Member Government Affairs Advisories

The Future of Prior Authorization

Written by Brian Werfel on February 7, 2017. Posted in Medicaid, Medicare, Member Advisories, Member-Only, Reimbursement.

In May 2014, CMS announced the creation of a three-year demonstration project that calls for the prior authorization of repetitive scheduled non-emergency ambulance transports. The demonstration project was first implemented in the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on their higher-than-average utilization rates for repetitive ground ambulance transportation. For example, in a June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC) cited these states as having particular high utilization rates for dialysis transports. Prior authorization went live in these states on December 15, 2014.

Congress Acts to Expand the Prior Authorization Regime

On April 16, 2015, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015. Section 515 of that law required CMS to expand the demonstration program into five additional states (Delaware, Maryland, North Carolina, Virginia, and West Virginia) and the District of Columbia on or before January 1, 2016. The law further instructed CMS to expand the prior authorization regime to the rest of the country beginning no earlier than January 1, 2017. However, the national expansion was conditioned on CMS determining that the demonstration project has been effective in reducing Medicare expenditures without jeopardizing patient’s access to necessary medical care.

Short Term Prospects for Expansion

As of the end of January 2017, CMS has yet to issue its report on the effectiveness of the prior authorization program in the original 8 states and the District of Columbia. Therefore, there it is highly unlikely that CMS will be expanding the program nationally in the foreseeable future. However, CMS has not officially ruled out the possibility of expanding the program at some point during 2017.

While CMS has not officially ruled out a national expansion in 2017, I rate the prospect as unlikely. I base this statement simply on the calendar. Even if CMS were to issue the required certifications tomorrow, it would still need to give its contractors instructions on how to implement the program. It would also need to give some advance notice to the provider community. If you assume it would want to give everyone involved at least a month to prepare, it would be April at the earliest before it could expand the program. Personally, I have a hard time believing that CMS would go through all that trouble—not to mention allocating the necessary funding—for 8 months.

Long Term Prospects for Prior Authorization

While I rate the short term prospects for prior authorization to be unlikely, I think that our industry should expect prior authorization for repetitive patients to be part of our long term future.

The data thus far suggests that prior authorization is highly effective at reducing Medicare expenditures. In 2014, the last year before prior authorization went into effect, Medicare paid more than $106 million for dialysis transports in New Jersey alone. In 2015, total spending on dialysis decreased to slightly more than $15 million, a decrease of more than 85%. While there has been anecdotal reports of patients in the state being unable to obtain transportation to their dialysis appointments, there is little empirical evidence to suggest that these are anything other than isolated occurrences, or that prior authorization is contributing to a systematic lack of access. The data from Pennsylvania and South Carolina shows similar dramatic decreases in spending on dialysis.

Collectively, total spending on dialysis in these three states was approximately $140 million less in 2015 than 2014. This corresponds to nearly 20% of total dialysis spending in 2014. To put these reductions in their proper perspective, it may be helpful to remember that the Congressional Budget Office scores the cost of our existing temporary adjustments (i.e., the 2% urban, 3% rural and super rural adjustments) at approximately $100 million a year.

Some will argue that the 2015 reductions in these states were magnified by what can be charitably described as “friction” in the implementation of the program. (We recognize that affected providers in these states are likely to use far less charitable descriptions.) These people would argue that the reductions in subsequent years is likely to be less dramatic. CMS will be releasing 2016 payment data in a few months; at which point we will know whether this prediction proves true. Regardless of whether the data shows an uptick in payments in these states, that same data is almost guaranteed to show a dramatic decrease in total spending on dialysis in these states over the 2014 base year.

In sum, the data makes clear that prior authorization offers substantial cost savings to the federal government. Moreover, the overwhelming majority of these cost savings come from dialysis transports, an area that CMS has long-identified with fraud, abuse, and overutilization. This represents a tempting target for both CMS and Congress when looking for future cost-savings.

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

Medicare Relief and Reform Letter by President Postma

Written by Mark Postma on January 25, 2017. Posted in Medicaid, Medicare, Member Advisories, Member-Only, Reimbursement.

This is a critical year for the legislative efforts of the American Ambulance Association and our members. First and foremost, our temporary Medicare ambulance increases expire at the end of the year. It is vital that we ensure the new 115^th Congress makes these increases permanent, or at the very least approves another long-term extension. To be successful, we will need all of your help in reaching out to your members of Congress in support of the increases.

The AAA and our partners have been also working to further the reform of the Medicare ambulance fee schedule. To accomplish the first steps in this process, ambulance services need to be treated as providers of health care services rather than only suppliers of medical transportation. In addition, we will need the cost data necessary for Congress, Centers for Medicare and Medicaid Services and the AAA to make data-driven decisions regarding the reform.

To achieve these goals, we are working with our champions in Congress to reintroduce a version of the Medicare Ambulance Access, Fraud Prevention and Reform Act (HR 745, S. 332 – 114^th Congress). We hope to have a bill reintroduced in the House and Senate in the coming weeks. Only with your help in sustained outreach to your legislators will we be able to get the provisions of this bill passed.

Our absolute top priority this year is preventing the expiration of the Medicare add-on payments. Building the increases into the base rates is also vital to the future of reform, as is provider standing and cost data collection. These changes will lead, we hope, to the demonstration of the need for additional reimbursement as well as recognition of the role ambulance services can play in the larger health care picture. The subsequent goal is coverage for services such as mobile integrated health and alternate destinations.

The AAA will also be closely following the debate and implications for our industry around repeal and replacement of the Affordable Care Act, potential Medicare and Medicaid reform, and other health care and broader initiatives of interest to us. We will keep you posted of new developments as the process unfolds.

Since this is such a vital year for us in Congress, I ask that each of you respond to our Calls to Action for help with your members of Congress on the Medicare increases and other legislative priorities. We will only be successful if we all push as one.

CMS Extends Temporary Moratorium (NJ, PA, TX)

Written by Brian Werfel on January 15, 2017. Posted in Medicare, Member Advisories, Member-Only, Reimbursement.

On January 9, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a notice in the Federal Register extending the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey, Pennsylvania, and Texas. The extended moratoria will run through July 29, 2017.

Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse. On July 31, 2013, CMS used this new authority to impose a moratorium on the enrollment of new ambulance providers in Houston, Texas and the surrounding counties. On February 4, 2014, CMS imposed a second moratorium on newly enrolling ambulance providers in the Philadelphia metropolitan areas. These moratoria have been extended every six months thereafter.

