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Talking Medicare: Prior Authorization Spending Update

Written by Brian Werfel on . Posted in Member-Only, News, Reimbursement, Talking Medicare.

Prior Authorization Data Shows Continued Reduction in Overall Spending on Dialysis Transports; Pendulum Swings Back Slightly in New Jersey and Pennsylvania

In May 2014, CMS announced the implementation of a three-year prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project was initially limited to the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress.

Medicare payment data from calendar year 2015 showed the effect of the demonstration project. Total spending on dialysis transports was $559 million that year, down 22% from the year before.  That correlates to a cost savings to the federal government of $158 million. Telling, $137 million (86%) of those savings came from the three states that participated in the demonstration project.

The chart to the right shows total spending on dialysis in those states in the years immediately preceding the implementation of the prior authorization project up through the first year of the project. While the three states had very different trajectories prior to 2015, each showed a significant decrease in payments under the demonstration project.

We now have Medicare payment data for 2016. This blog will focus on the second year of the prior authorization demonstration project. This includes tracking the effects of prior authorization on the five additional states (DE, MD, NC, VA, and WV) and the District of Columbia, which were added to the demonstration project for 2016.

Existing States

In the first year of the demonstration project, both New Jersey and Pennsylvania saw sizeable reductions (85.5% and 83.5%, respectively) in the total spending on dialysis transports. Both states saw dialysis payments rebound in 2016, with New Jersey increasing by 14.7% and Pennsylvania increasing by 3.7%. The financial community uses the phrase “dead cat bounce[1]” to describe a temporary recovery from a prolonged or pronounced decline. It is possible that explains why payments increased for these states in 2016. However, the more likely explanation is that Novitas, the Medicare Administrative Contractor in both states, recognized that the standards it used were overly restrictive during the first year of the project. If so, the increases in 2016 reflect the pendulum swinging back somewhat. If you accept that Novitas has reached an equilibrium point, total spending on dialysis in these states would be roughly 75% below pre-2015 levels.

By contrast, South Carolina saw total dialysis spending decrease by an additional 7.9% in 2016, over and above the roughly 25% reduction in 2015. Thus, spending in 2016 was roughly 30% lower than pre-2015 levels.

Expansion to New States

The follow charts track dialysis payments in the five states and the District of Columbia that were first subject to prior authorization in 2016.  The chart on the left shows those states where the prior authorization project is administered by Novitas, while the chart on the right shows those states administered by Palmetto.

The phrase expresses the concept that even a dead cat will bounce if dropped from a tall enough height.

As you can see, both Delaware (72.3%) and Maryland (68.0%) showed sizeable reductions in total dialysis payments. Payments in the District of Columbia actually increased by 30%. However, a closer examination of the numbers shows that the increase was largely the result of an increase in the number of emergency transports to a hospital for dialysis, i.e., claims that fell outside the prior authorization project. Payment for scheduled BLS non-emergency transports fell 82.9% in the District, in line with reductions in the other two states.

The reductions in the Palmetto states was far more moderate, with reductions ranging from 27.8% (North Carolina) to 45.4% (Virginia). West Virginia saw a 36.0% decline.

Key Takeaways

 With two years of experience under the prior authorization demonstration project, I think we can safely come to two conclusions:

  1. The implementation of a prior authorization process in a state will undoubtedly result in an overall decrease in the total payments for dialysis within that state; and
  1. The size of that reduction appears to be more dependent on the Medicare contractor than on any perceived level of over utilization.

The first conclusion should come as no surprise. Dialysis transports have long been the subject of scrutiny by the federal government. Moreover, the original states were not selected at random; they were selected based on data that suggested they were particularly suspect to over utilization.

The second conclusion is less intuitive. After all, Medicare coverage standards are intended to be national. While you could argue that a sizable reduction was expected for New Jersey and Pennsylvania, as there was evidence of widespread dialysis fraud in the Philadelphia metropolitan area, there was no basis to suspect widespread over utilization in Maryland or the District of Columbia. In fact, the District had only 58 BLS non-emergency dialysis transports in 2015, i.e., the equivalent of a single patient being transported for 2 months. Rather, the 2016 data suggests that Novitas has simply taken a far harder stance on dialysis than Palmetto.

