CMS released published a guidance document summarizing some of the steps that it has taken to relieve the administrative burden on health care providers and suppliers during the current public health emergency. As part of that document, CMS indicated that it will be “pausing” the Prior Authorization Model for scheduled, repetitive non-emergency ambulance transports. Under this program, ambulance suppliers are required to seek and obtain prior authorization for the transportation of repetitive patients beyond the third round-trip in a 30-day period. Absent prior authorization, claims will be stopped for pre-payment review. The Prior Authorization Model is currently in place in Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, West Virginia, and the District of Columbia.
CMS indicated that this pause went into effect as of March 29, 2020, and will continue for as long as the current public health emergency continues. During this pause, claims for repetitive, scheduled, non-emergency transports will not be stopped for pre-payment review if the prior authorization has not been requested and obtained prior to the fourth round-trip. However, CMS indicated that claims submitted and paid during the pause without prior authorization will be subject to postpayment review.
CMS further indicated that during this period: (1) the MACs will continue to review any prior authorization requests that have previously been submitted and (2) that ambulance suppliers may continue to submit new prior authorization requests.
Ambulance suppliers in these areas will have to make a business decision on whether to continue to request prior authorization during the current crisis. Please note that there are significant benefits to obtaining prior authorization for your repetitive patient population. Specifically, claims that are submitted based on an affirmative prior authorization decision are excluded from future medical review.
The existing Prior Authorization Model is scheduled to expire on December 1, 2020. CMS has indicated that, at the present time, it does not plan an extension beyond December 1, 2020. CMS further indicated that the Prior Authorization Model will not be expanded beyond the current states and territories during the public health emergency.
Moments ago, Congresswoman Terri Sewell (D-AL) and Congressman Devin Nunes (R-CA) introduced the Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2019 (H.R. 4938). Congressmen Peter Welch, (D-VT), Markwayne Mullin (R-OK), and Earl Blumenauer (D-OR) are original cosponsors of the legislation. Thank you to the bill sponsors for their continued support!
H.R. 4938 would help stabilize current and future Medicare reimbursement of ambulance services and set the stage for future reform of the Medicare ambulance fee schedule. If passed, this bill would:
The AAA has worked diligently to get this legislation introduced and we are excited to share this news with the membership. We would like to thank all the AAA members who have worked closely with their elected representatives to get this legislation introduced. In the coming weeks, the AAA will be asking members to contact their Members of Congress to voice their support of this legislation.
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 District of Columbia. National expansion is contingent upon CMS’ determination that certain expansion criteria have been met. CMS is indicating that if the decision is made to expand the program, such expansion may occur in multiple phases. CMS intends to use the information collected pursuant to this notice to determine the proper payment for repetitive scheduled non-emergent ambulance transportation.
In plain English, CMS is soliciting comments from stakeholders as to the efficacy of the current process, including whether the existing paperwork requirements are sufficient to ensure that approved patients meet the medical necessity requirements for an ambulance. CMS is also seeking suggestions for how to best expand the program nationally, e.g., whether it makes sense to expand the program in phases, etc.
The AAA Medicare Regulatory Committee has been monitoring the current model for several years. As a result, the AAA is in a good position to provide constructive feedback to CMS regarding the potential national expansion of the RSNAT Prior Authorization Model. These suggestions will be included in the AAA’s comment letter. The AAA also encourages members to offer their own comments. The AAA anticipates providing members with a sample comment letter in early December that members can use to submit their own comments.
To be considered, comments must be submitted no later than 5 p.m. on December 30, 2019. Comments may be submitted electronically by going to: http://www.regulations.gov. Commenters would then need to click the link for “Comment or Submission,” and follow the instructions from there. Comments may also be submitted by regular mail to the following address: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier: CMS-10708, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
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.
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.
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.
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.
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.
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On May 21, 2018, the Government Accountability Office (GAO) issued a report to the U.S. Senate Finance Committee on the use of prior authorization models by the Centers for Medicare and Medicaid Services (CMS). The GAO was asked to examine: (1) the impact of prior authorization on total expenditures, and the potential savings for items or service subject to prior authorization, (2) the reported benefits and challenges of prior authorization, and (3) CMS’ monitoring of these programs, and its plans for future prior authorization. To conduct its study, the GAO looked at payment data and other information provided by CMS. The GAO also interviewed CMS, the Medicare Administrative Contractors (MACs), and selected provider, supplier, and beneficiary groups.