However, on August 3, 2016, CMS announced changes to its existing moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that the moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier, but that it would expand the enrollment moratorium on non-emergency ambulance services to cover the entire states of New Jersey, Pennsylvania, and Texas. At the same time, CMS announced the creation of a new “waiver” program that would permit the enrollment of new non-emergency ambulance providers in these states under certain circumstances.

On or before July 29, 2017, CMS will need to make a determination on whether to extend or lift the enrollment moratorium.

Have a Medicare question? AAA members, send your inquiry to Brian Werfel, Esq. using our simple form!

GAO Report on Revised Provider Enrollment Screening Process

Written by Brian Werfel on December 21, 2016. Posted in Medicaid, Medicare, Member Advisories, Member-Only.

In March 2011, the Centers for Medicare and Medicaid Services (CMS) implemented a revised process for processing the enrollment of new Medicare providers and suppliers. This revised process also applied to existing Medicare providers and suppliers that were revalidating their enrollment information. This new process included assigning all providers and suppliers to one of three risk categories—limited, moderate, and high—based on the perceived risk of fraud and abuse. The risk category then determines the applicable screening process used for providers within that risk category.

Please note that ambulance providers and suppliers were placed in the moderate risk category. This risk category includes a verification of the information provided by the provider on its enrollment application, a check of the provider’s state licensure, a check of any adverse legal actions against the provider, and a site visit of the provider.

On December 15, 2016, the Government Accountability Office (GAO) released a report on the initial results of this revised provider enrollment screening process.

In its report, the GAO indicated that CMS applied its revised enrollment screening process to over 2.4 million newly enrolling and revalidating Medicare providers and suppliers from March 25, 2011 through December 31, 2015. Other relevant findings include:

The total number of enrolled Medicare providers and suppliers increased from 1.4 million in March 2011 to 1.9 million in December 2015, an increase of more than 30%.
CMS denied more than 6,000 applications for ineligible providers and suppliers. The most commonly cited reason for a denial was the failure of applicant to meet the provider/supplier type requirements. This included situations where the provider/supplier did not hold the required certification for that provider/supplier type.
CMS rejected 17,000 applications as incomplete. The GAO found that approximately 25% of the rejected applications were the result of the application being filed in error, either by the provider/supplier or the MAC. 21% of applications were rejected as being duplicates. Another 16% of rejections were the result of the provider/supplier failing to timely respond to the MAC’s request for additional information.
CMS screening of existing providers/suppliers resulted in more than 660,000 provider numbers being deactivated. This was typically (47%) the result of the provider failing to respond to the MAC’s request that they revalidate. Another 29% were the result of the provider/supplier voluntarily withdrawing from the Medicare program. Another 5% of deactivations were the result of the provider/supplier not submitting a claim to Medicare within the previous 12 months. The majority of these were likely individual practitioners (e.g., physicians) that either died, or who retired from professional practice, and who failed to inform the MAC at the time of retirement to request that their provider number be deactivated. This could also include organizational providers that were sold or otherwise no longer operational.
These were frequently the result of an individual practitioner (e.g., a physician) failing to deactivate his or her Medicare number upon their retirement, and their either not responding to a request to revalidate, or notifying the MAC of their retirement and agreeing to voluntarily withdraw
CMS revoked the billing privileges of 43,000 provider/suppliers. The most common reason cited (61%) was the failure of the provider/supplier to be professionally licensed. However, within the moderate risk category, which includes ambulance, 26% of all revocations were the result of a “CMS-approved revocation,” e.g., the result of some adverse legal action against the provider/supplier which was not properly disclosed to the MAC within 30 days.

CMS estimated that its revised screening procedures avoided $2.4 billion in Medicare payments to ineligible providers and suppliers over this period.

CMS also reported that it made several changes to its screening process over this period. This includes the implementation of a continuous license monitoring report in November 2013, and a continuous criminal monitoring report in July 2015. This also includes fingerprint-based criminal background checks for the owners and certain key employees of categorically high-risk providers and suppliers. In December 2015, CMS also began conducting site-visits for certain limited-risk providers and suppliers.

Despite the progress made by CMS, the GAO did find that certain program vulnerabilities still exist. For example, the GAO found that CMS had not established performance measures to monitor its ability to place providers and suppliers in the proper risk categories. The GAO recommended that CMS establish objectives and performance measures for assessing its progress in establishing better screening procedures for new enrollments and revalidations. CMS ultimately agreed with this recommendation.

Have a Medicare question? AAA members, send your inquiry to Brian Werfel, Esq. using our simple form!

OIG Releases Final Rule Revising Safe Harbor

Written by David Werfel on December 8, 2016. Posted in Government Affairs, Member Advisories, Member-Only.

Office of the Inspector General – Final Rule – Revisions to the Safe Harbors for Waiving Coinsurance, et.al

On December 7, 2016, the Office of the Inspector General published a Final Rule (81 Federal Register 88368) and will be effective January 6, 2017.

The Final Rule includes technical corrections to the existing Safe Harbor for referral services, a new Safe Harbor for waiver of patient cost-sharing for emergency ambulance services, a new Safe Harbor for free or discounted local transportation services, and an amendment to the definition of “remuneration” for purposes of the Civil Monetary penalties for beneficiary inducements. Since the Final Rule covers many issues that pertain to other providers and suppliers, such as pharmacies, outpatient hospital, Federally Qualified Health Centers, Medicare Advantage Plans, etc., this Member Advisory will focus on the two issues that impact ambulance services and transportation.