This has potential implications beyond the demonstration project, which is scheduled to expire at the end of this year. As many of you know, the national expansion of prior authorization is part of the House of Representative’s ambulance relief bill (it is not mentioned in the corresponding Senate bill). The data suggests that the AAA must continue its efforts to work with CMS and its contractors on developing more uniform standards for coverage of this patient population.

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

[1] The phrase expresses the concept that even a dead cat will bounce if dropped from a tall enough height.

CMS Extends Moratorium on Non-Emergency Ground Ambulance

Written by Brian Werfel on . Posted in Medicare, Member Advisories, Member-Only, News, Reimbursement.

CMS Extends Temporary Moratorium on Non-Emergency Ground Ambulance Services in New Jersey, Pennsylvania, and Texas

On July 28, 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 January 29, 2018.

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.

On August 3, 2016, CMS announced changes to the moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that: (1) the enrollment moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier and (2) the enrollment moratoria on non-emergency ambulance services would be expanded 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. The moratoria have been extended on these terms every six months thereafter.

On or before January 29, 2018, CMS will need to make a determination on whether to extend or lift the enrollment moratorium.

Board of Director Nominations – Now Open!

Written by Aidan Camas on . Posted in Elections, Member-Only, News.

Call For Nominations Now Open!

Submit a Nomination

Submit Candidate Questionnaire

In accordance with the Bylaws of the American Ambulance Association, it is time to call for members in good standing that wish to serve on the Board of Directors. The AAA is now seeking candidates for the following positions:
  • Region I Director (CT, MA, ME, NH, NJ, NY, RI & VT)
  • Region II Director (AL, DE, DC, FL, GA, MD, MS, NC, PA, SC, VA, WV)
  • Region III Director (IL, IN, KY, MI, OH, TN WI)
  • Region IV Director (AR, IA, KS, LA, MN, MO, OK, ND, NE, SD, TX)
  • Region V Director (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY

Individuals who wish to be considered for an elected position as Regional Director must:

1. Be the designated representative of an Active member of the AAA, in good standing;

2. Be ready to devote time and effort to matters which concern the Board of Directors and to actively participate in all Board activities;

3. Be prepared to assist other AAA members with concerns and problems which relate to the ambulance industry and the workings of the AAA; and,

4. Understand that these positions provide no compensation for time or reimbursement for expenses. All travel-related expenses, including transportation, lodging and food are the responsibility of the individual and/or the sponsoring organization.

5. Be willing to comply with all governance policies of the association including, Conflict of Interest, Standards of Conduct, and Board Confidentiality, Public Comment and Lobbying Agreement (PDF).

6. Have served on at least one (1) Association committee within the past five (5) years prior to his or her declaration as a candidate for election as a Director.

There are no restrictions against an individual running for more than one position in the same election cycle, though no person shall hold more than one position simultaneously.

All those who wish to stand for election and believe they are qualified are requested to complete a Nomination Form as well as answer the Candidate Questionnaire which describes both their qualifications and reasons for wanting to participate in the leadership of the AAA.

(Please note that the may Nomination Form be completed by any designated contact for an AAA active member for him or herself, or on behalf of another designated contact at a fellow AAA active member service. The Candidate Questionnaire must be completed by the nominee.)

Candidates’ statements and pictures, as well as the position(s) for which they are running for will be listed on the AAA website.

2017 Election Timeline

  • 8/31 | Nominations Close
  • 9/14 | Approval of Candidates by AAA Board of Directors
  • 10/3 | Voting Opens
    Election will be paperless and held online. Ballots will be delivered to AAA Active Member primary contacts via email.
  • 11/2 | Voting Closes 11:59pm
  • 11/14 | Election results announced at the 2017 AAA Annual Conference & Tradeshow.

Both forms must be submitted to by Thursday, August 31, 2017. 

