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Department of Health and Human Services Extends Deadline to Apply for Provider Relief Funds

Written by Brian Werfel on . Posted in Advocacy Priorities, Government Affairs, News, Regulatory.

The Department of Health and Human Services (HHS) recently announced that it would be extending the deadline for health care providers to apply to receive general distribution funding from the HHS Provider Relief Fund.  The deadline to apply for these funds was previously June 3, 2020.

Relevant Background

On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.  An additional $75 billion was allocated as part of the Paycheck Protection Program and Health Care Enhancement Act, bringing the total “Provider Relief Fund” up to $175 billion.  This $175 billion will be distributed to health care providers and suppliers to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.

HHS ultimately elected to allocate these funds through a $50 billion “general allocation,” and multiple smaller “targeted allocations.”

Under its general allocation program, HHS intended to provide health care providers with funds roughly equal to 2% of the provider’s 2018 “net patient revenue,” i.e., the provider’s total revenues from patient care minus provisions for bad debt, contractual write-offs, and certain other adjustments.   This general allocation was made in two tranches, with the first tranche being distributed to all providers in mid-April.  This first tranche was made based on provider’s 2019 Medicare revenues.  As a result, any provider that received payments from the Medicare Fee-for-Service Program in 2019 automatically received an initial relief payment.  However, HHS required providers to submit an application to receive relief funding as part of the second tranche.  The deadline for applying for the second tranche of relief funding was June 3, 2020.

Scope of New Extension

 HHS indicated that the new extension is limited to health care providers that missed the June 3, 2020 deadline to apply for the second tranche of relief funding.  The extension also applies to providers that were ineligible for the first tranche of relief funding due to a recent change of ownership.  The specific situations that HHS indicated would meet the requirements for the extension include:

  • Health care providers who were ineligible for the first tranche of relief funding because: (1) they underwent a change in ownership in calendar year 2019 or 2020 under Medicare Part A and (2) did not have Medicare Fee-for-Service revenues in calendar year 2019;
  • Health care providers who received a payment in the first tranche of funding but: (1) missed the June 3, 2020 deadline to submit revenue information or (2) did not receive funds in the first tranche that total approximately 2% of their net patient revenue; or
  • Health care providers who received a payment in the first tranche of funding, but who ultimately elected to refund that payment (e.g., because they did not believe they met the eligibility requirements), and who are now interested in reapplying.

Health care providers that meet one of the requirements listed above will have until August 28, 2020 to submit an application for additional relief funds.  This deadline aligns with the extended deadline for other eligible Phase 2 providers, such as Medicaid, Medicaid Managed Care, CHIP, and dental providers.

Applications should be submitted through the CARES Provider Relief Fund webpage, which can be found at: https://cares.linkhealth.com/#/.

Updated CMS FAQs on the Ambulance Data Collection

Written by Kathy Lester on . Posted in Cost Data Collection, Cost Survey, Regulatory.

Updated CMS FAQs on the Ambulance Data Collection System and Reporting Requirement Delay

As we recently reported, CMS announced that it will be delaying the implementation of the statutorily mandated ambulance data collection system.  CMS has released a new set of Frequently Asked Questions (FAQs) clarifying the delay.  In sum, ambulance organizations selected to provide cost data for 2020 will now be required to report 2021 data in Year 2.  CMS will also add a new set of ambulance organizations for Year 2 reporting as well.  This means that twice as many ambulance organizations will be reporting 2021 data in Year 2 and there will be no data reported for 2020.  Any organization selected that does not report data will be subject to the 10 percent penalty, unless an exception applies.  In addition to addressing concerns about reporting during the pandemic, the FAQs suggest that CMS is concerned that 2020 data “may not be reflective of typical costs and revenue associated with providing ground ambulance services.”

The complete list of these questions, as well as previous ambulance FAQs for COVID-19 on Medicare Fee-for-Service (FFS) Billing can be found here.  The new data collections are below.

Data Collection and Reporting Requirements for the Medicare Ground Ambulance Data Collection System

 1. Question: CMS requires selected ground ambulance organizations to collect cost, revenue, utilization, and other information through the Medicare Ground Ambulance Data Collection System. The collected information will be provided to MedPAC, which is required to submit a report to Congress on the adequacy of Medicare payment rates for ground ambulance services and geographic variations in the cost of furnishing such services. Will the data collection and reporting requirements for the Medicare Ground Ambulance Data Collection System be delayed due to COVID-19?

Answer: Yes. CMS has issued a blanket waiver: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration- waivers.pdf due to the PHE for the COVID-19 pandemic. CMS is modifying the data collection period and data reporting period, as defined at 42 CFR §414.626(a), for ground ambulance organizations that were selected by CMS to collect data beginning between January 1, 2020, and December 31, 2020 (Year 1).

Under this modification, these ground ambulance organizations can select a new data collection period that begins between January 1, 2021, and December 31, 2021; collect the necessary data during their selected data collection period; and submit the data during the data reporting period that corresponds to their selected data collection period.

CMS is modifying this data collection and reporting period to increase flexibilities for ground ambulance organizations that would otherwise be required to collect data in 2020–2021 so that they can focus on their operations in support of patient care.

As a result of this modification, ground ambulance organizations selected for year 1 data collection and reporting will collect and report data during the same period of time that will apply to ground ambulance organizations selected by CMS under §414.626(c) to collect data beginning between January 1, 2021, and December 31, 2021 (year 2) for purposes of complying with the data reporting requirements described at §414.626.

For additional information on the Medicare Ground Ambulance Data Collection System, please visit the Ambulances Services Center website at

https://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.

New: 6/16/20

2. Question: Will the 10 percent payment reduction still apply to ground ambulance organizations that are now required to collect and report data under the modified data collection and reporting period but do not sufficiently report the required data?

Answer: Yes. The 10 percent payment reduction described at 42 CFR §414.610(c)(9) will still apply if a ground ambulance organization is selected to collect and report data under the modified data collection and reporting timeframe, but does not sufficiently submit the required data according to the modified timeframe and is not granted a hardship exemption. The payment reduction will be applied to payments made under the Medicare Part B Ambulance Fee Schedule for services furnished during the calendar year that begins following the date that CMS provides written notification that the ground ambulance organization did not submit the required data.

New: 6/16/20

3. Question: The modification states that the ground ambulance organizations that were selected by CMS to collect data beginning between January 1, 2020, and December 31, 2020 (year 1) can select a new continuous 12-month data collection period that begins between January 1, 2021, and December 31, 2021. Do the ground ambulance organizations that were selected in year 1 have an option to continue with their current data collection period that started in early 2020 or choose to select a new data collection period starting in 2021?