Safe Harbor – Cost Sharing Reductions for Emergency Ambulance Services

In recent years, we have seen a number of OIG Advisory Opinions that permitted public EMS entities to waive the cost-sharing obligations of Medicare beneficiaries in specified circumstances. The OIG is now adding these as a “Safe Harbor”. The regulation, at 42 C.F.R 1001.952, will protect certain reductions or waivers of beneficiary cost-sharing for emergency ambulance services provided by public entities, which are paid by Federal health care programs under a fee-for-service basis. However, to qualify, all of the following must be met:

The provider or supplier must be owned and operated by a State, political division of a state or a tribal health program. NOTE: While this protects government entities that own and operate their ambulance service, it does not protect a supplier who contracts with that government entity even when that government entity pays the supplier for patient cost-sharing obligations through tax funded revenues. It also does not protect hospitals providing the emergency ambulance services.
The emergency ambulance services must be provided by a Part B provider or supplier. The definition of “Emergency” is the same one listed in 42 C.F.R. 414.605, which you use to determine whether to bill for an emergency base rate or a non-emergency base rate.
The reduction or waiver is not considered furnishing free services paid directly or indirectly by a government entity. It is not considered a free service if the government entity bills to the extent of insurance.
The reduction or waiver of cost-sharing is offered uniformly without considering patient- specific factors. NOTE: The OIG allows residency to be considered. Thus, a city may choose to waive or reduce cost-sharing for residents but not for non-residents.
The provider does not later claim the amount waived as a bad debt, or shift the burden to a government program.

If all of the above items are met, the government entity providing the emergency ambulance service can reduce or waive the patient’s cost-sharing obligation.

Please note, there is no change here with respect to membership programs by a public or private ambulance service, nor is there any change in policy or the law concerning a government entity paying a private ambulance company for copayments of its residents.

Safe Harbor for Free or Discounted Local Transportation

A new Safe Harbor has been created at 42 C.F.R. 1001.952(bb) to protect free or discounted local transportation made available by an “eligible entity” for beneficiaries of Federal health care programs. The key elements to this Safe Harbor are:

The transportation must be local. That is defined as up to 25 miles if urban and up to 50 miles if rural.
It can be provided to or from a provider of service.
It can be provided to the patient as well as to a person that assists the patient.
The transportation does not have to be scheduled ahead of time.
The entity can use a voucher program, if they want.
The transport cannot be provided by an air, luxury or ambulance level service.
An eligible entity cannot require an ambulance company to provide free or discounted transportation to its patients.
An eligible entity is defined as an individual or entity.
An “established” patient means a person who has selected and initiated contact with a provider or supplier to schedule an appointment or who has given consent to someone to do it for them.
The transportation cannot be advertised.
The transportation cannot be used to recruit patients.
The transportation must be for medically necessary services.
Eligible entities must have an established policy regarding the availability of transportation assistance and must apply it uniformly.
The eligible entity is not required to maintain documentation for each patient transported, but it would be a “best practice” to have such documentation.
Drivers cannot be paid on a per patient basis.
The eligible entity cannot have a sign saying “Donated by ___”, as that is marketing.
The eligible entity cannot shift the cost of the transportation to any government health care program.
Shuttles are permitted but the rules are slightly less stringent. The vehicle must be used for a set route or schedule, does not have to be for established patients, must be for local use (25 miles urban; 50 miles rural), it can make multiple stops and, while the entity cannot advertise, they can post a schedule.

Read the entire Final Rule is 42 (Federal Register).

CMS SMR Contractor Audit Error

Written by Brian Werfel on November 15, 2016. Posted in Medicaid, Medicare, Member Advisories, Member-Only.

Over the past week, we have learned that several ambulance suppliers have received letters from the CMS Supplemental Medical Review Contractor (SMRC), StrategicHealthSolutions, LLC. These letters indicate that the SMRC is conducting a medical review of their claims.

The letter contains a section that explains why the supplier has been selected for review. That section contains the following explanation:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017, and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the therapy thresholds and instead allows a targeted review process. CMS has tasked the SMRC with performing post-payment medical review of Part B therapy claims for providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers for dates of service July 1, 2015 to the present.

Our firm contacted the SMRC on behalf of a number of affected providers. On November 14, 2016, StrategicHealthSolutions responded to our inquiry. The SMRC indicated that its review was intended to be limited to suppliers of physical therapy services. Accordingly, the SMRC confirmed that these audit letters were sent to ambulance suppliers in error.

The SMRC further indicated that ambulance suppliers that received this audit letter in error will be notified by telephone that they were selected in error. The SMRC will also be sending letters to affected ambulance suppliers notifying them of its error. These letters are expected to be mailed tomorrow, Tuesday, November 15, 2016.

If your organization received a letter from StrategicHealthSolutions, LLC, please know that this letter was sent in error. Your organization is not being audited by the Supplemental Medical Review Contractor. You can expect to receive a phone call and/or a letter in the next few days formally notifying you of the contractor’s error. That letter should formally withdraw the SMRC’s request for medical records.

If you received a letter from the SMRC, and have any further questions, please feel free to contact Brian S. Werfel, Esq., the AAA’s Medicare Consultant. He can be reached via email at bwerfel@aol.com.

CMS List of Medically Unlikely Edits for Ambulance Services

Written by Brian Werfel on November 15, 2016. Posted in Medicaid, Medicare, Member Advisories, Member-Only, Reimbursement.

On October 1, 2016, the Centers for Medicare and Medicaid Services (CMS) updated its list of Medically Unlikely Edits (MUEs). The MEU program is designed to reduce the paid claims error rate for Part B claims. The program operates by estimating the maximum number of units of service that a provider/supplier would report under most circumstances for a single beneficiary on a single date of service. A claim that submits units of service in excess of this threshold will typically be denied by the Medicare Administrative Contractor.

For additional information on the CMS Medically Unlikely Edit Program, click here.

Effective October 1, 2016, claims for ambulance services will be subject to the following MUE edits:

HCPCS Code	MUE Threshold
A0425 (Ground Ambulance Mileage)	250
A0426 (Ground Ambulance, ALS Non-Emergency)	2
A0427 (Ground Ambulance, ALS Emergency)	2
A0428 (Ground Ambulance, BLS Non-Emergency)	4
A0429 (Ground Ambulance, BLS Emergency)	2
A0430 (Air Ambulance, Fixed Wing)	1
A0431 (Air Ambulance, Helicopter)	1
A0432 (Ground Ambulance, Paramedic Intercept)	1
A0433 (Ground Ambulance, ALS-2)	1
A0434 (Ground Ambulance, Specialty Care Transport)	2
A0435 (Air Ambulance, Fixed Wing Mileage)	999
A0436 (Air Ambulance, Helicopter Mileage)	300

AAA Posts 2015 National and State-Specific Medicare Data

Written by Brian Werfel on November 5, 2016. Posted in Medicare, Member Advisories, Member-Only.

