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

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...

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40 Under 40: Rebecca Szeles (Richmond Ambulance Authority – Richmond, VA)

40 Under 40 nominees were selected based on their contributions to the American Ambulance Association, their employer, state ambulance association, other professional associations, and/or the EMS profession. ____ Rebecca Szeles Communications Supervisor Richmond Ambulance Authority Richmond, Virginia ____ Nominated by: Mark Tenia Biography Rebecca Szeles is a Nationally Registered Paramedic and Communications Supervisor at the Richmond Ambulance Authority (RAA). She is a Virginia Commonwealth University graduate with a Bachelor of Science in Biology. She is also a member of RAA’s Critical Incident Stress Management Team (CISM) and Peer Support Program (PSP). Reason for Nomination Supervisor Szeles has not only dedicated herself to her position, but has also committed herself to supporting the mental health and well-being of her co-workers. In 2017 Supervisor Szeles invited Jim Marshall from the 911-Training Institute to speak to staff about resiliency. In 2018, she went through training to become a member of our Critical Incident Stress Management (CISM) team. CISM helps providers deal with traumatic events such as line of duty or pediatric deaths, and Mass Casualty Incidents (MCI). Supervisor Szeles realized more could be and needed to be done to help RAA’s providers on a day to day basis. After becoming a member of (more…)

CMS Announces Comment Period for National Expansion of Prior Authorization Process

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

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CMS Announces Extension of Prior Authorization Program

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

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CMS Announces Extension of Prior Authorization Program

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

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Talking Medicare: CMS Implements Further Dialysis Cuts

Talking Medicare: CMS Implements Further Cuts in Reimbursement for Dialysis Services; Medicare Payment Data Shows Continued Reduction in Overall Spending on Dialysis Transports, but Net Increase in Dialysis Payments in Prior Authorization States On October 1, 2018, CMS implemented an additional thirteen (13%) cut in reimbursement for non-emergency BLS transports to and from dialysis. This cut in reimbursement was mandated by Section 53108 of the Bipartisan Budget Act of 2018. This on top of a ten (10%) cut in reimbursement for dialysis transports that went into effect on October 1, 2013. As a result, BLS non-emergency ambulance transports to and from dialysis that occur on or after October 1, 2018 will be reimbursed at 77% of the applicable Medicare allowable. The payment reduction is partially the result of the reduction in the amounts paid for dialysis services. However, it is also reflective of an overall decline in the number of approved dialysis transports. For this, we can look primarily to the impact of a four-year demonstration project that requires prior authorization of dialysis transports in 8 states and the District of Columbia. As a reminder, the original prior authorization states were selected based on higher-than-average utilization rates and high rates of...

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Update on Medicare Reimbursement Issues

The AAA would like to take this opportunity to update members on a number of issues related to Medicare reimbursement: CMS and its contractors have begun adjusting claims for ground ambulance services to reflect the restoration of the temporary add-ons. Section 50203(a) of the Bipartisan Budget Act of 2018 retroactively reinstated the temporary add-ons for ground ambulance services. These add-ons increase the applicable Medicare allowables by 2% in urban areas, 3% in rural areas, and 22.6% in “super rural” areas (over and above the corresponding rural rate), retroactive to January 1, 2018. On a March 7, 2018 Open Door Forum, CMS indicated that it had updated the Medicare Ambulance fee schedule to reflect these higher rates, and that it has provided a Change Request to each of its Medicare Administrative Contractors (MACs). The AAA has confirmed that all MACs have successfully implemented the new rates, and that all are paying current claims at the correct rate. The AAA has further confirmed that MACs have started to adjust 2018 claims paid at the original (lower) rates. Unfortunately, neither CMS nor its MACs have committed to a firm timetable for the completion of all required adjustments; however, a number of MACs have...

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First Interim Evaluation Report on Medicare Prior Authorization

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

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Congrats to CAAS Accreditations & Recerts

Congratulations to the AAA members who received Commission on the Accreditation of Ambulance Services (CAAS) accreditation or reaccreditation in November and December! New certifications Superior Air-Ground Ambulance (Elmhurst, IL) Recertifications Ambucare (Bremen, GA) American Medical Response Central Mississippi (Jackson, MS) American Medical Response, Los Angeles (Irwindale, CA) American Medical Response, San Diego (San Diego, CA) American Medical Response of West Michigan (Grand Rapids, MI) American Medical Response South Mississippi (Gulfport, MS) Lifeguard Ambulance Service (Milton, FL) Metro West Ambulance (Hillsboro, OR) Richmond Ambulance Authority (Richmond, VA)

Summary of December 2017 Ambulance Open Door Forum

On December 14, 2017, CMS held its latest Open Door Forum. As usual, it started with a few announcements, as follows: 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%. 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. 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. Prior Authorization Demonstration Project – CMS indicated that it...