Prior authorization was first implemented by CMS in 2012 for certain power mobility devices (e.g., power wheelchairs) in seven states. Subsequent prior authorization models were implemented for non-emergency hyperbaric oxygen and home health services. Most relevant to our industry, CMS implemented a prior authorization model for repetitive, scheduled, non-emergency ambulance transportation in December of 2014. Originally, this model was implemented in only three states: New Jersey, Pennsylvania, and South Carolina. In January of 2016, the prior authorization model was expanded to include the states of Delaware, Maryland, North Carolina, Virginia, and West Virginia, as well as the District of Columbia.
The GAO’s key finding is that these prior authorization models have been effective in reducing Medicare’s expenditures for various items. The GAO’s analysis of actual expenditures found that the estimated savings from all demonstrations through March of 2017 could be as high as $1.1 to $1.9 billion. Given this fact, it should not be surprising that the GAO is calling on CMS to continue the use of prior authorization.
The majority of the data included in this report relates to non-ambulance services. However, I do want to highlight a few data points noted by the GAO.
From the model’s implementation in December 2014 through March 2017, MACs collectively handled more than 337,000 prior authorization requests, including a total of 3,231 requests for authorization of a repetitive, non-emergency, ambulance patient. This includes 2,620 initial requests, and 611 resubmissions (i.e., subsequent requests for prior authorization following the rejection of the initial request).
The GAO provisional affirmation rate for both initial and resubmitted authorization requests rose in each demonstration between the initial implementation date and March 2017. For example, the GAO noted that the affirmation rate (i.e., the rate at which patients are approved for repetitive ambulance transportation) during the first six months of the non-emergency ambulance model was 28 percent. This rose to 66 percent during the most recent six-month period (October 2016 through March 2017). The GAO noted that MAC officials attributed this increase, in part, to provider and supplier education, which they felt improved the documentation being submitted by providers and suppliers. While this is undoubtedly true, it is also likely the case that the MACs refined their approval process over time.
The GAO estimated the total potential savings from the prior authorization model for ambulance to be nearly $387.5 million from December 2014 through March 2017. Importantly, 90 percent of that savings was attributable to reductions in utilization in the original three states. Moreover, more than half the reduced expenditures took place within the first six months of the demonstration project.
In terms of fitting this report into the larger picture, I think it is best viewed as further confirmation of what we already suspected: namely, that the federal government perceives prior authorization to be an effective tool for combating the perceived overutilization of ambulance to transport patients to and from dialysis. CMS indicated as much when it adopted the program in 2014. Medicare payment data has borne out those expectations. Recently, CMS issued its first interim report on prior authorization’s effectiveness. The GAO’s report adds an independent imprimatur to that belief.
Big picture, all of the stars appear to be lining up for an expansion of prior authorization next year. Stay tuned!!
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The AAA would like to take this opportunity to update members on a number of issues related to Medicare reimbursement:
Have any questions about these updates? Contact Brian Werfel at firstname.lastname@example.org
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.
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 prior authorization on the utilization of ambulance transportation. Under the program, ambulance suppliers in the affected states would be required to submit documentation related to medical necessity to their Medicare Administrative Contractors (MACs) prior to Medicare payments being authorized. The MACs would review this documentation, and approve those they felt were medically necessary, while denying those patients that they believed could be safely transported by other means.
Mathematica was retained by CMS to conduct a five-year evaluation of the impact of the RSNAT prior authorization model. Specifically, Mathematica was asked to evaluate the program on five specific measures:
Mathematica indicated that it conducted its review using both quantitative and qualitative data analysis. It analyzed data from January 2012 through June 2016. Mathematica noted that it estimated program effects by measuring the change over time in certain key metrics between the pre-model years (2012 through 2014 for Year 1 States, 2012 through 2015 for Year 2 States) and post-implementation years (2015 through 2016 for Year 1 States, 2016 for Year 2 States) in the nine model states. It also compared these states against non-model states.
Because dialysis patients account for more than 75% of all repetitive transports, the report focused on ESRD patients.
The study concluded that the RSNAT prior authorization model successfully reduced the utilization of ambulance, as well as Medicare’s expenditures on repetitive ambulance transportation. The report indicated that a reduction of nearly 70% in the nine states combined. This was associated with an approximately $171 million reduction in Medicare payments for dialysis transports. Interestingly, the study concluded that it also led to a reduction in total Medicare FFS expenditures for ESRD beneficiaries.
