Tag: prior authorization

Summary of CMS Ambulance Open Door Forum of November 5, 2015

Written by David Werfel on November 6, 2015. Posted in Government Affairs, Medicaid, Medicare, Member Advisories, Member-Only, Regional Workshops, Regulatory.

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).

Payment Policies

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:

The 2% urban, 3% rural and 22.6% super rural adjustments have been extended through December 31, 2017.
Urban/Rural Designations – CMS will continue in 2016 and thereafter with the current geographic designations of urban and rural that were implemented on January 1, 2015. CMS also stated the Agency is further reviewing those zip codes which are a RUCA 2 or 3 and have a portion that include a rural census tract. The Agency will issue possible changes in a proposed rule. This review was requested by the AAA and should result in more urban zip codes being designated as rural.
Vehicle/Staff – For Medicare purposes, a BLS vehicle must include at least a driver and an EMT-Basic. However, the vehicle/staff must also meet all state and local rules.

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.

Meeting at the AAA

Rogers spoke at the AAA Workshop on Prior Authorization held at the AAA headquarters on October 2. He thanked the AAA for inviting him as a speaker.
Rogers mentioned one of the issues he discussed at the AAA headquarters was the transportation of psychiatric patients. Dr. Rogers indicated that his opinion is that when patients are in a “psychiatric hold”, that the psychiatric hold, by itself, does not constitute Medicare coverage for an ambulance. He indicated that coverage would exist if there was IV, EKG, medications administered, etc., but that possible elopement was not enough for coverage. Dr. Rogers’s statement was his individual opinion. The AAA does not agree with that opinion and we will be following up with Dr. Rogers and CMS on the matter.
Rogers stated another issue discussed at the AAA headquarters was on the proper level of service being determined at the time of dispatch. He stated that it was his opinion that Medicare should reimburse for the level of service dispatched.

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:

Medicare does not cover an ambulance transport of a psych patient, as the patient can be transported safely by other means, such as by law enforcement.
When physicians and facilities do not provide records needed for prior authorization, the ambulance provider may have to choose discontinuing transportation of that patient.
The denial rate for ICD-10 codes is the same as it was for ICD-9 codes.
No solution was offered for situations where the SNF uses 911 to call for an ambulance that they know is not needed.
When Medicaid pays and takes back its payment more than a year after the date of service, due to the patient receiving retroactive Medicare eligibility, Medicare can be billed.

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.

Prior Auth Expansion to MD, DE, DC, NC, VA, WV

Written by Kathy Lester on October 26, 2015. Posted in Medicare, Member Advisories, Member-Only, Reimbursement.

CMS Announces Expansion of Prior Authorization Program for Repetitive Scheduled Non-Emergent Ambulance Transports

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.

CMS Releases Article on Prior Authorization

Written by David Werfel on June 16, 2015. Posted in Medicare, Member Advisories, Reimbursement.

CMS has issued an article concerning prior authorization for repetitive non-emergency ambulance transports.

House Votes in Favor of Permanent Doc Fix, Bill Moves to the Senate

Written by Michael Hall on March 26, 2015. Posted in Government Affairs, Legislative, Medicare, Member Advisories, Regulatory, Reimbursement.

Earlier today, the U.S. House of Representatives voted in favor of H.R. 2, doing away with Medicare’s sustainable growth-rate formula and passing a permanent doc fix. The 392-37 vote was overwhelmingly bipartisan. As we reported on March 24, thanks to our champions on Capitol Hill, a 33-month extension of the temporary Medicare ambulance increases was included in the bill. If enacted, the bill would extend the deadline for expiration of Medicare ambulance relief from March 31 until December 31, 2017.

The Senate still needs to pass the bill and is working on a short time-line before they adjourn for recess. Senate Republicans and Democrats have expressed concerns about different aspects of the bill so it is unclear whether the chamber will consider H.R. 2 before it recesses. It is also uncertain if Congress would pass a short-term extension to give the Senate more time or if CMS would be required to formalize its 14-day claim hold policy should H.R. 2 not be enacted before March 31.

In addition to Medicare ambulance relief, the package also includes language from the Protecting Integrity of Medicare Act (H.R. 1021) expanding the current prior authorization pilot programs on repetitive BLS non-emergency ambulance transports in South Carolina, Pennsylvania and New Jersey. Starting in January 2016, the bill would expand the programs to Delaware, DC, Maryland, North Carolina, West Virginia and Virginia. The program would then expand nationwide starting in January 2017.

The AAA will continue to push for the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 377, H.R. 745). S. 377 and H.R. 745 would make the current temporary ambulance increases permanent and place our industry in a strong position moving forward for data-driven reforms to the ambulance fee schedule. S. 377 and H.R. 745 would also address fraud and abuse with repetitive BLS non-emergency dialysis transports. While a similar program to the current pilot programs. The prior authorization within S. 377 and H.R. 745 would apply only to dialysis transports and would institute additional safeguards to ensure timely prior authorization for medically necessary transports.

