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CMS “Pauses” Prior Authorization Model for Scheduled, Repetitive Non-Emergency Ambulance Transportation

Written by Brian Werfel on . Posted in Medicaid, Reimbursement.

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.

CMS Announces Comment Period for National Expansion of Prior Authorization Process

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

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.

CMS Announces Extension of Prior Authorization Program

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

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.

CMS Announces Extension of Prior Authorization Program

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

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.

Talking Medicare: CMS Implements Further Dialysis Cuts

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

Talking Medicare: CMS Implements Further Cuts in Reimbursement for Dialysis Services; Medicare Payment Data Shows Continued Reduction in Overall Spending on Dialysis Transports, but Net Increase in Dialysis Payments in Prior Authorization States

On October 1, 2018, CMS implemented an additional thirteen (13%) cut in reimbursement for non-emergency BLS transports to and from dialysis. This cut in reimbursement was mandated by Section 53108 of the Bipartisan Budget Act of 2018. This on top of a ten (10%) cut in reimbursement for dialysis transports that went into effect on October 1, 2013. As a result, BLS non-emergency ambulance transports to and from dialysis that occur on or after October 1, 2018 will be reimbursed at 77% of the applicable Medicare allowable.

In related news, CMS has released its national payment data for calendar year 2017. This data shows a continued reduction in total Medicare payments for dialysis transports. Medicare paid $477.7 million on dialysis transports in 2017, down from $488.9 million in 2016. This continues a downward trend that has seen total payments decline from a high of more than $750 million in 2013 (see accompanying chart to the right). Not coincidentally, it was in 2013 that our industry saw its first reduction in Medicare’s payments for dialysis transports.

The payment reduction is partially the result of the reduction in the amounts paid for dialysis services. However, it is also reflective of an overall decline in the number of approved dialysis transports. For this, we can look primarily to the impact of a four-year demonstration project that requires prior authorization of dialysis transports in 8 states and the District of Columbia.

As a reminder, the original prior authorization states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress. The chart below shows total spending on dialysis in those states in the years immediately preceding the implementation of the prior authorization project up through 2017, the third year of the demonstration project. While the three states had very different trajectories prior to 2015, each showed a significant decrease in total payments for dialysis under the demonstration project.

However, it is the trajectory of these changes that I want to discuss in this month’s blog. In previous blogs, I discussed the impact of the particular Medicare Administrative Contractor on the outcomes under prior authorization. Specifically, I noted that, while dialysis payments dropped in each state, the decline was far more dramatic in the states administered by Novitas Solutions (NJ, PA) than in the South Carolina, which was administered by Palmetto GBA. This trend continued in the second year of the program, which saw prior authorization expanded into five additional states and the District of Columbia. Those states administered by Novitas (DE, MD) saw far greater declines than the states administered by Palmetto (NC, VA, WV).

Given these declines, the data from the third year is somewhat surprising. The states administered by Palmetto continued to see declines in total dialysis payments, with the only exception being West Virginia. However, in the states administered by Novitas, we saw total dialysis payments increase, particularly in New Jersey, which saw nearly a 33% increase in total dialysis payments.

Three years into the prior authorization program, it is starting to become clear that the two MACs have approached the problem of overutilization of dialysis transports using two different approaches. Palmetto appears to have adopted a slow-and-steady approach, with total payments declining in a consistent manner year after year. By contrast, Novitas adopted more of a “shock the system” approach, where it rejected nearly all dialysis transports in the first year, and has adopted a somewhat more lenient approach in subsequent years.

Key Takeaways

 Last year, I wrote that two years of data under the prior authorization program permitted two conclusions: (1) the implementation of a prior authorization process in a state will undoubtedly result in an overall decrease in the total payments for dialysis within that state and (2) the size of that reduction appears to be highly dependent on the Medicare contractor.