Not surprisingly, the Year 1 States saw more dramatic reductions than the Year 2 States. Mathematic attributed this to the fact that the Year 1 States were specifically selected based on higher-than-average utilization rates, while the Year 2 States were selected based on their geographic proximity to the Year 1 States. Mathematic concluded that national expansion would likely result in additional reductions in Medicare payments, but that the impact would likely be less than what was seen with the Year 1 States.
With respect to issues related to access and quality of care, Mathematica found little quantitative evidence to suggest that prior authorization had a negative impact on quality or access to care. The authors noted that they defined a negative impact quite narrowly, limiting it to emergency department visits, emergency ambulance utilization, unplanned hospital admissions, and death. The study did note a 15% increase in emergency dialysis use, which the authors noted might suggest that some beneficiaries were delayed in receiving ESRD treatment. The authors further noted that some beneficiaries who were denied approval could experience difficulty in accessing alternative means of transportation. Finally, the study did note that stakeholders, including ambulance suppliers, expressed concerns that some beneficiaries may have turned to other services — including emergency ambulance transportation and ED services — in response to being turned down for ambulance transportation.
The study indicated that the MACs reported that they successfully implemented the prior authorization model, and that they have adequate staffing to ensure that they meet CMS’ timelines for responding to prior authorization requests. The MACs did note, however, that there were some difficulties in implementing the program in the Year 1 States, which they attributed to their underestimating the required amount of training. The MACs self-reported that they did far better implementing the program in the Year 2 States.
The impact on the ambulance supplier community was mixed. Mathematica noted a 15% decrease in the number of ambulance suppliers per 100,000 beneficiaries in the model states after implementation. The majority of the ambulance suppliers that (euphemistically) “left the program” were smaller services that specialized in dialysis transports. Other companies reported that they reduced their volume of dialysis transports, or stopped transporting dialysis patients entirely. Not surprisingly, the ambulance supplier community believed that the coverage standards being used by the MACs were too strict.
Finally, Mathematica indicated that it was difficult to determine the prior authorization model’s impact on improper payments. This was partly due to the fact that improperly paid claims for ambulance services increased in both the model states and non-model states during the review period.
Mathematica’s findings do not come as a surprise. Rather, they pretty much confirm what our industry has long recognized. The HHS Office of the Inspector General has long warned that dialysis transports are susceptible to overutilization. The Medicare Payment Advisory Commission (MedPAC) concluded the same thing in a June 2013 report to Congress.
Moreover, the A.A.A. has acknowledged the potential for fraud and abuse in connection with these transports. It was for this precise reason that the A.A.A. pushed for prior authorization as a better alternative to reductions in Medicare’s payment for dialysis transports. Our position was that payment reductions failed to adequately address the underlying incentives for overutilization, and, therefore, primarily punished the legitimate providers of such transports.
To its credit, Mathematica acknowledged that factors other than the ambulance suppliers’ financial motives contribute to overutilization. Specifically, it cited the difficulty many beneficiaries face in accessing alternative means of transportation, even where such alternative means would meet the patient’s medical needs. Mathematica also noted the confusion that exists among other health care providers, particularly physicians, in terms of when Medicare would cover an ambulance. Long term, my hope is that this acknowledgement will pave the way towards more constructive conversations between the industry and Congress, CMS, and other stakeholders.
In the short term, the report clears a statutory hurdle that has prevented CMS from considering the expansion of the prior authorization model to the rest of the nation. It remains to be seen whether CMS believes this report is sufficient to make a determination on national expansion, or whether CMS will want to see additional evidence.
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On December 14, 2017, CMS held its latest Open Door Forum. As usual, it started with a few announcements, as follows:
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:
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On December 4, 2017, CMS posted a notice on its website indicating that it would be extending the prior authorization demonstration project for another year. The extension is limited to those areas where prior authorization was in effect for calendar year 2017. 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, 2018.
In its notice, CMS indicated that claims with dates of service between December 2 and December 4, 2017 would not be subject to prior authorization or prepayment review, but that ambulance providers could elect to submit a request for prior authorization for these transports. All repetitive non-emergency transports on or after December 5, 2017 would require prior authorization.
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.
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 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.
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.
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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.
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” 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.
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.
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.
With two years of experience under the prior authorization demonstration project, I think we can safely come to two conclusions:
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.
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 The phrase expresses the concept that even a dead cat will bounce if dropped from a tall enough height.