The American Ambulance Association is pleased to announce the publication of its 2015 Medicare Data Payment Report. This report is based on the Physician/Supplier Procedure Summary Master File. This report contains information on all Part B and DME claims processed through the Medicare Common Working File and stored in the National Claims History Repository.

The report contains an overview of total Medicare spending nationwide in CY 2015, and then a separate breakdown of Medicare spending in each of the 50 states, the District of Columbia, and the various other U.S. Territories.

For each jurisdiction, the report contains two charts: the first reflects data for all ambulance services, while the second is limited solely to dialysis transports. Each chart lists total spending by procedure code (i.e., base rates and mileage). For comparison purposes, information is also provided on Medicare spending in CY 2014.

CMS Announces 2017 Inflation Factor

Written by David Werfel on October 25, 2016. Posted in Government Affairs, Medicare, Member Advisories, Member-Only, Regulatory, Reimbursement.

The Centers for Medicare and Medicare Services (CMS) issued Transmittal 3625 officially announcing that the inflation factor for payments under the Medicare ambulance fee schedule for 2017 will be 0.7%.

The calculation for determining the Medicare ambulance inflation factor is as follows: Consumer Price Index – Urban (which is the change in the CPI-U from June to June) minus the non-farm business multi-factor productivity adjustment (MFP) as projected by the Secretary of HHS (10-year average). The CPI-Urban for 2017 is 1.0% with a MFP of 0.3% which equals the 0.7% inflation factor. As part of the Affordable Care Act, a productivity adjustment is subtracted from the CPI-Urban for the final inflation update.

CMS Issues Transmittal on Changes to Ambulance Staffing Requirements

Written by Brian Werfel on September 27, 2016. Posted in Member Advisories, Member-Only, News.

CMS Issues Transmittal on Changes to Ambulance Staffing Requirements; Clarifications to Service Level Definitions for Ground Ambulance Services

On September 12, 2016, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 226. This Transmittal incorporates the recent changes to the vehicle staffing requirements into the Medicare Online Manual System. The Transmittal is also intended to provide clarification on the definitions for certain levels of ground ambulance service. The changes made by this Transmittal go into effect on December 12, 2016.

Vehicle Staffing Requirements

In the CY 2016 Physician Fee Schedule final rule (November 16, 2015), CMS revised its regulations related to the staffing of ground ambulance services. Previously, the Medicare regulations at 42 C.F.R. 410.41 required that all ground ambulances be staffed by a minimum of two crewmembers, at least one of whom must be certified as an EMT-Basic and who must be legally authorized to operate all of the lifesaving and life-sustaining equipment on board the vehicle. For ALS vehicles, there was a further requirement that at least one of the two crewmembers must be certified as a paramedic or EMT and qualified to perform one or more ALS services.

In the 2016 final rule, CMS revised the regulation to further require that the ambulance supplier meet all applicable state and local laws related to the staffing of vehicles. CMS indicated that these changes are intended to address jurisdictions that impose more stringent requirements on ambulance providers (e.g., a requirement that both staff members be certified as EMTs). CMS further indicated that these changes were prompted, in part, by a report from the HHS Office of the Inspector General, which expressed concern over the fact that the current regulations do not set forth licensure or certification requirements for the second crew member.

In this Transmittal, CMS is updating Section 10.1.2 of Chapter 10 of the Medicare Benefit Policy Manual to reflect the changes to the underlying regulations. Specifically, the Manual Section now makes clear that BLS and ALS vehicles must meet the staffing requirements under state and local laws. For BLS vehicles, the new definition also clarifies that at least one of the crewmembers must be certified at a minimum at the EMT-Basic level by the state or local authority where the services are being furnished. For ALS vehicles, the new definition clarifies that at least one of the crewmembers must be certified as an EMT-Intermediate or EMT-Paramedic by the state or local authority where the services are being furnished.

Note: A number of AAA members have expressed concern with the reference to “EMT-Intermediate” in the paragraph defining the staffing requirements for ALS vehicles. These members note that their state may be moving away from the “EMT-I” designation, in favor of the “Advanced EMT,” “EMT-Enhanced,” or other similar designation. These members expressed concern that Medicare contractors may interpret this clarification literally, and therefore downgrade claims properly billed ALS based on the services provided by Advanced EMTs or other higher EMT certifications.

The AAA recognizes the concerns expressed by these members. It should be noted that the Manual changes being made by this Transmittal accurately reflect the current wording of the regulation. It should also be noted that these changes do not impact the definition of “Advanced Life Support (ALS) personnel” set forth in 42 C.F.R. §414.605. While that definition also makes reference to the EMT-Intermediate licensure, the definition makes clear that any individual trained to a higher level than the EMT-Basic licensure qualifies as an ALS crewmember.

Ground Ambulance Service Definitions

The Transmittal also makes a number of clarifications to the ground ambulance services definitions set forth in Section 30.1.1 of Chapter 10 of the Medicare Benefit Policy Manual. These changes are summarized below:

Basic Life Support (BLS) – CMS is revising the definition to align with the new minimum staffing requirements discussed above.
Basic Life Support (BLS) – Emergency – The current definition of the BLS emergency level of service reads as follows:

“When medically necessary, the provision of BLS services, as specified above, in the context of an emergency response. An emergency response is one that, at the time the ambulance provider or supplier is called, it responds immediately. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.”

CMS is removing the second and third sentences of the current definition. In their place, CMS is inserting a parenthetical referencing the definition of an “emergency response” later in this same section of the manual.

Advanced Life Support, Level 1 (ALS1) – CMS is revising the definition to align with the new minimum staffing requirements discussed above. It is also clarifying that the ALS assessment must be provided by ALS personnel.
Advanced Life Support Assessment – The existing definition in the CMS Manual ends with the following sentence: “An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.” In recent years, a number of Medicare contractors have interpreted this sentence to mean that the provision of a valid ALS assessment would not necessarily entitle the ambulance supplier to bill for the ALS emergency base rate, unless the documentation clearly established the provision of an ALS intervention.

CMS is adding a sentence to the end of the definition that clarifies that an ambulance supplier would be permitted to bill for the ALS emergency base, even if the ALS assessment results in a determination that the patient would not require one or more ALS interventions. CMS further clarified that the ability to bill for an ALS emergency base rate is predicated on the ambulance transport otherwise meeting the medical necessity requirement.