Answer: No. The ground ambulance organizations that were selected for year 1 do not have an option and must select a new data collection period that begins in 2021. CMS cannot permit this option because the data collected in 2020 during the PHE may not be reflective of typical costs and revenue associated with providing ground ambulance services. New: 6/16/20

4. Question: Does the guidance mean that there will be no data reporting in 2021 and that both the ground ambulance organizations that were selected for year 1 and the ground ambulance organizations that will be selected for year 2 will collect and report data during the same time periods?

Answer: Yes. Under the modification, ground ambulance organizations that are selected for year 1 will not collect data in 2020. These ground ambulance organizations will select a new data collection period that begins in 2021 and must submit a completed Medicare Ground Ambulance Data Collection Instrument during the data reporting period that corresponds to their selected data collection period. As a result of the modification, year 1 and year 2 selected ground ambulance organizations will collect and report data during the same time periods. New: 6/16/20

Grants and Tax Credits Toolkit

Written by akingump on . Posted in Emergency Preparedness, Legislative, Medicare, Regulatory.

Grants and Tax Credits Toolkit

Download materials from Akin Gump including aid summaries and how-to guides on qualifying for tax credits and deferments and applying for financial assistance.

 

 

HHS Announces Release of Initial Tranche of CARES Act Provider Relief Funding

Written by Brian Werfel on . Posted in Advocacy Priorities, Finance, Government Affairs, Legislative, Medicare, Operations, Patient Care, Regulatory, Reimbursement.

On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.  These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.  These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19.  Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”

On April 9, 2020, the Department of Health and Human Services (HHS) indicated that it would be disbursing the first $30 billion of relief funding to eligible providers and suppliers starting on April 10, 2020.  This money will be disbursed via direct deposit into eligible providers and supplier bank accounts.  Please note that these are outright payments, i.e., these are not loans that will need to be repaid. 

Who is Eligible to Receive Relief Fund Payments?

HHS indicated that any healthcare provider or supplier that received Medicare Fee-For-Service reimbursements in 2019 will be eligible for the initial allocation.  Payments to practices that are part of larger medical groups will be sent to the group’s central billing office (based on Medicare enrollment information).  HHS indicated that billing organizations will be identified by their Taxpayer Identification Numbers (TINs).

Are There Any Conditions to Receipt of this Funding?

Yes.  As a condition to receiving relief funding, a healthcare provider or supplier must agree not to seek to collection out-of-pocket payments from COVID-19 patients that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.

How is the Amount of Relief Funding an Entity will Receive Determined?

HHS indicated that the amounts healthcare providers and suppliers will receive will be based on their pro-rata share of total Medicare FFS expenditures in 2019.  HHS indicated that Medicare FFS payments totaled $484 billion in 2019.

Providers and suppliers can estimate their initial relief payment amount by dividing their 2019 Medicare FFS reimbursement by $484 billion, and then multiplying that “ratio” by $30 billion.  Note: payments from Medicare Advantage plans are not included in the calculation of a provider’s/supplier’s total 2019 Medicare payments.

As an example, HHS cited a community hospital that received $121 million in Medicare payments in 2019.  HHS indicated that this hospital’s ratio would be 0.00025.  That amount is then multiplied by $30 billion to come up with its initial relief fund payment of $7.5 million.

The AAA has created a CARES Act Provider Relief Calculator
that you can use to estimate your initial relief payment.  |
USE DOWNLOADABLE EXCEL CALCULATOR►

Do I Need to do Anything to Receive Relief Funds?

No.  You do not need to do anything to receive your relief funding.  HHS has partnered with UnitedHealth Group (UHG) to disburse these monies using the Automated Clearing House (ACH) system.  Payments will be made automatically to the ACH account information on file with UHG or CMS.

Providers and suppliers that are normally paid by CMS through paper checks will receive a check from CMS within the next few weeks.

How Will I Know if I Received My Relief Funds?

The ACH deposit will come to you via Optum Bank.  The payment description will read “HHSPayment.”

Do I Need to do Anything Once I Receive My Relief Funds?

Yes.  You will need to sign an attestation statement confirming relief of the funds within 30 days.  These attestations will be made through a webportal that HHS anticipates opening the week of April 13, 2020.  The portal will need to be accessed through the CARES Act Provider Relief Fund webpage, which can be accessed by clicking here.

You will also be required to accept the Terms and Conditions within 30 days.  Providers and suppliers that do not wish to accept these terms and conditions are required to notify HHS within 30 days, and then remit full repayment of the relief funds.  The Terms and Conditions can be reviewed by clicking here.

How will HHS Distribute the Remaining $70 Billion in Relief Funds?

HHS has indicated that it intends to use the remaining relief funds to make targeted distributions to providers in areas particularly impacted by the COVID-19 outbreak, rural providers, providers of services with lower shares of Medicare reimbursement or who predominantly serve Medicaid populations, and providers requesting reimbursement for the treatment of uninsured Americans.

CMS Announces Delay to ET3 Start Date

Written by Brian Werfel on . Posted in Medicare, Operations, Patient Care, Regulatory, Reimbursement.

On April 8, 2020, the Centers for Medicare and Medicaid Services (CMS) announced that it will be delaying the start of the Emergency Triage, Treat and Transport (ET3) Model until Fall 2020.  The ET3 Model was previously set to start on May 1, 2020.  CMS cited the national response to the COVID-19 pandemic as the reason for this delay.

In its delay notice, CMS also reminded the EMS industry that it has issued a number of temporary regulatory waivers and new rules that are designed to give health care providers and suppliers maximum flexibility to respond to the current national emergency.  This includes a number of flexibilities offered specifically to the ambulance industry.

CMS Waives Restrictions on Ground Ambulances During COVID-19 Pandemic

Written by Kathy Lester on . Posted in Government Affairs, Operations, Patient Care, Professional Standards, Regulatory.

The Centers for Medicare and Medicaid Services (CMS) promulgated an interim final rule with comment period (IFC) entitled “Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.”  Consistent with the recommendations the AAA made to CMS, for the duration of the public health emergency (PHE), the IFC allows ground ambulance service providers and suppliers to transport patients both on an emergency or non-emergency basis to any destination that is equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished.  In related guidance, CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic, waived patient signature requirements, and is pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model. The policies of the IFC are effective retroactively to March 1, 2020.

On March 11, the AAA sent CMS a letter specifically requesting for the agency to waive during the COVID-19 pandemic the regulatory restrictions that prevent coverage for transport to alternative destinations.  Separately, the AAA has been pressing CMS to provide relief from signature requirements. The AAA had also been working with CMS to lifting of these restrictions and others to eliminate barriers the current Medicare regulations in responding to the COVID-19 crisis.

Paying for Transports to Alternative Destinations.  During the duration of the crisis, CMS has expanded the list of destinations for which Medicare covers ambulance transportation to include all destinations, from any point of origin, that are equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished.

