropriate payments for advanced life support emergency transports. The OIG seeks to determine whether Medicare payments for ambulance services were made in accordance with Medicare requirements. ...

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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...

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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: Notify the Medicare Administrative...

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Navigating a Post-Prior Authorization World

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,...

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OIG Releases SemiAnnual Report to Congress

The Office of the Inspector General of the Department of Health and Human Services (HHS-OIG) recently issued the “Measuring Compliance Program Effectiveness: A Resource Guide“. The Guide was developed by a group of HHS-OIG professionals who wanted to provide a set of metrics by which health care providers can measure the elements of their compliance program. The authors recognize that not all the metrics are applicable to all health care providers but intended to be used as a guide. The Guide was released on March 27. You can also read the full “Semiannual Report to Congress (October 1, 2016 – March 31, 2017)“.