Step 1: Nomination Form    Step 2: Candidate Questionnaire

Questions? Please contact acamas@ambulance.org for assistance.

Court Decision Overpayment Determination Statistical Sampling

Written by David Werfel on . Posted in Medicare, Member Advisories, Member-Only, News, Reimbursement.

Maxmed is a home health agency. In 2011, Medicare reviewed a sample of 40 claims involving 22 Medicare beneficiaries and determined that all but one were not medically necessary. The sample was extrapolated to their universe of claims, resulting in an overpayment of $773,967. The Administrative Law Judge invalidated the extrapolation methodology, but the Medicare Appeals Council reversed and Maxmed appealed to Federal District Court, where it lost. Maxmed then appealed claiming:
  • the extrapolation was invalid because the contractor failed to document the random numbers used in the sample and how they were selected.
  • a valid random sample must be for claims that are “defined correctly and independent” and here the same Medicare beneficiary had multiple claims in the sample.
On June 22, 2017, the U.S. Court of Appeals, Fifth Circuit, found the extrapolation and sampling methodology used was proper. The decision, Maxmed Healthcare Inc. v. Price, is just the latest in a recent line of decisions making it harder and harder to challenge statistical sampling and extrapolation of overpayments.

Medicare “Locality” Rule & ALS Assessment

Written by David Werfel on . Posted in Government Affairs, Member-Only.

“Locality” Rule – MAC Discretion – Since the inception of the CMS Internet Only Manual (in 2003), the Benefit Policy Manual 100-02, Chapter 10, section 10.3.5 has always defined “Locality” as:

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.

An example is then listed to indicate that the ambulance transportation to either of two large metropolitan hospitals that regularly provide services to the small community where the emergency arose would be covered destinations.

On June 16, 2017, CMS issued Transmittal 236 to add the following at the end of the paragraph before the example:

The MAC’s have the discretion to define locality in their service areas.

Effectively, there is no change as Carriers and Intermediaries (now MACs) have always had discretion to determine the “locality” around each facility. Often, they did this with mileage edits, e.g. in an urban area, they may have set a parameter of 15 miles, but in a rural area, they have allowed a much larger area. Nevertheless, it is a good time to ask your MAC for their definitions of the localities in their service area or the mileage edits that they use.

A copy of the Transmittal can be obtained at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R236BP.pdf

ALS Assessment

The same Transmittal made two changes to the CMS definition of “ALS Assessment”, as listed in the Benefit Policy Manual, 100-02, Chapter 10, section 30.1.1, as follows:

1. Assuming the ALS assessment is performed and meets the definition, this section now states that the services provided by the supplier or provider “shall” be covered at the ALS emergency level. Previously, the definition indicated the services “may” be covered at the ALS emergency level. This change was needed as some MACs thought they did not have to pay ALS emergency when the ALS assessment is performed in accordance with the definition.

2. The other change was to add to the end of the paragraph “and all other coverage requirements are met”. In other words, aside from providing the ALS assessment in accordance with the definition, there must also be ambulance transportation, the origin/destination requirements are met, the provider/supplier must meet all vehicle and crew requirements, transportation was medically necessary, the ALS assessment was medically necessary, etc.

The effective date for the changes noted above is September 18, 2017.

UnitedHealthCare Denials for ALS-2 Claims

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member-Only, Private Insurance, Reimbursement, Talking Medicare.

Talking Medicare

with Brian S. Werfel, AAA Medicare Consultant

Over the past few weeks, we have received emails from ambulance providers across the country reporting that UnitedHealthCare (UHC) has started to deny claims for the ALS-2 base rate. Affected claims include both commercial and Medicare Advantage claims. These providers are reporting that UHC is requiring the use of Current Procedural Terminology (CPT) Codes to support the ALS-2 level of service.

When these providers call UHC to question the denials, the customer service representative refers them to UHC’s online policies and procedures manual. The section of that manual devoted to the ALS-2 base rate largely mirrors Medicare’s definition. For example, it indicates that ALS-2 can be billed based on three separate administrations of one or more medications by IV push/bolus or continuous infusion, or upon provision of one or more of the designated ALS-2 procedures (e.g., an endotracheal intubation).