Advanced Life Support, Level 1 (ALS1) – Emergency – Similar to the change to the definition of BLS emergency discussed above, CMS is removing the second and third sentences of the current definition, and replacing them with a parenthetical reference to the definition of an “emergency response.”
Advanced Life Support, Level 2 (ALS2) – CMS is rewording the definition, without making any substantive change. ALS-2 continues to be billable in situations involving a medically necessary transport of a patient, where the crew either: (1) provides one of the seven listed ALS-2 procedures (manual defibrillation/cardioversion, endotracheal intubation, etc.) or (2) the administration of three or more medications by IV push/bolus or continuous infusion. The changes largely relate to how you count, for purposes of determining whether you can bill ALS-2, multiple administrations of the same IV medication. Conceptually, CMS is indicating that a single “dose” requires a suitable quantity and amount of time between administrations, in accordance with standard medical protocols. CMS is further indicating that a deliberate attempt to administer a standard dose in increments would not qualify as ALS-2. In sum, to the extent a medication is administered in standard doses in accordance with pre-existing protocols, each separate administration would count separately towards the ALS-2 standard of three or more administrations; however, any attempt to cut the standard dose into multiple administrations would count as only a single administration for purposes of determining whether the ALS-2 standard was met.
Specialty Care Transport (SCT) – CMS is rewording the language in the “Application” section of this definition, without making any substantive change.
Paramedic Intercept (PI) – CMS is revising the definition to reflect the change in how a “rural area” is identified. The old definition included any area: (1) designed as rural by a state law or regulation or (2) any area outside a Metropolitan Statistical Area (MSA) or in New England, outside a New England County Metropolitan Area. Under the new definition, an area is considered rural to the extent it is designated as such by state law or regulation or to the extent it is located in a rural census tract of an MSA using the most recent version of the Goldsmith Modification.
Services in a Rural Area – CMS is eliminating the reference to New England County Metropolitan Areas, as these areas are no longer relevant to a determination of rural. Under the new definition, an area will be considered rural to the extent: (1) it is located outside a Metropolitan Statistical Area (MSA) or (2) is identified as rural using the most recent version of the Goldsmith Modification, even though the area falls within an MSA.
Emergency Response – CMS is adding language clarifying that the nature of an ambulance provider’s response (i.e., emergent or non-emergent) does not independently establish medical necessity for the ambulance transport.
Interfacility Transport – CMS is adding a new definition for the purposes of billing SCT, which establishes that the interfacility transportation requirement is met whenever the origin and destination are both one of the following: (1) a hospital or skilled nursing facility that participates in the Medicare program or (2) a hospital-based facility that meets Medicare’s requirements for provider-based status.

Prior Authorization Expansion Delay

Written by David Werfel on September 21, 2016. Posted in Medicare, Member Advisories, News, Reimbursement.

Prior Authorization – Repetitive Non-Emergencies – Expansion Delay

CMS has notified the American Ambulance Association that the expansion of Prior Authorization for repetitive non-emergencies, to the states not already on Prior Authorization, will not be implemented January 1, 2017.

The reason for the delay is that, pursuant to Section 515(b) of the Medicare Access and CHIP Reauthorization Act (MACRA), CMS must make determinations as to whether: (1) Prior Authorization for repetitive non-emergencies saves money, (2) it adversely affects quality of care and (3) it adversely impacts access to care.

These studies are being conducted and are expected to show the program saves money without adversely affecting quality or access to care.

For those of you in states currently not under Prior Authorization, it is highly recommended that you still prepare for it to be implemented, even though it will not be implemented January 1, 2017. You should still ensure that these patients meet the requirements for medical necessity by reviewing your documents, obtaining documents from facilities, conducting assessments of repetitive patients, implementing internal procedures and processes, etc.

For those of you in states already under Prior Authorization for repetitive non-emergencies, there is no impact. Your program continues.

Novitas – Denials

Written by David Werfel on August 18, 2016. Posted in Medicare, Member Advisories, Member-Only.

This advisory is for members who have Novitas as their Medicare Administrative Contractor.

On August 17, 2016, Novitas called me to let me know that they are seeing many ambulance claims denied due solely to the diagnosis codes that are listed on claims. Novitas requires a minimum of two ICD-10 codes, as follows:

A primary diagnosis code that describes the patient’s medical condition at the time of transport, AND
A secondary diagnosis code that reflects the patient’s need for the ambulance at the time of transport.

The list of primary ICD-10 codes was published by Novitas in their Ambulance Local Coverage Article A54574. While the ICD-10 codes in A54574 are not the only codes that will be accepted, it is highly recommended that you use one of those as your primary code, whenever possible.

Novitas also requires a secondary “diagnosis code”. This list is in their Ambulance Local Coverage Determination (LCD) Policy L35162. That has the four “Z” codes, at least one of which must be used as the secondary diagnosis code:

Z74.01 – Bed Confined
Z74.3 – needs continuous supervision (includes EKG)
Z78.1 – physical restraints (patient safety, danger to self/others)
Z99.89 – dependence on enabling machines (includes IV fluids, active airway management)

If the claim does not list a primary AND a secondary code, the claim is automatically denied. While the claim can be corrected and resubmitted for processing, that delays cash flow and adds time and expense for the ambulance supplier. Therefore, please make sure you list an appropriate primary code AND an appropriate secondary code.

CMS Moratoria Update

Written by Kathy Lester on August 3, 2016. Posted in Government Affairs, Medicaid, Medicare, Member Advisories, Member-Only, Regulatory.

The Centers for Medicare & Medicaid Services Lifts Moratoria on Enrollment of Part B Emergency Ground Ambulance Suppliers in All Geographic Locations; Moratoria for Part B Non-Emergency Ground Ambulance Suppliers Extended

Effective July 29, the Centers for Medicare & Medicaid Services (CMS) has lifted the temporary moratoria in all geographic locations for Part B emergency ground ambulance suppliers. Beginning in 2013, CMS placed moratoria on Medicare Part B ground ambulance suppliers in Harris County, Texas, and surrounding counties (Brazoria, Chambers, Fort Bend, Galveston, Liberty, Montgomery, and Waller). In February 2014, CMS announced it would add six more months to these moratoria and add Philadelphia, Pennsylvania, and surrounding counties (Bucks, Delaware, and Montgomery), as well as the New Jersey counties of Burlington, Camden, and Gloucester. Since that date, CMS extended the moratoria four additional times, most recently in February of this year.