I want to thank all AAA members, staff and consultants who continue to work tirelessly on extending essential Medicare ambulance relief. We will keep you posted of new developments.

Prior Authorization Issues – South Carolina

Written by David Werfel on January 12, 2015. Posted in Government Affairs, Medicare, Regulatory, Reimbursement.

Based on implementation issues involving the Prior Authorization program for repetitive patients inSouth Carolina, Brian and I had a conference call with representatives of CMS and Palmetto on Friday January 9, 2015. Three main issues were discussed, as follows:

1. Legal Representative Payee – There was confusion concerning repetitive patients that had a Legal Representative Payee. These are patients who can not conduct their own affairs and have a form on file at the Social Security Administration for someone else to be their legal representative. When ambulance companies submitted for Prior Authorization for these patients, they were told thePrior Authorization did not apply for the patient. Palmetto posted their policy for these patients on their web site.

Unfortunately, you will not know right away which patients have a legal representative payee. Most likely you will not know until you receive a rejection of the Prior Authorization request. Therefore, until you have been told a repetitive patient has a legal representative payee, file with Palmetto for the priorauthorization.

Once you are told the patient has a legal representative payee, then submit claims, just as you would for non-repetitive patients, i.e. do not continue to try to obtain prior approval or a Unique Transaction Number (UTN).

We have asked Palmetto if there is a database that you can access before going through the priorauthorization process. So far, there is not, but they are checking on this issue.

FYI, this was a policy instituted by CMS for the Prior Authorization process based on other programs (not ambulance) they have in place.

2. Incorrect Edit for Non-Repetitive Patients – On Wednesday, January 7th, we advised Palmetto that claims for non-repetitive patients were either being denied or that they needed further development as there is a systems edit that is pulling patients who had multiple transports over a period of time, but are not supposed to be in this Prior Authorization program. For example, a patient who has had four hospital discharges following illnesses for a fracture, a CVA, pneumonia and surgery, is not “repetitive”, for Prior Authorization purposes. On the conference call on Friday, Palmetto and CMS agreed with our assessment of the situation. They indicated that not only has the cause of the problem been identified, but they believe that it will be fixed in approximately one week. They are testing it now. They are looking at January 19 as the date for the “fix” to be implemented.

They have located 485 claims in this status that are currently “suspended”. When the “fix” is implemented, they will release these claims for processing, i.e. those providers should not resubmit the claims as Palmetto will do it automatically. Claims for these non-repetitive patients that have already been rejected should be resubmitted.

NOTE: Novitas is having the same problem. They sent out a notice to providers in their jurisdiction advising them they are aware of the problem. We assume that the same “fix” will be tried by Novitas.

3. Common Errors – We asked Palmetto if they could come up with a list of the common errors being made by ambulance companies. Following the conference call, they provided us with the list below. Providers in South Carolina (as well as in New Jersey and Pennsylvania, even though NJ and PA submit to Novitas) should review the list to ensure you are not making these mistakes:

– The PCS submitted does not have a valid signature date.

– The date of the signature is post- dated, perhaps to match a future date the patient will be starting.

– The signature on the PCS is not identifiable. The name of the physician must be identifiable. This does not mean the signature itself must be legible, it means that Palmetto has to be able to read the name of the physician that signed the PCS.

– The PCS has been amended (e.g. to print or type the name of the physician) without any notation by the amending individual. Any amendments/additional information should be clearly signed or initialed and dated by the person making the change or note.

– Submission of contradictory documentation. For instance, the PCS may support the transport, but the supporting documentation from the certifying physician does not.

– If the Prior Authorization is approved, the UTN is not entered into the appropriate field or submitted at all.

– For claims that are non-emergent, non-repetitive, providers are listing something (e.g. “N/A” or “not a PA” or “non-repetitive”) in the UTN field. For these non-repetitive patients, do not put anything the UTN field. The edit for the prior authorization is hard coded. Therefore, if their computer finds anything in this field, for patients who do not have prior authorization, the claim will reject.

Palmetto indicated that they will have a conference call with ambulance providers to discuss “hot issues”, including those above. At this time, they are looking to have that conference call on January 19th, although that is subject to change. For those affected, check the Palmetto web site and otherwise look for the notice for this conference call.

Finally, implementing a program of this nature is always going to have some start-up problems. Now that the two issues noted in #1 and #2 above have been identified and are about to be resolved, the remaining problems, such as those noted in #3 above, are mostly left up to the providers to understand what is needed, where the information is to be listed, etc. Once that is understood, the process will work smoothly as it did for many years in Ohio, when Palmetto and its predecessor used a prior authorization process for ambulance transports of non-emergency dialysis patients.

Of course, there will always be those situations where you believe medical necessity is met, but Palmetto does not agree. In those situations you will have to decide if more information is needed, whether you agree with Palmetto and the patient can be transported via wheelchair van, whether you need to advise the patient/facility accordingly, whether to accept the denial or whether to appeal.