These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH) or skilled nursing facility (SNF), community mental health centers, federal qualified health clinic (FQHCs), rural health clinics (RHCs), physicians’ offices, urgent care facilities, ambulatory surgery centers (ASCs), any location furnishing dialysis services outside of an ESRD facility when an ESRD facility is not available, and the beneficiary’s home.

This expanded list of destinations applies to medically necessary emergency and non-emergency ground ambulance transports of beneficiaries during the PHE for the COVID-19 pandemic.  The IFC does not waive the medically necessary requirements for ground ambulance transport of a patient in order for an ambulance service to be covered.

The AAA is working closely with CMS to confirm that patients who require isolation meet the medical necessity requirements.

Suspension of Audits and Relief on Patient Signatures.  In guidance released separately, CMS indicates that it is suspending nearly all audits of providers and suppliers for the duration of the PHE.

CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.

CMS also indicates in this guidance that a beneficiary’s signature will not be required for proof of delivery, as it relates to durable medical equipment services, during the PHE.  In a follow-up exchange with CMS, the AAA has confirmed that this policy of not requiring a beneficiary’s signature also applies to ground ambulance providers and suppliers. The AAA has requested that this clarification for ground ambulances also be provided in a written FAQ.

Pause in the Non-Emergency Prior Authorization Model.  CMS has paused the claims processing requirements for the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model, effective March 29 until the end of the PHE.  During this pause, claims for repetitive, scheduled non-emergent ground ambulance transports for the COVID-19 pandemic in States in which the model operates will not be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period. During the pause, the MAC will continue to review any prior authorization requests that have already been submitted, and ambulance suppliers may continue to submit new prior authorization requests for review during the pause. Claims that have received a provisional affirmative prior authorization decision and are submitted with an affirmed unique tracking number (UTN) will continue to be excluded from future medical review. Following the end of the PHE for the COVID-19 pandemic, the MACs will conduct postpayment review on claims otherwise subject to the model that were submitted and paid during the pause.

Telehealth Services.  While CMS does not provide authority for ambulance organizations to bill directly for telehealth services, it does modify for the duration of the PHE the “direct supervision” requirements to allow physicians enter into a contractual arrangement with an entity that provides ambulance services to allow the physician to use the ambulance organization’s personnel as auxiliary personnel under a leased agreement.  Under such circumstances, the provider or supplier would seek payment for any services it provided from the billing physician and would not submit claims to Medicare for such services directly.

Ongoing work of the AAA.  The rule does not address two critical issues:  (1) reimbursement for treatment in place and (2) direct reimbursement for telehealth services.  The AAA will continue to work with CMS and the Congress to address these issues that are critical to meeting the needs of patients and your community during the epidemic.

URGENT – CALL TO ACTION Congress Still Negotiating Stimulus Package Ambulance Specific Relief Not Yet Included: Act Now!

Written by on . Posted in Advocacy Priorities, Executive, Government Affairs, Legislative, Regulatory, Reimbursement.

None of the proposals offered so far on an economic stimulus package to address the impact of COVID-19 include our specific provisions to provide ambulance relief! Negotiators on a final package failed to reach an agreement over the weekend. There is still time to influence the final outcome! Please write to your members of Congress!

There are provisions in the packages that would help businesses, first responders and Medicare providers and suppliers. However, the AAA is advocating for specific help for ambulance services with the prioritization of COVID-19 resources, coverage of services, as well as direct financial assistance. The Congress has heard directly from the AAA about our requests and they need to hear from their constituents about assistance to your operations. If you have not yet contacted your members of Congress, please do so today!

Please e-mail today the health aides for your members of Congress!

It will take you only a few minutes per congressional office to email a letter. Just follow these steps.

1. USE LETTER TEMPLATE: CLICK HERE to access a draft letter. Please customize your letter including the cities and towns you serve, if you are sending to the office of a Senator or Representative and any additional details as to services you are providing during the COVID-19 outbreak and the financial impact on your operation.

2. LOOK UP HEALTH STAFFER AND EMAIL ADDRESS: CLICK HERE to access a list of the name of the health staffer and email address for all congressional offices.

3. SEND E-MAILS TO STAFFERS: Copy and paste the email address of the health staffer and copy and paste the letter as the body of the e-mail and send.

While the Congress may not include all of our requests in this stimulus package, there are likely to be future legislative vehicles in which the AAA will continue to press for passage of additional relief for ambulance service organizations and personnel.

AAA Sends Letter to CMS on COVID-19 Response

Written by on . Posted in Government Affairs, Legislative, Member Advisories, Member-Only, News, Regulatory.

The AAA has sent a letter to CMS on how the agency can most help ground ambulance service providers and suppliers be better prepared to respond to potential cases of COVID-19. The AAA has requested priority access to personal protection equipment for EMS personnel and COVID-19 test kits and results, as well as easing Medicare and Medicaid policies on alternative destinations and treatment in place. The letter was also sent to the National Highway Traffic Safety Administration (NHTSA) and the Assistant Secretary for Preparedness and Response (ASPR). Read the letter HERE.

Read the Letter

COVID-19 Update II for EMS

Written by Rob Lawrence on . Posted in Emergency Preparedness, Patient Care, Regulatory.

First Case of 2019 Novel Coronavirus in the United States

The New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County WA ‘Patient 1’. This was the first reported case of COVID 19 in the US. This seminal document, which given the magnitude of the case and its initial findings is released in full here

The work by Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, et al for the Washington State 2019-nCoV Case Investigation Team was turned round in just over 5 weeks and below is an ‘Executive summary’ ( as extracted from the paper) but the full paper and range of results should be read in full.

Patient Presentation

On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.

On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.

Viral Presence

Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24).

Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).

Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus

Day 8: Condition Improves

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.

History Taking

This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.

Conclusion

There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID 19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken

 

Sample COVID-19 Policies for Mobile Healthcare Providers

Thank you to the following organizations for sharing their policies as examples.
Global Medical Response maintains a COVID-19 page to provide information to all members of the GMR community—clinicians and non-clinicians.

Updates from GMR Chief Medical Officer, Dr. Ed Racht

GMR Procedures

General Information for Caregivers

Compliance

HIPAA Reminder

FirstWatch Solutions

The intention of the COVID-19 Process/Policy Template is to provide agencies, medical directors, or others who want to utilize it, an outline/template on which to build an agency-specific policy/protocol to address COVID-19. This includes suggestions for development and/or oversight committees, outside partners and stakeholders, as well as preparation and process for EMS workers who provide best practice care for patients as well as providing for the protection of pre-hospital providers and medical director(s). Its application is totally up to the user.

This document is meant to be a living document that can be revised as circumstances or guidance changes. It can also be a discussion piece for those who choose to develop a different type of policy but may want to use some of the components of the document as a starting point.