CMS considers qualitative and quantitative factors when determining if there is a high risk of fraud, waste, and abuse in a particular area and whether or not it should establish a moratorium. If CMS identifies an area as posing an increased risk to the Medicaid program, the State Medicaid agency must impose a similar temporary moratorium as well. CMS also consults with the Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) when identifying potential areas and providers/suppliers that should be subject to a temporary moratorium. Finally, CMS also considers whether imposing a moratorium would have a negative impact on beneficiary access to care. In areas where there is a temporary moratorium, the policy does not apply to changes in practice location, changes to provider/supplier information (e.g., phone number, address), or change in ownership. Temporary moratoria remain in place for six months, unless CMS extends the policy through notice in the Federal Register.

CMS may lift a moratorium at any time if the President declares an area a disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, if circumstances warranting the imposition of a moratorium have abated, if the Secretary of HHS has declared a public health emergency, or if, in the judgment of the Secretary of HHS, the moratorium is no longer needed. After a moratorium is lifted, providers/suppliers previously subject to it will be designated to CMS’s “high screening level” for six months from the date on which the moratorium was lifted.

CMS has announced it will lift the moratoria on new Part B emergency ambulance suppliers in all geographic locations because the Agency’s evaluation has shown the primary risk of fraud, waste, and abuse comes from the non-emergency ambulance supplier category and that there are potential access to care issues for emergency ambulance services in the areas with moratoria. New emergency ambulance suppliers seeking to enroll as Medicare suppliers will be subject to “high risk” screening. If enrolled, these suppliers will be permitted to bill only for emergency transportation services. They will not be permitted to bill for non-emergency services.

The moratoria remain in place for Medicare Part B non-emergency ground ambulance suppliers for all counties in which moratoria already are in place in New Jersey, Pennsylvania, and Texas.

2016 Ambulance Ride-Alongs

Written by Tristan North on July 20, 2016. Posted in Government Affairs, Legislative, Member Advisories.

The AAA 2016 Congressional Ride-Along Toolkit is now available.

Congress adjourned on July 15 for their August congressional recess with members of Congress returning home to their districts and states. This is the perfect opportunity for you to educate your members of Congress about those issues, in particular Medicare ambulance relief and reform, which are important to your operation. The most effective way to deliver these key messages is to host your member of Congress or their staff on a tour of your operation and an ambulance ride-along. If you cannot host a tour and ride-along, we strongly encourage you to arrange local meetings with your members of Congress during August. The AAA has made the process of arranging a ride-long or scheduling a meeting easy for you with our 2016 Congressional Ride-Along Toolkit.

While the current temporary Medicare ambulance relief increases don’t expire unit December 31, 2017, meet with your members of Congress now to gain their support for making the relief permanent. Also, there is a potential opportunity this year to make progress on provisions to change our status from “suppliers” to “providers” of health care services and to direct CMS to collect ambulance cost data. Enactment of these two provisions is necessary to set the stage for future reform of the Medicare fee schedule and reimbursement for services other than a transport. During the tours or meetings, please therefore request your members of Congress to cosponsor the Medicare Ambulance Access, Fraud Prevention and Relief Act (S. 377, H.R. 745) and support moving the provider status and cost data provisions of the bill this year.

Everything you need to arrange the ride-along or schedule a meeting is included on the AAA Website.

Email the AAA at info@ambulance.org if you need any assistance.

AAA Launches Medicare Audit Activity Survey

Written by Tristan North on June 27, 2016. Posted in Finance, Medicare, Member Advisories, Reimbursement.

In an effort to better determine a pattern of Medicare audit issues facing our members, the AAA has launched a survey to identify the different types of audit activity. The AAA will use the survey to inform federal policymakers about problems identified with the audits and how best to address the issues to reduce the burden of the audits on AAA members. It is therefore critical that you complete the survey to help us determine what audit issues your operation is facing.

Start Survey

The survey is comprised of only 14 questions including contact, demographic and characteristic information about your organization and requests data about your claim denial and audit activity. The information will be kept confidential and privileged and will only be reported in the aggregate with no organization identifying information. Contact information will be used only to follow up should we have any questions.

Should you have any questions regarding the survey, please contact AAA Senior Vice President of Government Affairs Tristan North at tnorth@ambulance.org.

Thank you in advance for completing this important survey.

MedPAC Issues June 2016 Report to the Congress

Written by Kathy Lester on June 24, 2016. Posted in Finance, Government Affairs, Medicare, Member Advisories, Member-Only, Regulatory.

MedPAC Issues June 2016 Report to the Congress with Chapter on Improving Efficiency and Preserving Access to Emergency Care in Rural Areas

Medicare Payment Advisory Commission (MedPAC or the Commission) has issued its June 2016 Report to the Congress. The June report includes recommended refinements to Medicare payment systems and identifies issues affecting the Medicare program, broader changes in health care delivery, and the market for health care services.

Chapter 7 focuses on preserving access to emergency care in rural areas. The Commission recognizes that access to inpatient and emergency services in rural areas is threatened because of the dwindling populations. Declining populations can lead to fewer hospital admissions and reduced efficiencies that can create financial and staff problems for hospitals. The Report notes that “[d]eclining volume is a concern because low-volume rural hospitals tend to have worse mortality metrics and worse performance on some process measures.” In addition, “low-volume CAHs have the difficult job of competing with each other for a shrinking pool of clinicians who want the lifestyle of operating an outpatient practice during the day, covering inpatient issues that arise at night, and covering the emergency department.”

Under current policies, most rural hospitals are critical access hospitals (CAHs). They receive a cost-based payment for providing inpatient and outpatient services to Medicare beneficiaries. To receive these payments, a hospital must maintain acute inpatient services. In rural areas, many small towns do not have a sufficient population to support such a model. Yet eliminating these services would mean giving up the supplemental payments that their hospitals receive through the CAH cost-based payment model.

The hospital prospective payment system serves as the payment model for other hospitals. Rural providers receive supplemental payments, which are also linked to providing inpatient services.

MedPAC highlights the concerns with cost-based payment models:

Cost-based payments do not direct payments toward isolated hospitals having the greatest financial difficulty, but rather reward hospitals in high-income areas with higher non-Medicare margins by providing them with higher Medicare payments.

