CMS Announces Comment Period for National Expansion of Prior Authorization Process

On October 29, 2019, the Centers for Medicare and Medicaid Services (CMS) posted a notice in the Federal Register announcing an opportunity for the public to provide comments on the proposed national expansion of the prior authorization process for repetitive, scheduled non-emergent ground ambulance transportation.  CMS refers to this process as its “RSNAT Prior Authorization Model.”  The CMS Notice can be viewed in its entirety at: https://www.govinfo.gov/content/pkg/FR-2019-10-29/pdf/2019-23584.pdf. Under the Paperwork Reduction Act of 1995, federal agencies are required to publish a notice in the Federal Register concerning each proposed collection of information, and to allow 60 days for the public to comment on the proposed action.  Interested parties are encouraged to provide comments regarding the agency’s burden estimates and other aspects of the proposed collection of information, including the necessity and utility of the proposed information for the proper performance of the agency’s functions, and ways in which the collection of such information can be enhanced. In this instance, CMS is indicating that it is pursuing approval to potentially expand the existing RSNAT Prior Authorization Model nationwide.  Currently, the RSNAT Prior Authorization Model is in place in 8 states (DE, MD, NJ, NC, PA, SC, VA, and WV) and the...

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CMS Announces Extension of Prior Authorization Program

On September 16, 2019, CMS published a notice in the Federal Register that it would be extending the prior authorization demonstration project for another year. The extension is limited to those states where prior authorization was in effect for calendar year 2019. The affected states are Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia and West Virginia, as well as the District of Columbia. The extension will run through December 1, 2020.  In its notice, CMS indicated that the prior authorization demonstration project is being extended “while we continue to work towards nationwide expansion.”  This strongly suggests that CMS believes the program has met the statutory requirements for nationwide expansion under the Medicare Access and CHIP Reauthorization Act of 2015.  However, CMS indicated that it would use the additional year to continue to test whether prior authorization helps reduce expenditures, while maintaining or improving the quality of care offered to Medicare beneficiaries. CMS has also updated its CMS Ambulance Prior Authorization webpage to reflect the expansion of prior authorization in the existing states through December 1, 2020....

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CMS Announces Extension of Prior Authorization Program

On November 30, 2018, CMS issued a notice on its website that it would be extending the prior authorization demonstration project for another year. The extension is limited to those states where prior authorization was in effect for calendar year 2018. The affected states are Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia and West Virginia, as well as the District of Columbia. The extension will run through December 1, 2019.  CMS indicated that the extension will provide it with an additional year to evaluate the prior authorization program, and to determine whether the program meets the statutory requirements for nationwide expansion under the Medicare Access and CHIP Reauthorization Act of 2015. CMS has also updated its Ambulance Prior Authorization FAQs and its Physician/Practitioner Letter to reflect the expansion of the program. The updated FAQ and Physician Letter can be downloaded from the CMS Ambulance Prior Authorization webpage by clicking here....

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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. 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...

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CMS Announces Revisions to Provider Enrollment Waiver Demonstration (PEWD) Program

CMS Announces Revisions to Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) Program On August 20, 2018, the Centers for Medicare & Medicaid Services (CMS) published a notice in the Federal Register that it would be revising the terms of its Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) Program. These revisions became effective on August 20, 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. Based on this authority, CMS has implemented temporary moratoria on the enrollment of new non-emergency ambulance providers in the states of New Jersey and Pennsylvania. Under the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) Program, CMS has the authority to grant waivers to statewide enrollment moratorium on a case-by-case basis in response to access to care issues.  However, since the implementation of the PEWD Program in 2016, CMS has identified a handful of technical issues that have complicated the implementation of the PEWD Program.  The revisions in this notice are intended to resolve these technical issues. The specific revisions CMS is making include: In December 2016, Congress enacted the 21st...

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CMS Extends Moratorium on Non-Emergency Ground Services

CMS Extends Temporary Moratorium on Non-Emergency Ground Ambulance Services in New Jersey and Pennsylvania The Centers for Medicare & Medicaid Services (CMS) has announced that it intends to extend 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 January 29, 2019.  Notice of the extension of the temporary moratorium will appear in the Federal Register on August 2, 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. ...

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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: 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...

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First Interim Evaluation Report on Medicare Prior Authorization

Talking Medicare: First Interim Evaluation Report on Medicare Prior Authorization (An 80-page report confirming what you already likely suspected) On February 28, 2018, the Centers for Medicare and Medicaid Services (CMS) posted an interim report on its prior authorization demonstration project for repetitive, scheduled, non-emergent ambulance transportation. The report, titled First Interim Evaluation Report of the Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT), was conducted by Mathematica Policy Research, a nonpartisan think tank. Mathematica studied the impact of the prior authorization model on Medicare payments, ambulance utilization, and patient quality of care. Background CMS implemented the prior authorization demonstration project in December 2014 in three states: New Jersey, Pennsylvania, and South Carolina (referred to in the report as “Year 1 States”). These states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) subsequently expanded the demonstration project to five additional states (Delaware, Maryland, North Carolina, Virginia, and West Virginia) and the District of Columbia on January 1, 2016 (referred to in the report as “Year 2 States”). The goal of the demonstration project was to study the impact of...

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