Agency Guidance
CDC Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States
NEW March 6, 2020: CMS COVID-19 FAQs for Healthcare Providers (PDF Download)

March 5, 2020: CMS issued a second Healthcare Common Procedure Coding System (HCPCS) code for certain COVID-19 laboratory tests, in addition to three fact sheets about coverage and benefits for medical services related to COVID-19 for CMS programs.  https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests

March 4, 2020: CMS issued a call to action to healthcare providers nationwide and offered important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare. https://www.cms.gov/newsroom/press-releases/cms-announces-actions-address-spread-coronavirus

February 13, 2020: CMS issued a new HCPCS code for providers and laboratories to test patients for COVID-19.  https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test

February 6, 2020: CMS gave CLIA-certified laboratories information about how they can test for SARS-CoV-2. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/notification-surveyors-authorization-emergency-use-cdc-2019-novel-coronavirus-2019-ncov-real-time-rt

February 6, 2020: CMS issued a memo to help the nation’s healthcare facilities take critical steps to prepare for COVID-19.  https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/information-healthcare-facilities-concerning-2019-novel-coronavirus-illness-2019-ncov

Member Advisory: CMMI Releases Initial List of ET3 Participants

Written by Tristan North on . Posted in ET3, Government Affairs, Member Advisories, Member-Only, News, Regulatory, Reimbursement.

The Centers for Medicare and Medicaid Services (CMMI) has released its initial list of applicants selected to participate in the ET3 pilot program. CMMI notes that the list is not final as it still needs to execute participation agreements with the applicants. CMMI will issue a final list once it completes the process.

Applicants from 36 states and the District of Columbia were selected to participate in the program. Approximately 200 applicants were approved with instances in which the same ambulance service organization submitted applications for multiple counties as well as more than one organization submitting an application for the same county. CMMI has sent notifications to each of the applicants letting them know to expect a follow up email with the partnership agreement, program guidance and additional details.

The ET3 program is a five-year voluntary pilot program designed to test the potential benefit to the Medicare program and patients of ambulance service providers and suppliers furnishing treatment in place as well as transport to alternative destinations. For more information about the ET3 program, please go the ET3 website.

CMS Announces New Healthy Adult Opportunity Initiative

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

On January 30, 2020, the Centers for Medicare and Medicaid Services (CMS) announced the roll-out of its “Healthy Adult Opportunity” (HAO) initiative.  Under the initiative, participating states will have a portion of their current federal Medicaid funding converted to block grants.  In return, the states will gain greater flexibility in providing for the health care needs of certain portions of their existing Medicaid populations.

In a letter directed to State Medicaid Directors, CMS outlined the details of how the HAO initiative would operate.  The initiative will be operated under CMS’ 1115 waiver authority.  In order to participate, a state must submit an application setting forth the specific demonstration projects it intends to implement.  CMS reiterated that participation in the HAO initiative is voluntary.  CMS further indicated that it will review state applications on a case-by-case basis and make an independent decision on whether the proposed policies merit approval.  States with existing Section 1115 waivers that cover eligible populations will be permitted to transition existing demonstrations into the HAO initiative.

CMS indicated that HAO demonstrations will generally be approved for an initial 5-year period, and successful demonstrations may be renewed for a period of up to 10 years.

A summary of some of the major provisions of this initiative is provided below.

Federal Funding

The Medicaid Program is a joint federal and state program that provides free or low-cost health coverage to nearly 65 million Americans.  The Program is administered by each state, with the federal government reimbursing states for a percentage of their qualifying Medicaid expenditures.  The amount of federal matching funds is based on a statutory formula that compares a state’s per capita income to the national average.  States with lower per capita incomes receive a higher Federal Medical Assistance Percentage (FMAP).  FMAPs range from 50% to a maximum of 83%.  In addition, the federal government provides higher matching rate (called an Enhanced FMAP) for certain services or populations.  For example, the federal government currently pays 90% of the costs of providing health care to those covered by the Medicaid expansion included in the Affordable Care Act.

Under the HAO initiative, participating states would forego the FMAP for certain Medicaid populations.  Instead, these states would receive a fixed amount of federal funding (i.e., a block-grant), which will be calculated based on either a total expenses or per-enrollee basis.  To the extent the state spends more than its budgeted amount, it would not be eligible for additional federal matching funds.  To the extent the state ends up spending less than its budgeted amount, the state would participate in the cost-savings.

Eligible Medicaid Populations

The HAO initiative is focused on the non-mandatory adult Medicaid populations, i.e., individuals that are under the age of 65, and who are not eligible for Medicaid on the basis of disability, or their need for long term care, and who are not otherwise eligible under a State Medicaid Plan.  In other words, this initiative is largely targeted at those individuals that become eligible for Medicaid as a result of the Affordable Care Act.

Benefit Package Design

Under the HAO initiative, states will have the ability to design benefit packages that closely resemble the benefit packages provided by private insurers.  At a minimum, this would include benefit packages that cover all of the Essential Health Benefits (EHBs) required for commercial insurances sold on the State ACA Exchanges.  States may also design federally qualified health center coverages that facilitate the use of value-based payment design among safety-net providers.

Beneficiaries that are shifted into HAO demonstration projects will retain certain beneficiary protections, including all federal disability and civil rights laws, fair hearing rights, and limits on their mandatory cost-sharing amounts.

Coverage of Prescription Drugs

One major change would be to state’s coverage of prescription drugs.  The initiative would give states the flexibility to offer formularies under an HAO demonstration project similar to those provided in commercial health insurance markets.  This would remove the current mandate that states provide a so-called “open formulary.”  States that elect to establish their own formulary would be required to comply with the EHB requirements regarding prescription drug benefits.  States would also be required to cover substantially all drugs used to treat: (1) mental health disorders (i.e., antipsychotics and antidepressants), (2) HIV (i.e., antiretroviral drugs), and (3) opioid use disorders (i.e., all forms, formulations, and delivery mechanisms) where there are rebate agreements in place with the manufacturers.

In theory, this would permit states to cover only a single drug for many pharmaceutical classes.

Cost-Sharing Amounts

States would have the flexibility to impose additional cost-sharing obligations on beneficiaries covered under a demonstration program, subject to two broad limitations:

  1. Aggregate out-of-pocket costs for beneficiaries covered under an HAO demonstration must not exceed 5% of the beneficiary’s household income, measured on a monthly or quarterly basis; and
  2. Premiums and cost-sharing charges for tribal beneficiaries, those beneficiaries living with HIV, those beneficiaries needing treatment for substance use disorders, and the cost-sharing charges for prescription drugs used to treat mental health conditions must not exceed amounts permitted under the implementing regulations. States would also not be permitted to suspend enrollment for these individuals if they fail to pay their premiums or cost-sharing amounts.

Wrap-Around Services (Including NEMT)

States would be given the flexibility to discontinue the coverage of Alternative Benefit Plan wrap-around services, including non-emergency medical transportation (NEMT) and early and periodic screening, diagnostic and treatment services (EPSDT) for individuals aged 19-20.