Cost-based payments encourage providers to expand service lines with high Medicare and private-payer shares rather than primarily focus on services that are needed on an emergency basis.

Cost-based models reduce the incentive for hospitals to control their costs, which can lead to unnecessary growth in capital costs, despite declining volumes.

In light of these challenges, MedPAC sets forth a two of options that would give isolated rural hospitals the option of converting to an outpatient-only model while maintaining their special payment arrangements. These models seek to ensure access to essential services:

Establishing a 24/7 emergency department model; and
Adopting a clinic with ambulance services model.

Under the 24/7 emergency department model, the hospital would be paid under the outpatient prospective payment rates and would receive an annual grant/fixed payment from Medicare to cover the standby costs associated with 24/7 emergency services. The current supplemental payments would be redirected to support this annual grant/fixed payment amount. If a hospital chose to use inpatient beds as skilled nursing facility (SNF) beds, it would be reimbursed under the Medicare SNF prospective payment system. The hospital could be required to use the fixed payment for emergency standby capacity, ambulance service losses, telehealth capacity, and uncompensated care in the emergency department.

Under the clinic and ambulance model, hospitals could convert their existing inpatient facilities into primary care clinics. These clinics would be “affiliated” with an ambulance service. Medicare would pay the prospective rates for primary care visits and ambulance transports. Medicare would provide an annual grant/fixed payment to support the capital costs of having a primary care practice, the standby costs of the ambulance service, and uncompensated care costs.

The Commission recognizes that the “low population density would also make it difficult to retain primary care providers and support an ambulance service.” It could also be difficult to describe the exact level of primary care and ambulance access that is required to receive the fixed Medicare payment.

MedPAC reiterates its position that “supplemental payments beyond the standard PPS rates should be targeted to isolated rural providers that are essential for access to care.” Thus, it states that a program to support stand-alone emergency departments should be limited to facilities that are a minimum distance in road miles from the nearest hospital.

AAA Issues Response to GAO Claims Report

Written by Tristan North on June 21, 2016. Posted in Medicare, Member Advisories, Regulatory.

On May 13, the Government Accountability Office (GAO) issued a report entitled “Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data“. In the report, the GAO recommended that CMS be provided legislative authority to allow Recovery Auditors to use prepayment claims reviews to address improper Medicare payments. CMS fortunately disagreed with the GAO on the recommendation and cited better options such as prior authorization to address potentially improper payments.

The AAA has now issued a Formal Statement in response to the GAO report noting the problems with prepayment claims review for ambulance services and promoting the better alternative of prior authorization for nonemergency BLS transports of dialysis patients. The statement is in follow up to our Member Advisory providing an in-depth review of the report. Please feel free to share the statement if you receive questions about the report.

On June 26, 2015, the AAA had participated in a conference call with the GAO officials conducting the report in which AAA representatives had pushed for recommendations in line with our statement. The AAA will continue to advocate for policies to address improper payments that address the issue but are also the least burdensome to AAA members and help ensure our ability to continue to provide high-quality emergency and nonemergency ambulance services to patients.

Indian Health Service Issues Final Rule on Payments to Non-Contracted Providers

Written by Brian Werfel on May 18, 2016. Posted in Government Affairs, Medicare, Member Advisories, Talking Medicare.

On March 21, 2016, the Indian Health Service (IHS), an agency with the Department of Health and Human Services, issued a final rule with comment period titled “Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medicare Charges Associated with Non-Hospital-Based Care.” This final rule will change the way the Indian Health Service pays for Purchased/Referred Care (PRC), formerly known as Contract Health Services (CHS). The provisions of this final rule will become effective on May 20, 2016.

Under current regulations, payment for PRC services is based on rates established by arms-length negotiations between the physician or other health care provider (including ambulance providers and suppliers) and the IHS, Tribe, Tribal Organization or urban Indian organizations (collectively referred to hereinafter as I/T/U programs). In the absence of an agreement, the health care provider is generally paid its full billed charges.

Provisions of Final Rule

The final rule amends the regulations at 42 C.F.R. 136.1 e. seq. to provide that payment for PRC services will now be based on Medicare payment methodologies. Specifically, payments would generally be set at the lowest of: (1) the amount provided for such service under the applicable Medicare fee schedule or Medicare waiver, (2) the amount negotiated with a specific provider or its agent, or the amount negotiated by a repricing agent, if applicable, or (3) the rate for such service paid by the health care provider’s or supplier’s “Most Favored Customer” (MFC). For these purposes, IHS has indicated that the MFC rate will be evidenced by commercial price lists or paid invoices and other related pricing and discount data.

While the previous paragraph sets forth the general rate-setting regime, a number of important exceptions will apply. First, any negotiated rate between the parties must be equal to or better than the provider’s or supplier’s MFC rate. The AAA is interpreting this requirement to require the provider or supplier to offer better (i.e. lower pricing) to the I/T/U program than it offers to any nongovernmental entities, including insurance plans. However, IHS indicated that this restriction would not apply to the extent the I/T/U program determines that the negotiated rate is otherwise fair and reasonable, and is otherwise in the best interests of the I/T/U (as determined by the I/T/U). Second, in the event that no agreement exists, and the Medicare Fee Schedule amount is greater than the provider’s or supplier’s MFC rate (i.e. the provider or supplier has voluntarily elected to accept a rate lower than the corresponding Medicare allowable from at least one nongovernmental entity), then the rate may not exceed the MFC rate, but may be lower than the MFC rate.

The final rule can be viewed in its entirety here.

The GAO Releases New Report on Claims Review Programs, Recommending Additional Prepayment Review Authority and Written Guidance on Calculating Savings from Prepayment Review

Written by Kathy Lester on May 17, 2016. Posted in Government Affairs, Medicare, Member Advisories, Reimbursement, Talking Medicare.

On Friday, May 13, the Government Accountability Office (GAO) publicly released a new Medicare report entitled, “Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data,” which it shared with the Congress and the Centers for Medicare & Medicaid Services (CMS) in April. The report is addressed to the Senate Finance Committee Chairman Orrin Hatch (R-UT) in response to his request.

The Report examines:

1. The differences, if any, between prepayment and post-payment reviews, and the extent to which the contractors utilize these types of reviews;

2. The extent to which the Medicare claim review contractors focus their reviews on different types of claims; and

3. CMS’s cost per review and the amount of improper payments identified by the claim review contractors per dollar paid by CMS.