With an additional year of data, I think both conclusions remain valid, although I would revise the second to suggest that the initial reduction has more to do with the Medicare contractor. The evidence from the third year of the program suggests that the trends tend to equalize after the first few years. It is also possible that Novitas felt a more aggressive approach was needed in the first few years to address evidence of widespread dialysis overutilization in the Philadelphia metropolitan area.

This has potential implications beyond the demonstration project, as CMS looks towards a possible national expansion of the program. Among other issues, it suggests that the AAA must continue its efforts to work with CMS and its contractors on developing more uniform standards for coverage of this patient population.

What the AAA is Doing

The AAA continues to work on legislation that would restructure this cut to dialysis transport reimbursement. The AAA strongly supports the NEATSA Act (H.R.6269) introduced by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) that would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports. AAA members and the AAA are working to get a Senate companion bill introduced shortly. The goal of this legislation would be to have the restructured offset go into effect as soon as possible. Thank you to the dozens of AAA members who have already contacted their members of Congress voicing their support for this critical legislation.

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

Update on Medicare Reimbursement Issues

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

The AAA would like to take this opportunity to update members on a number of issues related to Medicare reimbursement:

  1. 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 indicated that they anticipate completing all required adjustments by the end of the second quarter of 2018.
  1. Further reduction in Medicare’s payment for non-emergency BLS transports to and from dialysis. The Bipartisan Budget Act of 2018 further required CMS to implement an additional 13% reduction in Medicare’s payment for scheduled, non-emergency BLS transports to and from dialysis. This reduction is on top of the existing 10% payment reduction. Collectively, this means that dialysis transports will be reimbursed at a rate that is 23% less than the rate that would otherwise be applicable to BLS non-emergency transports in your area. The AAA. is reminding members that this additional reduction in payments will go into effect for transports on or after October 1, 2018.
  1. CMS has updated its SNF Consolidated Billing file to resolve the error that resulted in certain ambulance claims being incorrectly denied as being the responsibility of the SNF. Each year, CMS updates the SNF Consolidated Billing file provided to MACs. This file contains several lists of Healthcare Common Procedure Coding System (HCPCS) codes, and provides instructions to the MACs on whether these codes: (i) should be accepted for separate payment under Medicare Part B or (ii) should always be denied for inclusion in the SNF Consolidated Billing system. Ambulance HCPCS codes (A0425, A0426, A0427, etc.) have always been included in the first list, as the issue of whether an ambulance transportation is bundled to the SNF is conditioned on the nature of the services that the patient will receive at the destination. To the extent the service the patient will receive at the destination is bundled, the ambulance services to and from that service will also be bundled, and vice versa. Note: there are two exceptions to this general rule. The first is that ambulance transportation to and from dialysis is specifically exempted from the SNF Consolidated Billing regime, and therefore will always be separately billable to Medicare Part B. The second exception relates to the provision of chemotherapy services furnished on an outpatient basis in a hospital. Chemotherapy services are generally bundled to the SNF; however, several years ago, Congress elected to exempt a number of particularly expensive forms of chemotherapy from the SNF bundle. In these instances, while the SNF is not responsible for the payment of the expensive chemotherapy, the SNF remains responsible for payment of the ambulance transportation to and from the hospital. Because ambulance codes may or may not be bundled to the SNF based on the nature of the transport, they are not automatically denied. Instead, the MACs are supposed to use further edits to identify those situations in which the ambulance transport would be bundled vs. separately payable. Unfortunately, in its 2018 update, CMS inadvertently left the ambulance HCPCS codes off the list of codes that are not automatically denied as being bundled to the SNF.  