In May 2014, CMS announced the creation of a three-year demonstration project that calls for the prior authorization of repetitive scheduled non-emergency ambulance transports. The demonstration project was first implemented in the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on their higher-than-average utilization rates for repetitive ground ambulance transportation. For example, in a June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC) cited these states as having particular high utilization rates for dialysis transports. Prior authorization went live in these states on December 15, 2014.
On April 16, 2015, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015. Section 515 of that law required CMS to expand the demonstration program into five additional states (Delaware, Maryland, North Carolina, Virginia, and West Virginia) and the District of Columbia on or before January 1, 2016. The law further instructed CMS to expand the prior authorization regime to the rest of the country beginning no earlier than January 1, 2017. However, the national expansion was conditioned on CMS determining that the demonstration project has been effective in reducing Medicare expenditures without jeopardizing patient’s access to necessary medical care.
As of the end of January 2017, CMS has yet to issue its report on the effectiveness of the prior authorization program in the original 8 states and the District of Columbia. Therefore, there it is highly unlikely that CMS will be expanding the program nationally in the foreseeable future. However, CMS has not officially ruled out the possibility of expanding the program at some point during 2017.
While CMS has not officially ruled out a national expansion in 2017, I rate the prospect as unlikely. I base this statement simply on the calendar. Even if CMS were to issue the required certifications tomorrow, it would still need to give its contractors instructions on how to implement the program. It would also need to give some advance notice to the provider community. If you assume it would want to give everyone involved at least a month to prepare, it would be April at the earliest before it could expand the program. Personally, I have a hard time believing that CMS would go through all that trouble—not to mention allocating the necessary funding—for 8 months.
While I rate the short term prospects for prior authorization to be unlikely, I think that our industry should expect prior authorization for repetitive patients to be part of our long term future.
The data thus far suggests that prior authorization is highly effective at reducing Medicare expenditures. In 2014, the last year before prior authorization went into effect, Medicare paid more than $106 million for dialysis transports in New Jersey alone. In 2015, total spending on dialysis decreased to slightly more than $15 million, a decrease of more than 85%. While there has been anecdotal reports of patients in the state being unable to obtain transportation to their dialysis appointments, there is little empirical evidence to suggest that these are anything other than isolated occurrences, or that prior authorization is contributing to a systematic lack of access. The data from Pennsylvania and South Carolina shows similar dramatic decreases in spending on dialysis.
Collectively, total spending on dialysis in these three states was approximately $140 million less in 2015 than 2014. This corresponds to nearly 20% of total dialysis spending in 2014. To put these reductions in their proper perspective, it may be helpful to remember that the Congressional Budget Office scores the cost of our existing temporary adjustments (i.e., the 2% urban, 3% rural and super rural adjustments) at approximately $100 million a year.
Some will argue that the 2015 reductions in these states were magnified by what can be charitably described as “friction” in the implementation of the program. (We recognize that affected providers in these states are likely to use far less charitable descriptions.) These people would argue that the reductions in subsequent years is likely to be less dramatic. CMS will be releasing 2016 payment data in a few months; at which point we will know whether this prediction proves true. Regardless of whether the data shows an uptick in payments in these states, that same data is almost guaranteed to show a dramatic decrease in total spending on dialysis in these states over the 2014 base year.
In sum, the data makes clear that prior authorization offers substantial cost savings to the federal government. Moreover, the overwhelming majority of these cost savings come from dialysis transports, an area that CMS has long-identified with fraud, abuse, and overutilization. This represents a tempting target for both CMS and Congress when looking for future cost-savings.
In May 2014, CMS announced the implementation of a three-year prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. CMS initially elected to limit this demonstration to three states: 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. The Medicare Payment Advisory Commission (MedPAC) had previously singled out these states as having higher than average utilization of dialysis transports in a June 2013 report to Congress.
This demonstration project went into effect on December 15, 2014. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) subsequently expanded the demonstration project to five additional states and the District of Columbia on January 1, 2016, with a further expansion to all remaining states expected to occur at some time during 2017. However, national expansion is contingent upon CMS determining that the demonstration project has been effective in reducing Medicare expenditures without jeopardizing patient’s access to necessary medical care.
Every year, CMS also releases data on aggregate Medicare payments for the preceding year. This file is referred to as the Physician/Supplier Procedure Master File (PSP Master File). This past month, CMS released the 2016 PSP Master File, which contains information on all Part B and DME claims processed through the Medicare Common Working File with 2015 dates of service. I will be discussing this report in greater detail in next month’s blog.
