Tag: Virginia

Spotlight: Tristan North


Tristan North
Vice President of Government Affairs, AMG
Senior Vice President of Government Affairs, AAA
McLean, VA

Tell us a little about yourself, please.

I grew up in the suburbs of Washington, DC and went to Langley High School near the CIA headquarters. I attended Babson College outside of Boston where I received my B.S. in Finance. During college I played rugby and was a member of the Tau Kappa Epsilon fraternity. Between junior and senior years of college, I worked in the Document Room of the U.S. House of Representatives.

Following college, I landed an internship with the Committee on Financial Services of the U.S. House of Representatives. I started in the press office but ultimately became a professional staff member with the investigation team. I worked on a number of issues during my tenure including currency anti-counterfeiting, credit unions and the solvency of the banking system.

After Capitol Hill I joined the Government Affairs Section of the PR firm, Fleishman-Hillard. I expanded my portfolio to include health care issues and became part of the lobbying team for the American Ambulance Association. The AAA then hired me internally as their first Director of Government Affairs and the rest is history.

I live in Virginia and my wife and I have two children, a boy and a girl. I am an avid skier as well as SCUBA diver and enjoy visiting new places.

When and how did you get involved with the AAA?

I joined the AAA lobbying team at Fleishman-Hillard in 1996 and the AAA staff as Director of Government Affairs in 2000.

How do you help the AAA?

As the Senior Vice President of Government Affairs for the AAA, I coordinate all aspects of the legislative and regulatory agenda of the Association before the Congress and federal agencies. I am the primary registered lobbyist for the AAA and responsible for helping shape and implement the public policy of the organization.

I manage the AAA Government Affairs team in DC which includes John Jonas and his team at Akin Gump, Kathy Lester, David Werfel, Brian Werfel and Chris Hogan who is not well known to AAA members but is invaluable. Steve Williamson and Jamie Pafford-Gresham as co-chairs of the AAA Government Affairs Committee lead the team on the legislative front and Angie Lehman and Rebecca Williamson as co-chairs of the Medicare Regulatory Committee on the regulatory side.

What is your typical day like?

My typical day in the office is usually spent on conference calls, drafting policy material and communicating with the other members of the Government Affairs team and congressional staff. On average, I spend one day a week in meetings on Capitol Hill although lately I’ve been spending two or three days a week on the Hill.

What are the biggest challenges you foresee for our industry? Any tips or last thoughts?

On the government affairs front, the biggest challenge I foresee is having the cost data necessary to make data-driven changes to Medicare ambulance policies. We need accurate data from all ambulance service providers to best position our industry for whatever the health care reimbursement model is in the next 5 years as well as 20 years. Data will also be necessary if we want to be reimbursed for services other than just the transport.

We will need data from all types and sizes of ambulance services serving urban, rural and super rural areas. It will be a burden on the industry but fortunately the AAA has been pushing for limited data to be collected from all ambulance service providers but then only cost data from a statistically significant but much smaller number of providers every three years. This would be far less of a burden on small providers than a mandatory annual cost report and would result in more accurate data.

It is therefore critical that AAA members ask their members of Congress to support the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 377, H.R. 745) which would implement the AAA data collection method as well as make permanent the current temporary Medicare ambulance relief.

Staff Visit to Richmond Ambulance Authority

Last week, American Ambulance Association staff took a road trip south to tour the Richmond Ambulance Authority. Known across the country and around the world for their innovative approach to EMS, RAA certainly did not disappoint.

Thank you to Chip Decker, Rob Lawrence, Dan Fellows, Elizabeth Papelino, Danny Garrison, Dempsey Whit, Jason Roach, and the whole RAA team for the hospitality and generosity with their time!

Musings on 2014 Medicare Payment Data…Part 2

Brian S. Werfel, AAA Medicare Consultant

Every year, the Centers for Medicare and Medicaid Services (CMS) releases data on Medicare payments for the preceding year. The 2015 Physician/Supplier Procedure Master File (PSP Master File) was released in late November 2015. This report contains information on all Part B and DME claims processed through the Medicare Common Working File with 2014 dates of service.

In last month’s post, I focused on total Medicare spending. This month, I want to shine the spotlight on Medicare’s payment for ambulance transports to and from dialysis.