As a result, ambulance providers have indicated that claims were being denied using remark code “OA109.”  In some cases, claims for dates of service in 2016 or 2017 that were previously paid were being recouped. CMS recognized its error fairly quickly, and updated the SNF Consolidated Billing file in mid-February. All MACs were provided with updated instructions by February 27, 2018. Therefore, the issue has been resolved for current claims. What remains to be resolved is how CMS and its MACs will adjust or reprocess claims that were incorrectly denied. Several MACs have notified providers of the issue, and asked that they refrain from appealing the claims. These MACs are indicating that they will automatically adjust/reprocess affected claims. In other instances, the MACs have asked the providers to make a refund of affected claims that were previously paid, promising to then reprocess the entire claim. The AAA is advising members to carefully track the claims that were affected by this mistake, and to follow the instructions issued by their MAC for ensuring their reprocessing.
  1. CMS has delayed the mailing new ID cards to all Medicare beneficiaries. As part of the Medicare Access and CHIP Reauthorization Act of 2015, Congress mandated that CMS remove a beneficiary’s social security number (SSN) from their Medicare ID card by April 2019. As part of this initiative, CMS will be replacing the SSN-based Health Insurance Claim Number (HICN) with the new Medicare Beneficiary Identifier (MBI). CMS has already started mailing cards with the MBI to newly enrolling Medicare beneficiaries. CMS originally announced that it would be mailing new cards to existing Medicare beneficiaries starting in April 2018, but recently indicated that it would delay the mailing of new cards to existing Medicare beneficiaries until May 2018. From May to June, CMS will mail new cards to existing Medicare beneficiaries residing in Alaska, California, Delaware, Hawaii, Maryland, Oregon, Pennsylvania, Virginia, West Virginia, the District of Columbia, and the U.S. territories of American Samoa, Guam, and the Northern Mariana Islands. The mailing program will then be extended to additional states in 5 “waves” over the coming year. To the extent you provide services in the above-mentioned states, you may want to educate crewmembers and other employees on the differences between the HICN and the MBI. You may want to also consider updating your existing patient databases to include the new identifier. As a reminder, CMS will permit claims to be submitted with either the HICN or the MBI during a transition period running through December 31, 2019.  Effective January 1, 2020, claims must be submitted with a patient’s MBI. This requirement applies regardless of whether the date of service occurred prior to the expiration of the transition period.
  1. Extension of prior authorization project for scheduled, repetitive transports. In December 2017, CMS indicated that it would be extending the prior authorization program for an additional year. This program is currently in place for the states of Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, West Virginia, and the District of Columbia. The extension of the program is limited to those states. CMS has further indicated that it will be making a determination on possible national expansion at some point in the near future. CMS recently released its first interim report on the prior authorization program. As expected, that report indicated that prior authorization has been successful in reducing Medicare expenditures on scheduled, repetitive transports, without any material impact on beneficiary access to and quality of care.