This month, I want to focus on the impact the prior authorization project has had on total dialysis payments in the original three target states. Reproduced below is a chart tracking the total payments for dialysis transports in these three states between 2010 and 2015. Interestingly, these three states demonstrated very different trajectories prior to last year.
New Jersey saw a sustained, dramatic increase in payments over that time, increasing from approximately $56 million in 2010 to more than $106 million in 2014, an increase of nearly 90% over a 5-year period. (Note: spending figures for 2014 and 2015 take into account the 10% reduction in payments for dialysis transports).
South Carolina saw a much more moderate increase over that same period, increasing from $51 million in 2010 to slightly more than $60 million in 2014, an increase of roughly 18%. By contrast, payments in Pennsylvania peaked in 2011 at $69.6 million, and have been in steady decline ever since.
While these states’ trajectories were different prior to 2015, the results for 2015 are fairly similar. Each state saw a significant reduction in the total expenditures for dialysis once the prior authorization project went into effect.
The fact that these states saw a reduction in overall spending on dialysis is not surprising (to me at least, I recognize this came as a shock to many providers in these states). These states were not selected at random; CMS selected these states based on its belief that they were particularly suspect to overutilization.
What I do find surprising is the relative sizes of the declines in these states. New Jersey and Pennsylvania both experienced a more than 80% reduction in payments for dialysis. By contrast, the reduction in South Carolina (approximately 25%) was far less dramatic.
Does this suggest that abuse was more prevalent in New Jersey and Pennsylvania? Perhaps. An ongoing federal Medicare Strike Force in the Philadelphia metropolitan area has resulted in a number of convictions against fraudulent providers in these states. However, the impact has not been limited to these alleged “bad actors.” Even those companies employing accepted best practices have seen significant reductions in their approved patient populations.
To me, the common factor seems to be the applicable Medicare contractor. New Jersey and Pennsylvania are both administered by Novitas Solutions, Inc., whereas South Carolina is administered by Palmetto GBA. While Medicare’s coverage standards are intended to be national, it seems reasonable to conclude that Novitas has taken a far harder stance on dialysis than Palmetto. Anecdotal evidence from the states that came went live with prior authorization in January 2016 seems to confirm this thesis, although we will not be able to know for sure until the 2016 Medicare payment data is released this time next year.
Those of you that have attended this year’s AAA Regional Conferences, or who participated on AAA webinars this past year have heard me say that the Medicare Administrative Contractor’s stance on dialysis is the most important factor in determining whether an ambulance provider needs to rethink its current approach to its repetitive patient population. To the extent the MAC takes a fairly lenient stance, providers will likely find that only a few “tweaks” are needed to align their existing practices with a prior authorization regime. AAA members in these states may even find it worthwhile to even considering expanding the spectrum of patients they accept for transport. If, however, the MAC takes a fairly restrictive stances (as Novitas has clearly done), providers will likely find it necessary to dramatically trim these populations, or to arrange for alternative sources of payment for these transports.
I also encourage AAA members to attend our panel discussion at this year’s Annual Conference & Tradeshow in exciting Las Vegas (November 7 – 9th). I have the privilege of serving as the moderator for a panel consisting of several providers that are currently operating under the prior authorization project. These providers will talk about their experiences, and will be able to offer helpful tips on how to best navigate this major shift in Medicare’s coverage rules. (See full Conference Agenda)
CMS has notified the American Ambulance Association that the expansion of Prior Authorization for repetitive non-emergencies, to the states not already on Prior Authorization, will not be implemented January 1, 2017.
The reason for the delay is that, pursuant to Section 515(b) of the Medicare Access and CHIP Reauthorization Act (MACRA), CMS must make determinations as to whether: (1) Prior Authorization for repetitive non-emergencies saves money, (2) it adversely affects quality of care and (3) it adversely impacts access to care.
These studies are being conducted and are expected to show the program saves money without adversely affecting quality or access to care.
For those of you in states currently not under Prior Authorization, it is highly recommended that you still prepare for it to be implemented, even though it will not be implemented January 1, 2017. You should still ensure that these patients meet the requirements for medical necessity by reviewing your documents, obtaining documents from facilities, conducting assessments of repetitive patients, implementing internal procedures and processes, etc.
For those of you in states already under Prior Authorization for repetitive non-emergencies, there is no impact. Your program continues.
Palmetto GBA asked AAA to share the following announcement with our members.
Palmetto GBA will hold Repetitive Scheduled Non-Emergent Ambulance Transportation Prior Authorization Demonstration face-to-face workshops in North Carolina for ambulance providers providing repetitive scheduled non-emergent transports to familiarize them with The Centers for Medicare & Medicaid Services (CMS) demonstration currently going on in South Carolina.