However, the manual section then goes on to indicate that “Ambulance Providers or Suppliers are required to report CPT or HCPCS codes… when reporting A0433.  Ambulance transport services that do not include the services described in criteria 1 or 2 above should be reported with a more appropriate ambulance transport code.”

The manual section concludes with links to two lists of CPT codes. The first list, designated as “ALS2 Criteria 1 Codes” relate to the intravenous administration of various medications. These codes fall within the range of: 96365 – 96376. The second list, designated as “ALS2 Criteria 2 Codes” correspond to the various ALS interventions:

CPT Code:                            Description:
31500                                    Endotracheal Intubation, Emergency
31603                                    Under Incision Procedures on Trachea and Bronchi
31605                                    Under Incision Procedures on Trachea and Bronchi
36000                                    Under Intravenous Vascular Introduction & Injection Procedure
36555                                    Central Venous Catheter Placement, Patient Under Five Years
36556                                    Central Venous Catheter Placement, Patient Over Five Years
36568                                    Insertion of Central Venous Access Device
36569                                    PICC Line Insertion
36680                                    Intraosseous Line Infusions
92950                                    Cardiopulmonary Resuscitation
92953                                    Other Therapeutic Cardiovascular Services
92960                                    External Electrical Cardioversion, Non-Emergency
92961                                    External Electrical Cardioversion, Emergency

The ambulance providers have indicated that they have questioned UHC on the necessity of including CPT codes on these claims. These providers argue, correctly, that CMS does not require the use of CPT codes on Medicare claims. Instead, Medicare requires the ambulance provider to document in the billing narrative the justification for billing ALS-2. For example, a provider might list multiple administrations of epinephrine, the use of an intraosseous line, etc.

The fact that UHC is asking for the CPT codes suggests that it does not currently review the billing narratives. Instead, UHC appears to be using the CPT codes to ensure that the ALS-2 criteria are met.

Is UHC correct to insist upon the use of CPT codes? Probably not, at least for its Medicare Advantage claims. However, I think the more appropriate question to ask ourselves is whether it is worth fighting UHC on this issue? If using CPT codes ensure that UHC correctly processes and pays these claims with minimal delay, my opinion is that it is probably easier just to comply with their policy.

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

CMS Letter Regarding Merit-Based Incentive Payment System

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, News, Regulatory.

Over the past week, multiple members have contacted the American Ambulance Association to report that they have received a letter from the Centers for Medicare and Medicaid Services (CMS) related to their participation in the Merit-Based Incentive Payment System (MIPS). The letter appears to have been sent to any entity with a taxpayer identification number (TIN) that is enrolled in the Medicare Part B Program. The stated purpose of the letter is to inform the provider whether it is exempt from participation in the MIPS program.

This member advisory is being issued to advise ambulance suppliers that:

(1) they are not eligible to participate in the MIPS program
(2) no positive or negative adjustments will be made to the ambulance suppliers Medicare payments
(3) no further action is required on their part

Therefore, AAA members that received this letter can safely disregard it. 

 

ACA Repeal and Replace Update

Written by John Jonas on . Posted in Executive, Government Affairs, Legislative, Member-Only, News.

Congress returns to Washington next week, and House Republican Leadership maintains an ambitious agenda to pass the American Health Care Act (AHCA) despite an unclear path navigating its moderate and conservative factions. President Trump, who refuses to let health care reform disappear from the agenda, is especially eager for a victory, and today predicted AHCA would pass within the next few weeks.

During the in-district work period these past two weeks, the White House, House Leadership and Republican committee staff have kept conversations going with the two disagreeing factions within their caucus – the moderate Tuesday Group and the conservative Freedom Caucus. At this stage, there appears to be no agreement within the Republican Caucus, and there are varying reports on how close are discussions. The wild card is whether President Trump and his team can help force a deal. As soon as a deal materializes, the House will move the bill to the floor.