Ambulance Cost Collection Rule Summary

Written by Kathy Lester on . Posted in Cost Data Collection, Cost Survey, Member-Only, Regulatory.

The proposed rule sets the foundation for the data collection system for ground ambulances.  It proposes a stratified random sample method, that is very similar to the one the AAA proposed via the work we commissioned through The Moran Company. We are working through the stratification categories, which are slightly different than those we identified.

CMS also proposes the cost and revenue data elements it plans to use.  There are some details in the proposed rule text and others will be in the proposed tool that will be posted the CMS website today.

CMS also proposes the collection period and penalties for failing to report.

While the data collection provision was the key component for ground ambulance services, CMS also proposed changes to the PCS requirement sought by the AAA. CMS is proposing to reference the PCS also as non-physician certification agreements. The agency is further proposing to clarify that the focus is on the certification of the medical necessity provisions and the form of the certification statement is not prescribed.  As part of the non-physician statement, CMS is proposing expanding the staff of you may sign the statement when an attending physician is unable to sign.

Download Full PDF Summary by Kathy Lester, Esq.

CMS Releases Proposed Cost Collection Rule

Written by Aidan Camas on . Posted in Cost Data Collection, Government Affairs, Legislative, Member Advisories, News, Regulatory.

Today, CMS has released the proposed rule that would establish the ambulance fee schedule cost collection system as required by statute. The AAA is currently reviewing the rule and will provide a more detailed summary in the coming days.

On Tueusday, July 30 at 12:00pm Eastern, the AAA will be hosting a free webinar during which AAA counsel will provide an overview of the proposals in the rule. Do not miss out on this chance for the most up to date information.

Read the Proposed Rule

Sign Up for the Webinar

Questions?: Contact Us:

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

Rural Health Day Advocacy Update

Written by Kathy Lester on . Posted in Advocacy Priorities, Government Affairs, Legislative, Member Advisories, Member-Only, News, Regulatory, Reimbursement.

Happy National Rural Health Day! Thank you to all of the ambulance service providers who work hard providing life-saving treatment in rural areas every day.

In part of our ongoing advocacy efforts, the AAA sent a letter today to the Rural Caucuses in the United States Senate and House of Representatives. Addressed to leadership of the caucuses, Sen. Pat Roberts (R-KS), Sen. Heidi Heitkamp (D-ND), Rep. Adrian Smith (R-NE), and Rep. Tim Walz (D-MN), this in-depth letter highlights the critical work that our members do every day around the country and raises important issues affecting the industry. Issues covered in the letter include:

Stabilizing the Ambulance Fee Schedule
  • Make the add-ons permanent and build them into the base rate
  • Use new data from the ambulance cost collection program to ensure reimbursement is adequate going forward
  • New data should be used to assess the problems with the current ZIP-code methodology for determining rural and super-rural services
Ambulance Fee Schedule Reform
  • Proposed alternative models for rural ambulance services
  • Encouraging Congress to look at alternative destination options for ambulance service providers
Recognizing Ambulance Services as Providers of Health Care
  • Moving non-fire-based ambulance services from suppliers to providers under Medicare

The letter also highlights some of the burdensome regulations facing ambulance service providers that the AAA has recommended Congress address through its Red Tape initiative. These include:

Removing Unnecessary Regulatory Burdens:
  • Reduce the burdens created by the Physician Certificate Statement
  • Simplify the 855B Ambulance Enrollment Form
  • Address burdensome requirements of the patient signature on claims and the strict application of the revocation of billing authority

This letter from the AAA to Congressional leaders is just one part of the AAA’s ongoing effort to educate Congress on the crucial role ambulance service providers play in America’s healthcare system. The AAA wants Congress to know that in many rural areas of the country, ambulances are the medical safety net, yet face extreme challenges to staying in business thanks to below cost reimbursement and burdensome regulations. The AAA will continue to pursue this list of priorities with our members next year and going forward.

Read the Full Letter

Again, Happy Rural Health Day to our members – thanks for all that you do!

If you have any questions about our letter or rural advocacy, please contact us:

Questions?: Contact Us

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

MedPAC Examines Beneficiary Use of Emergency Departments

Written by Kathy Lester on . Posted in Medicare, Member Advisories, Member-Only, Regulatory, Reimbursement.

During its October meeting, the Medicare Payment Advisory Commission (MedPAC), reviewed Medicare’s current policies related to non-urgent and emergency care, as these topics relate to the use of hospital emergency departments (EDs) and urgent care centers (UCCs). The Commission is examining this topic because the use of ED services in recent years has grown faster than that of physician offices.  At the same time, the share of ED visits that are coded as high acuity has increased.

The Commission is exploring Medicare beneficiaries’ use of EDs and UCCs for non-urgent services. In addition, the Commission is analyzing ED coding to determine if the increase in coding high-acuity visits reflects real change in the patients treated in EDs. This slide deck shows the potential savings Medicare could realize if beneficiaries shift certain care to the UCC setting.

During the meeting, the staff sought feedback from Commissioners for developing next steps. This topic will likely continue to be addressed in future meetings.

From the perspective of ambulance payment reform, the observations made by the Commissioners and staff would also seem to support incorporating scope-appropriate ambulance services in the context of community paramedicine or treatment at the scene with referral. While additional work needs to be done by the ambulance community before these services can be incorporated into the Medicare reimbursement program, discussions like the one at MedPAC last week, show the importance of getting the details right so that ambulance services can be part of new payment models likely to be considered.

The American Ambulance Association is leading the effort with the Medicare program to develop appropriate models that account for the cost of providing services through sustainable reimbursement rates, rather than the use of temporary grants. We are also focused on ensuring services align with the scope of practice laws. Led by the Payment Reform and the Medicare Regulatory Committees, our efforts include regular meetings and discussions with leaders at the Centers for Medicare & Medicaid Services, as well as key Members of Congress. Follow us on Facebook and Twitter to learn more about our ongoing efforts.

Government Affairs Update

Written by Tristan North on . Posted in Advocacy Priorities, Government Affairs, Member-Only, News, Regulatory.

Government Affairs Update: What We’re Working On

The AAA continues to press policy initiatives with Congress and the Administration that are important to our members. While not as high-profile as our successful efforts earlier this year on the five-year extension of the Medicare ambulance add-ons, the AAA is working hard on ambulance legislation and regulations that impact the EMS industry and ambulance services across the country. Here is a snapshot of those current efforts. Over the next month, we will be providing weekly in-depth updates highlighting these issues.

Ambulance Cost Data Collection System

The AAA was successful in getting our preferred language of an ambulance cost data collection system using a survey and random sample methodology included with the extension of the add-ons in the Bipartisan Budget Act of 2018. However, that was just the first key step in the process. We now need to ensure that CMS gets the details right as the agency develops the structural specifics and data elements for the system. It is critical that the system is designed in a way that ambulance service suppliers and providers will submit the most accurate data possible.