In compiling the Report, the GAO reviewed Administration documents, interviewed CMS officials, Recovery Auditors (RAs), and Medicare Administrative Contractors (MACs). The GAO also interviewed representatives from 10 Medicare provider/supplier organizations that have experienced claim reviews on both a pre- and post-payment review basis. The AAA worked the GAO by participating in a telephone interview and providing written comments.

The GAO examined three types of contractors – the RAs, the MACs, and the Supplemental Medicare Review Contractor (SMRC). These contractors are responsible for reviewing claims that are at high risk of improper payment and claims that pose the greatest financial risk to Medicare. Only MACs conduct both pre- and post-payment reviews. RAs and the SMRC conduct only post-payment reviews, but RAs did participate in a pre-payment review demonstration project. RAs are paid on a contingent basis from recovered overpayments. During the demonstration, RAs were paid contingency fees based on claim denial amounts.

In its review, the GAO found that few differences exist between pre- and post-payment reviews, but noted that pre-payment reviews “better protect Medicare funds.” The GAO found that CMS is not always able to collect overpayments from post-payment reviews and that post-payment reviews require more administrative resources than pre-payment reviews.

The provider/supplier organizations highlighted two issues that need to be resolved with regard to pre-payment review audits. First, they identified that the option to hold discussions with RAs before payment determinations are made in the context of post-payment reviews can be helpful. These discussions are not part of the pre-payment review process; nor are they part of the MAC process. CMS indicated that it is not practical to have such an option in these contexts because of the timing requirements.

Second, the providers/suppliers noted that pre-payment reviews create cash flow burdens, in light of the appeals process. When appealing a post-payment review, providers/suppliers retain their Medicare payments through the first two rounds of review. If the denial is overturned at a higher level, CMS must pay back the recovered amount with interest accrued. However, for pre-payment reviews, providers/suppliers do not receive payment and CMS does not provide interest on the dollars withheld if the provider/supplier wins on appeal.

MACs have traditionally relied upon post-payment review. MACs will also use post-payment reviews to analyze billing patterns to inform other review activities, such as future pre-payment reviews and educational outreach. CMS has encouraged MACs to perform extrapolation, especially for providers/suppliers that submit large volumes of low-dollar claims with high improper payment rates.

The SMRC reviews often include studies to develop sampling methodologies or other policies that could be rolled out more broadly in the future.

The GAO also found that different contractors focused on different claims during 2013 and 2014. RAs focused on inpatient claim reviews primarily. RAs have the discretion to select the claims they review and the GAO stated that “their focus on reviewing inpatient claims is consistent with the financial incentives associated with the contingency fees they receive, as inpatient claims generally have higher payment amounts compared to other claim types.” The GAO also found that RA claim reviews had higher average identified improper payment amounts per post-payment claim review relative to other claim types in 2013 and 2014. For the upcoming contracts, CMS has indicated that it will more closely monitor RAs to ensure that they are reviewing all types of claims. For DME claims in particular, CMS has increased the contingency fee percentage paid to the RAs for DME, home health agencies, and hospice claims.

In contracts, MAC claim reviews focused primarily on physician and DME claims. DME claims accounted for 29 percent of their reviews in 2013 and 26 percent in 2014, while representing 22 percent of total improper payments in fiscal year 2013 and 16 percent of improper payments in fiscal year 2014. DME claims also had the highest rates of improper payments in both years.

Physician claims is a broadly used term that includes labs, ambulances, and individual physician.

The SMRC focused its claim reviews on studies that CMS directs the contractor to conduct. In 2013, the SMRC reviews focused on outpatient and physician claims, but in 2014 the focus shifted to home health agency claims and certain DME suppliers.

The GAO concluded that both RAs and SMRC generated savings for CMS, but unreliable data prevented comparing these results to those of MACs. CMS paid the RAs an average of $158 per review; the RAs averaged $14 in identified improper payments per dollar paid by CMS in both 2013 and 2014. CMS paid the SMRC an average of $256 per review, and the SMRC averaged $7 in identified improper payments per dollar paid in 2013 and 2014. The higher SMRC costs related to the study costs and extrapolation.

CMS lacks reliable MAC cost and savings data. CMS does not collect reliable data on claim review funding and does not have consistent data on identified improper payments. While CMS has established ways to collect this information, some MACs are not reporting it. MACs also use different methods to calculate and report savings.

The GAO recommended that CMS take two actions:

• In order to better ensure proper Medicare payments and protect Medicare funds, CMS should seek legislative authority to allow the RAs to conduct prepayment claim reviews.

• In order to ensure that CMS has the information it needs to evaluate MAC effectiveness in preventing improper payments and to evaluate and compare contractor performance across its Medicare claim review program, CMS should provide the MACs with written guidance on how to accurately calculate and report savings from prepayment claim reviews.

CMS did not agree with the first recommendation, stating that it has a strategy to move away from “pay and chase” using different policies, such as prior authorization initiatives and enhanced provider enrollment screening. CMS concurred with the second recommendation.

CMS Releases Medicare Provider Utilization and Payment Data for CY 2014 for Ambulance Suppliers, Physicians and Other Part B Organizations

Written by Brian Werfel on May 17, 2016. Posted in Government Affairs, Medicare, Member Advisories, Reimbursement, Talking Medicare.

On May 5, 2016, CMS publicly released the “Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File,” which provides information on the services and procedures provided to Medicare beneficiaries by ambulance suppliers, physicians and other healthcare provider groups. The data file is based on calendar year 2014 data. This release follows on last year’s release of payment data for calendar year 2012.

The database lists all individual and organizations providers by National Provider Identifier (NPI), and provides information on utilization, total payments and submitted charges. It can also be searched by Healthcare Common Procedure Coding System (HCPCS) code and place of service.

The Public Use File can be obtained here. Please note that you will need to download the desired file and then import it into an appropriate database or statistical software program. CMS is indicating that Microsoft Excel is not sufficient for these purposes, and that importing it into Excel may result in an incomplete loading of data.

A number of news organizations have already created searchable databases that will allow you to search the CY 2012-2013 data by physician/organizational name, provider specialty, city, state, etc. It is expected that these news organizations will be updating their websites to incorporate the CY 2014 data in the coming weeks. The searchable database created by the Wall Street Journal can be accessed here.