It is no secret that the federal government has long viewed dialysis transports with suspicion. In 1994, the HHS Office of the Inspector General (OIG) issued a report citing dialysis transports as an area of concern. In a 2013 report, the OIG cited the dramatic increase in the volume of dialysis transports since the implementation of the Medicare Ambulance Fee Schedule as evidence that the Medicare ambulance benefit is vulnerable to fraud and abuse. Dialysis transports were also featured heavily in the OIG’s 2015 report on questionable billing practices.  A 2013 report by the Medicare Payment Advisory Commission (MedPAC) noted that the utilization of BLS non-emergency transports, dialysis in particular, had grown faster than the utilization of other ambulance levels of service.

The Numbers Don’t Lie…

According to statistics provided by the U.S. Department of Health and Human Services, the population of ESRD patients increased by 85% from 2002 to 2011. Over that same period of time, the OIG noted that the number of covered ambulance transports to and from dialysis increased by more than 269%. In other words, while the ESRD population has grown steadily over time, an increasing number of those patients are transported to and from their dialysis appointments by ambulance.

Medicare payment data confirms this. In 2007, Medicare paid a total of $445.8 million for dialysis transports. In 2014, Medicare paid $717.1 million for dialysis, an increase of 60.86%. The increase is even more dramatic when you consider that Congress mandated a permanent 10% reduction in Medicare’s payments for dialysis transports furnished on or after October 1, 2013. Without that reduction, Medicare’s payments for dialysis would have been closer to $800 million in 2014, an increase of nearly 80%. Over that same period of time, total Medicare payments for ambulance increased by only 27.08%.

Between 2007 and 2014, Medicare’s payments for ambulance services increased by approximately $1.06 billion, with dialysis transports accounting for $354 million. In other words, approximately one-third of the total increase in Medicare spending on ambulance is attributable to dialysis.

If you focus only on BLS non-emergency transports, the impact of dialysis is even more striking. In 2014, Medicare paid $1.139 million for BLS non-emergency transports (not counting mileage). This is almost essentially unchanged from the $1.131 million it spent in 2010. However, during that same period, payments for BLS non-emergency transports to dialysis increased from $513.7 million to $558.4 million. Put another way, if you remove transports for dialysis, Medicare’s payments for BLS non-emergency transports (and non-emergency transports in general) actually declined over the past five years.

In its 2013 report on ambulance utilization, the OIG noted that dialysis transports had increased to 19% of all covered ambulance transports in 2011, up from 9% in 2002. Note: in 2014, dialysis transports had dropped to 17.1% of all covered transports, suggesting we may start to see the pendulum shifting back a bit.

Our industry may ultimately look back on 2013 as a tipping point. That year marked the first time that the total volume of BLS non-emergency transports to and from dialysis exceeded the number of BLS non-emergency transports to or from places other than dialysis.

But They don’t Tell the Full Story Either…

While the overall trend has been upwards, the increase in dialysis transports is not a national phenomenon. Rather, this increase is largely confined to a handful of states.

As noted above, Medicare’s payments for dialysis transports increased by approximately $45 million between 2010 and 2014. During that same period, Medicare’s payments for dialysis transports in New Jersey increased by $50.7 million. You read that right, if you exclude New Jersey, total Medicare payments for dialysis would have declined nationwide. If you have ever asked: “Why was New Jersey selected to be one of the initial 3 states for the prior authorization program?”, you have your answer.

Other states that saw significant increases over that period include:

State 2010 Dialysis Payments 2013 (2014)

Dialysis Payments

California $87.7 million $106.0 million
Georgia $25.5 million $69.9 million (2014)
Illinois $13.5 million $19.3 million (2014)
Louisiana $4.0 million $6.4 million
Michigan $12.7 million $17.5 million
New York $23.5 million $30.1 million (2014)
South Carolina $51.1 million $62.4 million
Virginia $25.3 million $30.2 million
West Virginia $7.9 million $9.9 million (2014)

If your state is not one of the ones listed above, chances are Medicare’s payments for dialysis are lower today than they were 5 years ago. This includes a number of states and/or territories that, historically, have been recognized as having a so-called “dialysis problem.” For example, total payments for dialysis have declined in Texas from $86.7 million in 2010 (itself a significant reduction from 2007) down to $53.8 million in 2014. This is likely the result of ongoing enforcement efforts in the state, including a moratorium on the enrollment of new ambulance providers. Pennsylvania, also selected to be part of the initial prior authorization program, saw payments for dialysis transports drop to $39.2 million in 2014, down from $62.6 million in 2010.