The data will ultimately provide the information necessary for Congress, the Centers for Medicare and Medicaid Services (CMS) as well as the AAA and other stakeholders to reform the Medicare ambulance fee schedule. Reform will include potential reimbursement for services such as community paramedicine, treat and refer, and other items that don’t involve transporting the patient.  However, in order to determine the reimbursement levels, we first need the data on what it could cost for these additional services. The AAA therefore has been working closely with officials at CMS on the development of the data collection system.

Medicare Community Bill

The five-year extension of the add-ons and authorization of data cost collection system were the first steps needed in the long-term goal of reforming the Medicare ambulance fee schedule. The AAA is now developing the next piece of legislation as step two of the process. The “Community Bill” would make the Medicare ambulance add-ons permanent, treat ambulance service suppliers like providers in three specific instances, direct the Centers for Medicare and Medicaid Services (CMMI) to do additional pilot programs on innovative services being done by ambulance agencies, reduce regulatory burdens, and implement a more accurate definition of what Goldsmith Modification zip codes should remain as rural. The AAA is currently developing the draft bill and reaching out to congressional offices regarding the introduction of the bill which will likely occur early next Congress.

Restructuring of Dialysis Offset

The AAA is supporting the efforts of our members who would be significantly adversely affected by the upcoming reduction in dialysis transport reimbursement to restructure the cut. Congress included in the Bipartisan Budget Act of 2018 an offset to go along with the extension of the add-ons that will cut reimbursement for BLS nonemergency transports to and from dialysis centers by an additional 13%. This will be on top of the existing 10% reduction.  The NEATSA Act (H.R.6269) by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) 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. The cut is currently scheduled to be implemented on October 1 and impacted AAA members and the AAA are working to get a Senate companion bill introduced shortly.

Rural EMS Grant Program

As an amendment to the Farm Bill (S. 3042) that passed the Senate, Senator Dick Durbin (D-IL) included language similar to the SIREN Act (S. 2830, H.R. 5429) to reauthorize the Rural EMS Grant program. However, in an effort to ensure the funding would go to the most needy, small, and rural EMS providers, the language of the amendment and SIREN Act would change the eligibility to just governmental and non-profit EMS agencies. Therefore, small rural for-profit ambulance service providers would no longer be eligible to apply for grants.

The AAA is pressing Senator Durbin as well as other members supportive of the reauthorization to revise the language to ensure small rural for-profit providers would still be able to apply for grants. In the next few weeks, the AAA will be asking AAA members to reach out to their members of Congress in support of the final Farm Bill including the reauthorization language and that it continues to also apply to for-profit providers as well.

Easing Regulatory Burdens

Over the last year, the AAA has responded to several requests for information from CMS as well as Congress on how to ease regulatory burdens for Medicare providers and suppliers. In addition to these broader opportunities, representatives of the AAA and our members have been meeting with CMS officials to reduce burdens for our industry. As a specific example, we are pushing for the elimination of the PCS for interfacility transports and to expand the categories of facility personnel eligible to sign the form.

Protecting Non-Emergency Ambulance Services

The AAA continues to educate members of Congress and congressional staff about the importance of non-emergency ambulance services. We are providing congressional offices with a clearer picture as to the vital role of these transports as part of the overall health care system. We are also looking to ensure that changes in federal payor policies strengthen the role and distinction of non-emergency ambulance transports from non-medical transportation services to health care facilities.

Zip Code Changes

The current use of Rural-Urban Commuting Areas (RUCA) as the basis of the Goldsmith Modification for determining rural areas in larger urban counties needs to be reformed. There are numerous examples of zip codes that are designated as urban under the Medicare ambulance fee schedule that are clearly rural. The AAA Rural Task Force is leading the way on both short-term and long-term efforts to more accurately capture rural zip codes in large urban counties. The AAA will include the ultimate reform provision crafted by the Task Force within the Community Bill as well as look at other legislative opportunities to make the changes.

Questions?: Contact Us

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (703) 610-0216

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (703) 610-5821

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (703) 610-9039

Thank you for your continued membership and support.

CMS Non-Emergency Ambulance Transport Open Door Forum 7/26

Written by Kathy Lester on . Posted in Medicare, Member Advisories, Member-Only, News, Regulatory.

CMS Issues Data Elements and Templates for Non-Emergency Ambulance Transports (NEAT): Open Door Forum for
Thursday, July 26, 2018 Just Announced

As part of its Patients Over Paperwork Project, the Centers for Medicare & Medicaid Services (CMS) Provider Compliance Group (PCG) has been hosting quarterly listening sessions and reviewing the Request for Information submissions. The American Ambulance Association has been actively engaged in these efforts, highlighting the recommendations we submitted to CMS and the House Ways & Means Committee last year. These recommendations included suggestions as to how CMS could streamline regulatory requirements to eliminate duplicative requirements and reduce regulatory burdens.  In addition to these efforts, CMS has been working to standardize documentation data elements and establish templates that providers and suppliers can use to help make the current documentation processes less burdensome as well.

On July 24, CMS released draft documentation-related clinical data elements and clinical templates that could be used for the Physician Certification Statement, Progress Notes, and Prior Authorization requests. View the Documents. These documents are not intended to change current law.

CMS also announced yesterday that it will discuss the templates on a Special Open Door Forum which is scheduled for July 26 at 2-3 pm ET.  The call-in information is:

  • Participant Dial-In Number: 1-(888)-989-4575
  • Conference ID: 3068545

We have shared our concern about the short notice about the call and CMS has indicated it will continue to take comments on the documents after the call as well. The AAA is in the process of reviewing these documents closely and will develop a written comment letter to provide to CMS after the call on Thursday. We welcome input from all our members as part of this process.

While these new documents may be helpful for many services, the AAA also remains committed to move its recommendations which would result in some changes in the PCS and other ambulance provider and supplier requirements.

 

 

Talking Medicare: A Good Thing Poorly Explained

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

On April 13, 2018, CMS released two Transmittals, Transmittal 243 and Transmittal 4021, and a related MedLearns Matter Article (MM10550). Collectively, these documents clarify Medicare’s coverage of ambulance transportation of SNF residents in a stay not covered by Part B, but who have Part B benefits, to the nearest supplier of medically necessary services that are not available at the SNF. This clarification relates to both the ambulance transport to the site of medical care, and the return trip.

In order to properly understand the clarification, it is helpful to review Medicare’s coverage of ambulance transportation provided to SNF residents. At the onset, it is important to note that Medicare draws a distinction between the first 100 days of a beneficiary’s SNF stay, and any subsequent days of the same stay. The first 100 days are commonly referred to as the “Part A Period.” Under current Medicare rules, all ambulance transportation provided during the Part A Period is the financial responsibility of the SNF, unless a specific exemption applies. Outside the Part A Period, Medicare’s coverage rules generally mirror the rules applicable to ambulance transports that originate at the patient’s residence. However, there is an exception that relates to transportation to and from therapeutic or diagnostic sites (i.e., those facilities identified with the “D” modifier). This clarification relates to transportation to and from diagnostic sites.