Have any questions about these updates? Contact Brian Werfel at bwerfel@aol.com

First Interim Evaluation Report on Medicare Prior Authorization

Written by Brian Werfel on . Posted in Medicare, Talking Medicare.

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 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.

Reports Methodology

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:

  1. The effect of prior authorization on Medicare use and cost. Did the model realize savings for the Medicare Program?
  2. How does the prior authorization model affect the quality of and access to care for Medicare beneficiaries?
  3. How does the prior authorization model affect Medicare program operations? What was the impact, if any, of the model on MAC operations?
  4. How does the prior authorization model impact non-emergency ambulance suppliers’ and other health care providers’ behavior? Did ambulance suppliers and other health care providers change their behavior in response to the model?
  5. Does prior authorization impact improper payment rates, the rate at which claims are denied, and related program integrity concerns?

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.

Key Findings

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.

Analysis

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.

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

Summary of December 2017 Ambulance Open Door Forum

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

On December 14, 2017, CMS held its latest Open Door Forum. As usual, it started with a few announcements, as follows:

  1. Ambulance Inflation Factor – CMS announced that it had published Transmittal 3893 on October 27, 2017, which sets forth the Ambulance Inflation Factor (AIF) for calendar year 2018. In that Transmittal, CMS indicated that the CY 2018 AIF would be 1.1%. This is based on an increase in the CPI-U of 1.6%, and a multi-factor productivity adjustment of 0.5%.
  1. Expiration of Temporary Adjustments – CMS indicated that the current temporary adjustments for urban (2%), rural (3%) and super rural ground ambulance transports are set to expire on December 31, 2017. CMS also indicated that they were aware of proposed legislation that would extend these adjustments for 2018 and beyond, but that they have yet to be enacted into law.
  1. CY 2018 Public Use File – CMS indicated that the Public Use File on its website has been updated to include Medicare allowables for 2018. CMS made a point of noting that the 2018 rates do not include the temporary adjustments, as they are set to expire on December 31, 2017.
  1. Prior Authorization Demonstration Project – CMS indicated that it had decided to extend the Prior Authorization Demonstration Project for schedule, non-emergency ground ambulance transportation of repetitive patients for another year. The extension is limited to the 8 states (DE, MD, NJ, NC, PA, SC, VA, and WV) and the District of Columbia in which the program was in effect in 2017.  CMS further indicated that the extension would be effective for dates of service on or after December 5, 2018.  As a result, claims for dates of service between December 2 and December 4 would not be subject to prepayment review if a prior authorization was not received; however, ambulance providers in these states would be permitted to request prior authorization for those dates. CMS further indicated that it had developed a “streamlined” process to allow for prior authorization of transports in situations where the patient was approved for transport, but where the duration of the authorization was shortened from the normal 60-day period to account for the program’s scheduled expiration on December 1, 2017. An example would be an authorization that was granted for transports starting on November 1, 2017. The provider was likely given authorization for only a 30-day period. The streamlined process would allow them to submit a request to allow that 30-day authorization to be extended to a fully 60 days. CMS indicated that the streamlined process would not require the submission of medical records to establish medical necessity for the ambulance.

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:

  1. CMS was asked when it anticipated issuing its report on the effectiveness of the Prior Authorization Demonstration Program.  CMS responded that it expected to issue that report during the first quarter of 2018.
  2. CMS was asked when it expected to expand the Prior Authorization Demonstration Program to additional states and/or the nation as a whole.  CMS responded that it was still evaluating the effectiveness of the program.  Therefore, CMS indicated that no decision on national expansion had been made at this time.

Have questions? Please write to the Werfels at bwerfel@aol.com.

CMS Extends Prior Authorization for 2018

Written by Brian Werfel on . Posted in Member Advisories, News, Reimbursement.

CMS Announces Extension of Prior Authorization for Repetitive Non-Emergency Ground Ambulance Transports

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.

Read the Full CMS Notice

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.

Navigating a Post-Prior Authorization World

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

Talking Medicare: Navigating a Post-Prior Authorization World

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

First a little background. In May 2014, CMS announced the implementation of a three-year prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project was initially limited to the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress. As initially conceived, the prior authorization demonstration project first went into effect on December 15, 2014.

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

Where Do We Go From Here?

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

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

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

What We Can Expect from Medicare and its Contractors

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

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

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

Other Potential Impacts

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

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

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

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

No really, it’s true…

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

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

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

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

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

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

Talking Medicare: Prior Authorization Spending Update

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

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

In May 2014, CMS announced the implementation of a three-year prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project was initially limited to the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress.

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

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

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

Existing States

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

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

Expansion to New States

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

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

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

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

Key Takeaways

 With two years of experience under the prior authorization demonstration project, I think we can safely come to two conclusions:

  1. The implementation of a prior authorization process in a state will undoubtedly result in an overall decrease in the total payments for dialysis within that state; and
  1. The size of that reduction appears to be more dependent on the Medicare contractor than on any perceived level of over utilization.

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

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

This has potential implications beyond the demonstration project, which is scheduled to expire at the end of this year. As many of you know, the national expansion of prior authorization is part of the House of Representative’s ambulance relief bill (it is not mentioned in the corresponding Senate bill). The data suggests that the AAA must continue its efforts to work with CMS and its contractors on developing more uniform standards for coverage of this patient population.

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

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

The Future of Prior Authorization

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, Reimbursement.

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.

Congress Acts to Expand the Prior Authorization Regime

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.

Short Term Prospects for Expansion

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.

Long Term Prospects for Prior Authorization

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.

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

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

Written by Michael Hall on . 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 . 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.

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