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Navigating a Post-Prior Authorization World

Talking Medicare: Navigating a Post-Prior Authorization World Novitas Solutions, Inc. recently announced that it will no longer issue prior authorizations for scheduled, repetitive non-emergency transports, effective December 1, 2017. This announcement was based on Novitas’ expectation that the demonstration project will expire at the end of this calendar year. For ambulance suppliers in the states that currently operate under prior authorization, the focus invariably turns to what that means for their repetitive patient populations? First a little background. In May 2014, CMS announced the implementation of a three-year prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project was initially limited to the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress. As initially conceived, the prior authorization demonstration project first went into effect on December 15, 2014. Congress subsequently elected to expand this demonstration project to additional states as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Specifically,...

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Can You Fire for Hate Group Participation?

I am often asked by ambulance service managers if an employer can discipline or terminate an employee for their off-duty conduct. The answer is not an easy one and becomes more challenging when it involves an employee’s Constitutional Rights. In light of the activities in Charlottesville, Virginia this past weekend, the Society for Human Resource Management (SHRM) published a good article examining the issue. Without a doubt there will be increased legal activity related to this issue over the coming months and the we will keep our members updated on the law as it develops....

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Talking Medicare: Prior Authorization Spending Update

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. 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,...

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Alabama Governor Signs REPLICA Compact

Governor Kay Ivey recently signed into law Alabama’s REPLICA legislation, HB250. Alabama joins ten other states—Colorado, Texas, Virginia, Idaho, Kansas, Tennessee, Utah, Wyoming, Mississippi, and Georgia—in this forward-thinking interstate compact. REPLICA, the Recognition of EMS Personnel Licensure Interstate Compact,  recognizes the day-to-day movement of EMS personnel across state lines. It extends the privilege to practice under authorized circumstances to EMS personnel based on their home state license, as well as allows for the rapid exchange of licensure history between Compact member states.. Learn more about how REPLICA participation can help your state at http://www.emsreplica.org.

EMS Week Contest Winners Announced

EMS professionals across the country recently celebrated EMS Week, held May 21-27, by hosting a variety of activities, memorials and both fun-filled and informative events. The AAA asked our members to tell us about some of their favorite ways they honored and celebrated their profession throughout the week, and we have selected three stories as our EMS Week contest winners. Here are some of the highlights: LifeCare Medical Transports (Fredericksburg, VA): “This year’s EMS Week began with us honoring those who gave their lives so that others might live, at our National EMS Memorial Service. On Sunday, May 21, we co-hosted the EMS Service Cyclists for a dinner on their stop in Fredericksburg, VA. The remainder of the week consisted of fun yet educational online EMS Challenges each day, with participants being entered into raffles for great prizes. All employees received a letter from our leadership, as well as EMS gift bags.” Armstrong Ambulance Service (Arlington, MA): “We love celebrating our employees every year with a week-long celebration of EMS Week. We annually begin the week with breakfast catered to the bases. This year, we brought carnival food trucks to the bases for a catered lunch of fair food favorites, including hot dogs, hamburgers, sausages and fried dough. On (more…)

REPLICA Compact Enacted

REPLICA Meets Goal, Interstate Compact Becomes Official May 8, 2017 For Immediate Release Contact: Sue Prentiss 603-381-9195 prentiss@emsreplica.org May 8, 2017 (Falls Church, VA). With the 10th member state enactment, the Recognition of Emergency Medical Services Licensure Interstate Compact (REPLICA) has become official. Governor Nathan Deal of Georgia signed Senate Bill 109 on today activating the nation’s first EMS licensure compact. States that have passed REPLICA to date include: Colorado, Texas, Kansas, Virginia, Tennessee, Idaho, Utah, Mississippi, Wyoming and Georgia. Released in 2014, REPLICA’s model legislation creates a formal pathway for the licensed individual to provide pre-hospital care across state lines under authorized circumstances. According to Keith Wages, president of the National Association of State EMS Officials (NASEMSO), “REPLICA represents a collective, nationwide effort to address the problems faced by responders when needing to cross state borders in the line of their duties.” Wages highlighted the compact’s abilities to “increase access to healthcare, reduce regulatory barriers for EMS responders, and place an umbrella of quality over cross border practice not previously seen in the EMS profession.” Wages also noted that the partnership with the National Registry of Emergency Medical Technicians (NREMT) has been essential during the advocacy and implementation phases. (more…)

Lifetime Achievement of Susan McHenry

Congratulations to Susan McHenry of the National Highway Traffic Safety Administration’s Office of EMS! The National Association of State EMS Officials passes Resolution 2017-01 honoring the lifetime achievement of Susan McHenry. Her 40 year career began at the Virginia Department of Health in 1976 and has continued at the on at the National Highway Traffic Safety Administration’s Office of EMS since 1996. View the resolution here....

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The Future of Prior Authorization

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...

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