Medicare rules are clear that transportation of an SNF resident outside the Part A Period for the purpose of receiving medically necessary care that could not be provided at the SNF will be covered to the extent the ambulance transportation was both medically reasonable and necessary. This is true regardless of the type of facility to which the patient is transported. In this context, the term “reasonable” refers to the costs of transporting the patient to the site of medical care. Where it is cheaper to bring the patient to the service (e.g., an MRI or CT scan), Medicare will cover the service. Where it is cheaper to bring the service to the patient (e.g., certain minor procedures), Medicare rules indicate that the transportation would not be covered.

In other words, once an SNF resident is outside the Part A Period, Medicare will cover a medically necessary ambulance transport to a diagnostic site provided that it is cheaper to transport the patient to that site than to transport the equipment needed to provide care to the SNF.

As you can imagine, determinations as to the reasonableness of a particular service can be quite subjective. Moreover, these determinations can typically only be made on a case-by-case basis, i.e., it is extremely difficult for Medicare Administrative Contractors to make such decisions without seeing the ambulance trip report and other supporting documentation. As a result, CMS has historically given its MACs broad discretion to make these determinations.

The MACs have elected to utilize this discretion in various ways. Some MACs have essentially elected to rely upon the ambulance provider to make such determinations prior to submitting the claims. These MACs have therefore elected not to implement front-end edits for such claims.

Other MACs have elected to issue an initial denial, and handle reasonableness determinations through the appeals process. These MACs do so by implementing edits into their claims processing system that automatically deny claims submitted with the “ND” modifiers. However, because Medicare coverage rules indicate that transportation from anywhere to an SNF may be covered, these MACs do not have a corresponding edit to deny claims submitted with the “DN” modifiers.

The result is various inconsistencies in the ways claims for these situations are handled. Depending on the MAC jurisdiction in which you operate, a claim for an ambulance transport from an SNF to a diagnostic site (“ND”) for a beneficiary outside the Part A Period may be paid or denied. For those of you that operate in jurisdictions where the MAC denies this claim, you may also see the return trip either paid or denied. Note: if the transportation to the diagnostic site is denied as not being “reasonable,” the return trip should be denied as well.

It is these inconsistencies that CMS is addressing. Essentially, CMS is instructing those MACs that use claims processing edits to deny the “ND” transport to remove those edits. The practical effect is to force the MACs to use some other criteria to determine whether the roundtrip is reasonable (and, therefore, covered by Medicare Part B).

Please note that the coverage rules and clarification summarized above applies only to therapeutic and diagnostic facilities. It does not apply to ambulance transportation to and from a physician’s office. With the narrow exception of emergency ambulance transportation to a physician’s office as an interim stop on the way to a hospital, such transportation has always been and remains a non-covered service.

While I believe the change is, on net, a positive one for the industry, I would caution against reading too much into this clarification. CMS is not indicating that these transports will be covered in all instances. CMS is simply saying that, with respect to the initial processing of claims, it is willing to sacrifice some potential accuracy for the sake of greater national consistency. CMS in not restricting its MACs from using other means to make reasonableness determinations, e.g., the use of development requests, prepayment review, etc. While it is reasonable to assume that most MACs will elect not to utilize these tools, only time will tell if that is indeed what comes to pass. In the meantime, I am going to enjoy one of those rare instances where CMS used common sense, and removed an additional burden on our industry.

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

Is the TX Moratorium Ending?

Written by Brian Werfel on . Posted in Regulatory.

Is CMS Ending the Temporary Moratorium on Enrollment of New Non-Emergency Ground Ambulance Providers in Texas?

On September 2, 2017, the Centers for Medicare and Medicaid Services (CMS) posted a notice on its website that it was lifting the temporary moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017.  CMS indicated that the lifting of this temporary moratorium was intended to aid in the disaster response to Hurricane Harvey.

For reasons I will discuss in greater detail below, this explanation has struck a number of commentators as curious.  These commentators have speculated that this may notice may foretell a permanent elimination of the enrollment moratorium for non-emergency ground ambulance providers in Texas.

Background on Temporary Moratorium on New Enrollments in Texas

The Affordable Care Act granted CMS several new tools to combat fraud, waste, and abuse in the Medicare, Medicaid, and Children’s Health Insurance Programs.  This included Section 6401(a), which granted the CMS Secretary the authority to impose temporary moratoria on the enrollment of new Medicare, Medicaid, or CHIP providers to the extent the Secretary determined that doing was necessary to prevent fraud and abuse.

The implementation of the first enrollment moratorium under this new authority was made on July 30, 2013, when CMS announced enrollment moratoria on new home health agencies in Chicago, Illinois, and Miami, Florida, as well as on new ground ambulance suppliers in the Houston, Texas metropolitan area.  On January 30, 2014, CMS expanded the enrollment moratorium on new ground ambulance suppliers to the Philadelphia, Pennsylvania metropolitan area.  CMS subsequently extended these enrollment moratoria every 6 months thereafter, up to July 29, 2016.  On that date, CMS announced that it was making several significant changes to the enrollment moratoria:

  1. It was lifting the moratoria on the enrollment of new emergency ground ambulance suppliers in both areas;
  2. At the same time, it was expanding the moratorium on the enrollment of new non-emergency ground ambulance suppliers to the entire states of New Jersey, Pennsylvania, and Texas.

CMS further announced the creation of an “Enrollment Moratoria Access Waiver Demonstration” program that would permit non-emergency ambulance providers in those states to apply for a waiver (i.e., to permit them to enroll in the Medicare, Medicaid, or CHIP Programs) to the extent they could demonstrate an access to care issue.

Temporary Lifting or Permanent Elimination?

The Medicare enrollment process is a lengthy one.  Following the submission of an enrollment form (CMS-855b), it typically takes the Medicare contractor up to 60 days to review the form and approve it.  Moreover, the Medicare contractor will frequently request additional information, which can add up to several months to the process.  Once approved by the Medicare contractor, the application is passed along to the Site Review Contractor for a visit to the enrollee’s physical practice locations.  All told, it is not unusual for the process to take 4-6 months from start to finish.  The time limits for enrollment in Medicaid and CHIP are similar.

It seems unlikely that a ground ambulance supplier that temporarily responded to the areas affected by Hurricane Harvey would go through the enrollment process, especially considering they would likely be seeking reimbursement for their efforts either directly through the Federal Emergency Management Agency (FEMA) and its contractor, or through the existing 1135a waiver program.  For this reason, it seems logical to assume that an ambulance supplier would only go through the enrollment process only if it intends to permanently establish operations in the affected area.