These workshops are designed to familiarize providers, whose ambulances are garaged in potential demonstration expansion states, with demonstration requirements including the process of submitting a prior authorization request, billing for repetitive scheduled non-emergent ambulance transports under the repetitive scheduled non-emergent transportation demonstration, as well as common errors identified during the demonstration in South Carolina. Each event will include a question and answer period at the end of the formal presentation.
The purpose of the current prior authorization demonstration is to ensure that beneficiaries continue to receive medically necessary care while reducing expenditures and minimizing the risk of improper payments to protect the Medicare Trust Fund by granting provisional affirmation for a service prior to submission of the claim. Prior authorization allows providers and suppliers to address issues with claims prior to rendering services and to avoid the appeal process.
Prior authorization will not create new clinical documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process.
Ambulance Prior Authorization Workshop: Repetitive Scheduled Non-Emergent Ambulance Transports
Audience: Part B Ambulance providers of repetitive scheduled non-emergent ambulance transports
Event Type: In Person Seminar
The schedule of workshops and registration information is listed below. To reserve your seat or find out more about the workshops in your area, please make sure you:
**As a reminder, providers are encouraged to telephone the Provider Contact Center (PCC) at 855-696-0705 with any claim specific questions they may have as these will not be able to be addressed at the workshop.
By David M. Werfel, Esq. | Updated November 6, 2015
On November 5, 2015, the Centers for Medicare and Medicaid Services (CMS) conducted its latest Ambulance Open Door Forum. As usual, CMS started with announcements, which were as follows:
As required under the Medicare Access and CHIP Reauthorization Act (HR 2), the pilot program for prior authorization for non-emergency repetitive patients will be expanded to Delaware, the District of Columbia, Maryland, North Carolina, Virginia and West Virginia, effective January 1, 2016. A Special Open Door Forum on the topic will be held by CMS on November 10, 2015 from 12:30 to 1:30 pm. (Link to PDF).
On October 30, CMS released the final rule on changes in CY 2016 to the Medicare ambulance fee schedule. The final rule will be published in the Federal Register on November 16, 2015. The rule finalizes the following:
ICD-10 – CMS published an ambulance crosswalk from ICD-9 codes to ICD-10 codes. Also, the condition codes list is only a guide and using one of the codes does not guarantee coverage.
Healthcare Marketplace – individuals can apply for health coverage through the marketplace from November 1, 2015 to January 31, 2016 through healthcare.gov.
Medicare Open Enrollment – CMS announced the Open Enrollment period has begun for Medicare beneficiaries to select their plan.
The question and answer period followed the announcements. As usual, several resulted in the caller being asked to e-mail their question to CMS. Questions concerning the prior authorization program were asked but the callers were told the questions would be answered on the Special Open Door Forum for prior authorization that will be held on November 10. Answers to questions asked were as follows:
No date was given for the next Ambulance Open Door Forum, other than the November 10 date for the Special Open Door Forum on the expansion of prior authorization.
October 26, 2015
CMS has announced that consistent with the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), it will expand the current prior authorization demonstration program for repetitive scheduled non-emergent ambulance transports beginning on January 1, 2016, to Maryland, Delaware, the District of Columbia, North Carolina, Virginia, and West Virginia. The current demonstration program is operating in three states (New Jersey, Pennsylvania, and South Carolina).
The demonstration seeks “to test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care, using the established prior authorization process for repetitive scheduled non-emergent ambulance transport to reduce utilization of services that do not comply with Medicare policy.”
The Agency reiterates that the prior authorization process does not create new clinical documentation requirements. Requesting a prior authorization is not mandatory, but CMS encourages ambulance services to submit a request for prior authorization to their MACs along with the relevant documentation to support coverage. If an ambulance service does not request prior authorization, by the fourth round-trip in a 30-day period, the claims will be stopped for pre-payment review.
To be approved, the request must meet all applicable rules and policy, as well as any local coverage determination requirements. The MAC will “make every effort” to review and decide on the request within 10 business days for an initial submission. If an ambulance service requests a subsequent prior authorization after a non-affirmative decision, the MAC will try to review and decide upon the subsequent request within 20 business days. Ambulance services may also request an expedited review.
If granted, the prior authorization may affirm a specified number of trips within a specific amount of time. The maximum number of trips is 40 round trips within a 60-day period.