As I look at this data, two thoughts come to mind. The first is that, to the extent you agree that there is a problem with dialysis transports (and I am one of those that does), it is clear that the problem is largely confined to a handful of states.

The second is that our overall perspective on our industry may need to change. Traditionally, we have viewed the industry through the prism of “emergency” vs. “non-emergency.” And there are valid operations reasons to distinguish between these two categories. However, I can’t help but wonder if that worldview isn’t overly simplistic these days. Maybe we need to start viewing our industry as having three components, emergencies, non-emergencies, and dialysis.


AAA members, submit a Medicare question to Brian! Not yet a member? Learn more.

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

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

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.

Novitas Issues Guidance for Ambulance Providers, Facilities and Beneficiaries Regarding Expansion of Prior Authorization Project for Repetitive Patients

September 17, 2015

Novitas Solutions, Inc. (Novitas) recently issued a series of guidance documents on the expansion of the prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project is currently operating in the states of New Jersey, Pennsylvania, and South Carolina.

The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. Law 114-10), enacted on April 16, 2015, requires that this program be expanded into the remaining states of MAC Regions L (Delaware, Maryland, and the District of Columbia) and M (North Carolina, Virginia, and West Virginia), effective January 1, 2016. The program will be further expanded to cover all remaining states starting on January 1, 2017.

Novitas is the Medicare Administrative Contractor for MAC Region L, and therefore will be responsible for implementing this program in Delaware, Maryland and the District of Columbia. These guidance documents are intended to educate ambulance services, health care professionals and facilities, and beneficiaries located in these states on the programs requirements.

Guidance Document for Ambulance Services

On August 17, 2015, Novitas issued a “Dear Ambulance Company” letter that provides guidance to ambulance companies on how the program will operate. As noted in the letter, participation is voluntary.

However, ambulance services that elect not to seek prior authorization for repetitive patients (defined as a patient that is transported by non-emergency ambulance for the same service either: (1) three or more times in a 10-day period or (2) once a week for three straight weeks) will find that claims for these patients will be subject to a prepayment review. For this reason, it is anticipated that most ambulance services will elect to seek prior authorization for their repetitive patient population.

The letter further summarizes the documentation requirements needed to request prior authorization for a patient. These include the submission of a prior authorization cover sheet (which can be found on Novitas’ website), a valid Physician Certification Statement (PCS) signed by the beneficiary’s attending physician within sixty (60) days of the requested first transport date, and all other medical records supporting medical necessity.

Novitas will review the submitted documentation and issue either a prior authorization covering all transports within a set date range, or a rejection. To the extent an application is rejected, the provider will be entitled to resubmit the application with additional documentation to support medical necessity.

Guidance Document for Health Care Professionals and Facilities

On August 24, 2015, Novitas issued a “Dear Healthcare Provider/Facility” letter that provides guidance to physicians, healthcare practitioners, and facilities on how the prior authorization project will operate. This letter includes bolded language that indicates that these individuals and facilities must provide certain records to the transporting ambulance service and/or the beneficiary. The letter specifically includes a statement that “[a]ttending physicians must provide a physician certification statement (PCS) and medical records that support medical necessity.” Members may want to download copies of this letter for distribution to physicians and facilities from which they may need to obtain PCS forms and other medical records.

Guidance Document for Beneficiaries

On August 20, 2015, Novitas issued a “Dear Medicare Beneficiary” letter that is intended to educate Medicare beneficiaries on the operation of the prior authorization project. The letter indicates that the pre-approval process is intended to allow the beneficiary to know whether his or her transports will be covered by Medicare prior to the provision of services. The letter indicates that either the beneficiary or the ambulance service can obtain a prior authorization, but notes that the ambulance provider will typically be the one submitting requests. Members may want to download copies of this letter for distribution to beneficiaries and their families.

AAA to hold Prior Authorization Workshop on October 2, 2015

The AAA will be holding a one-day workshop devoted exclusively to the prior authorization program. The workshop will take place on October 2, 2015 at the AAA Headquarters located in McLean, Virginia. This workshop will feature representatives from both Novitas and Palmetto (the MAC for Region M), who will be able to provide additional details on how the project will operate in their areas. Dr. William Rogers from the Centers for Medicare and Medicaid Services will also be in attendance to offer CMS’ perspective on this new program. This is a wonderful opportunity for CEOs and senior ambulance executives in the affected states to hear first-hand how this project will impact their ambulance services.

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