Editor’s Note: it is possible that CMS intended to address storm damage to an enrolled provider’s existing practice locations, i.e., the lifting of the moratorium would make it easier for these providers to add additional practice locations while they repaired their existing facilities.  However, there is nothing in CMS’ website notice that suggests that this was intended to be limited to existing enrolled providers.  This is simply speculation on my part.

CMS indicated that it would be publishing a notice in the Federal Register formally announcing the lifting of the enrollment moratorium.  A month ago, it was assumed by most commentators (myself included) that the notice would make clear that the lifting of the moratorium was temporary, and that it would set a date for its re-establishment.  However, it has now been more than a month since CMS announced the lifting of the moratorium, and that notice has yet to appear in the Federal Register.  The longer we go without an announcement from CMS, the more this starts to look like a permanent lifting of the moratorium.

What This Means Today to Non-Emergency Ambulance Suppliers in Texas

The lifting of this moratorium applies to new enrollments in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  Therefore, as of today, and pending a subsequent re-establishment of the enrollment moratorium by CMS, Part B ground ambulance suppliers in Texas that are not otherwise enrolled as non-emergency ground ambulance suppliers will now be permitted to enroll in the Medicare, Medicaid, and CHIP Programs.  The lifting of the moratorium will also permit companies that are already enrolled as non-emergency ambulance suppliers to add additional practice locations throughout the state.  CMS has indicated that both new enrollments and changes in enrollment to add additional practice locations will be subject to “high” screening under 42 C.F.R. §424.518(c)(3)(iii).

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: CMS Transmittal 236

Written by Brian Werfel on . Posted in Government Affairs, Member Advisories, Regulatory, Talking Medicare.

On June 16, 2017, the Centers for Medicare & Medicaid Services (CMS) released Transmittal 236. This Transmittal makes some minor changes to Chapter 10 of the Medicare Benefit Policy Manual. Specifically, CMS is clarifying its definitions related to the “ALS assessment” and “locality.” The change to the locality definition has prompted some discussion within the industry as to the impact on Medicare’s reimbursement for mileage beyond the nearest appropriate facility. In this month’s blog, I will explain the recent change, and hopefully convince you that this isn’t something that should cause you undue concern.

Medicare’s Definition of “Locality”

The definition of “locality” appears in Section 10.3.5 of Chapter 10 of the Medicare Benefit Policy Manual. That definition reads as follows:

The term “locality” with respect to ambulance service means the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services.

CMS then includes the following example to explain how that definition should be applied to real world situations:

EXAMPLE: Mr. A becomes ill at home and requires ambulance service to the hospital. The small community in which he lives has a 35-bed hospital. Two large metropolitan hospitals are located some distance from Mr. A’s community and both regularly provide hospital services to the community’s residents. The community is within the “locality” of both metropolitan hospitals and direct ambulance service to either of these (as well as to the local community hospital) is covered.

Conceptually, the locality definition is intended to address situations where there are several local options that residents of a community could choose for the receipt of necessary medical care. CMS recognizes that a strict adherence to its general policy of only covering mileage to the nearest appropriate facility would undermine a patient’s right to choose from these various institutional health care providers. The locality definition ensures that, when the two or more facilities are reasonably close to one another, the patient can safely choose the further facility without fear that they may end up being responsible for some incremental portion of the mileage.

The Proposed Clarification

Effective September 18, 2017, Transmittal 236 adds the following sentence to the end of the current definition of locality:

The MACs have the discretion to define locality in their service areas.

Analysis of the Proposed Clarification

The first question that should be asked is whether this clarification is actually a change in CMS policy? I would argue that it not, as Medicare Administrative Contractors have always had the discretion to define what constitutes the “locality” for an ambulance transport. For that reason, I view the purpose of this Transmittal as simply clarifying “who” (i.e., CMS vs. the MACs) has the primary responsibility for making these determinations.

Nor do I believe that this clarification is being made in response to potential abuse of the locality issue, either by providers billing for excess mileage under an expansive reading of “locality” or by the MACs in processing claims. Rather, I think this clarification is being made in response to repeated questions from the provider community, both on Open Door Forums and at state association meetings with their MACs. In other words, I think CMS is simply making clear that concerns regarding locality should be raised with the MACs, rather than CMS itself.

The Transmittal does leave open the possibility that MACs could impose their own definitions of locality. However, as I noted above, they already have this authority. I am not aware of any MAC ever electing to define the issue. Typically, the MAC will simply restate the CMS Manual definition of locality in its LCD.

So why have MACs been reluctant, up to this point, to define localities? I think it has to do with the administrative burden that would be involved. First and foremost, the MAC would need to have a sense of the larger demographic trends that dictate patient referral patterns in any given area. While that information is available, in theory, it is not available in any way that is readily useable by the MAC. Moreover, as the test focuses on what is “normal” or “expected” for patients, this would be a moving target, as patient preferences change over time, new facilities open, other facilities close or change the services they offer, etc. Thus, to the extent a MAC defined a locality, it would be constantly forced to revisit that definition every so often.  Finally, the MAC would have to make allowances for transports that are outside the locality, but where the patient is seeking specialized care that may not be available within the locality.

In sum, defining the locality for even a single community would be a significant administrative burden on the MAC. When you consider that there are hundreds, if not thousands of distinct communities within each state, you can understand the MACs reluctance to offer specific guidance on this approach.

Instead, I believe that the MACs will continue to address the mileage issue in the same way they have done up to this point. Most MACs have imposed an upper limit on the mileage they will pay without question. This upper mileage limit may be for its entire MAC Jurisdiction, it could be statewide, or it could have two or more mileage limits for a particular state.  For example, some MACs use a smaller mileage edit for transports that originate in and around a major metropolitan center, and a larger mileage edit for transports in the more rural areas of a state.

This approach offers a number of administrative benefits to the MAC.  First, it limits the number of claims that run afoul of the edit, and therefore that potentially may need to be reviewed by the MAC on appeal.  It also offers clarity to the provider community.

So, if your MAC has previously indicated that it has a mileage edit, I think you can safely assume that this will continue to be the guiding principle used by the MAC after the effective date. If the MAC doesn’t have a published mileage edit, I don’t think that is likely to change come September.

I would suggest that ambulance providers continue to monitor their remittances. If you are seeing mileage over a certain amount consistently denied by the MAC, that is their mileage edit. Please note that the MAC is not indicating this mileage is never covered, just that it has determined that it will not necessarily pay this higher number of miles without seeing the underlying documentation. In other words, the MAC is putting the burden on you to prove that the entire mileage was covered. If you are not seeing mileage being denied, I wouldn’t expect that to change either. I hope this helps to put everyone’s mind at ease.

Have a wonderful Fourth of July.

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

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