Tag: Washington D.C.

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 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.

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:

  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

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:

  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

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

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.

Stars of Life Recognized for Their Service

EMS professionals from all walks of life descended on the Omni Shoreham Hotel in Washington, D.C., this past week to be honored as the 2017 Stars of Life. The Stars were recognized by the American Ambulance Association (AAA) for their exceptional duty, service, and bravery while serving their communities as EMTs, paramedics, and as other ambulance services members. 107 Stars celebrated this distinction with their friends, family, and peers during the event, held June 12-14, which also shined a light on the importance of the services EMS professionals provide.

The Stars, hailing from across the country, plus Trinidad and Tobago, began their celebration with a luncheon, where their achievements were commemorated with a medal and a pin for their exceptional service. During the luncheon, keynote speaker Zubin Damania, MD, aka ZDoggMD, used humor and songs to address the future of health care and to congratulate the Stars on their award (along with garnering a few laughs) before AAA President Mark Postma presented the Stars with their medals and pins of recognition.

While Damania provided some humor and the Stars spent some time taking in the sights around the nation’s capitol, the following day provided the honorees an opportunity to head down to Capitol Hill to do some more serious work. The Stars met with members of the Senate and the House of Representatives to discuss the importance of EMS-related legislation, such as Medicare ambulance relief and add-on payments. The Stars hoped to convince Congress to support future measures that would provide critical resources and help improve EMS services. In addition to discussing important EMS policies, the Stars were honored by their representatives for their work in their community. Over 100 meetings took place between Stars, the representatives, and their aides.

The final night of the event brought all the Stars together, along with family and friends, during an awards banquet and dinner. During the event, the Stars were presented with plaques and commended for their exemplary work and for being an inspiration to all those working in the EMS field.

Learn more about the 2017 Stars of Life.


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.