In addition to health care, the discretionary aspects of the Federal government are under a temporary continuing resolution which expires at the end of next week. An effort is underway to pass a measure that will fund the government through the remainder of the 2017 Fiscal Year, which ends September 30. This effort is not without controversy, and includes an attempt by the Trump Administration to appropriate funds to build its border wall. However, Republicans will need at least eight Senate Democrats to vote with them to pass an omnibus spending bill, so compromise will be required. There may be a series of short-term funding patches as Congress considers spending priorities.

One of the more interesting issues Congress and the Trump Administration face is what to do with Affordable Care Act (ACA) subsidies that were meant to help reduce cost sharing (deductibles, co-payments) for especially poor, non-Medicaid eligible individuals buying insurance on the exchange. House Republicans had successfully sued the Obama Administration in district court arguing that Congress must appropriate the money before the ACA’s Cost Sharing Reduction (CSR) subsidies could be paid. With an injunction from the district court in place, Congress must decide whether to appropriate the money in the upcoming spending bill. Some Democrats have stated they will not vote to pass any budget without funds for the CSR program included. If Republicans can pass a budget without funding the CSR subsidies, they aren’t out of the woods yet on the CSR program. Specifically, the President still has to decide whether to appeal the district court decision on May 22. If President Trump chooses to accept the district court decision and there is no appropriation, the President could unilaterally shut down the CSR subsidy program. The President has threatened to use this court decision to bring Democrats to the negotiating table, in the event that the program is not appropriated and AHCA is not passed.

The AAA will continue to keep members up to date on these issues.

Understanding CERT

Written by Brian Werfel on . Posted in Medicare, Member-Only, Talking Medicare.

Talking Medicare: Understanding CERT

Every year around this time, our firm receives a steady stream of questions from AAA members about the CERT Program. Typically, the provider has received a notice from what appears to be the Centers for Medicare and Medicaid Services (CMS), which asks for medical records for one or two patient transports. These providers naturally wonder whether they are being audited, and how they should respond. The intent of this post is to clear up any confusion.

What is the CERT program?

The Comprehensive Error Rate Testing (CERT) program is an attempt by CMS to measure the rate of improper payments in the Medicare Fee-for-Service Program. It does so by evaluating a statistically valid random sample of claims to determine whether these claims were properly paid under the applicable Medicare coverage, coding, and billing rules.

In August 2016, CMS awarded responsibility for conducting CERT reviews to AdvanceMed. Therefore, if you receive a letter from AdvanceMed, and that review is asking for only a single claim, it is likely that you are being asked to participate in the FY 2017 CERT review.

What is the National Error Rate for ambulance services?

In its report for Fiscal Year 2016, CMS indicated that the overall improper payment rate was 11.00% across all provider types. CMS estimated that this represented approximately $41.08 billion in improper payments. This is down slightly from the FY 2015 review, which estimated the improper payment rate at 12.09%, representing $43.33 billion in improper payments. The FY 2016 reporting period ran from July 1, 2014 through June 30, 2015.

The overall error rate for Part A Providers, i.e., hospitals, nursing homes, etc., was 13.98%. The overall error rate for Part B providers was 11.71%.  In contrast, the error rate for durable medical equipment, prosthetics, orthotics, and supplies (DME) was 46.26%.

The overall error rate for ambulance was 11.7%, or basically the same as the overall Part B error rate. The ambulance error rate was further broken down based on the basis for a payment error. The most common error, comprising more than three-fourths of all errors, was either no documentation or insufficient documentation. The lack of medical necessity for the ambulance comprised only 15.6% of all improperly paid ambulance claims.

Should I freak out if my service is selected for review?

In a word, “No.” The odds of your service being selected under the CERT program are quite low. If you are selected, it is helpful to keep in mind that the focus of this review is not on your billing practices. Rather, the focus is on whether your contractor processed your claim correctly. This is not to say that CMS will not attempt to recoup payment on the claim if it ultimately determines that the claim was paid in error; it will. However, from your perspective, that recoupment is the end of the matter.

In other words, the worst that can happen with a CERT review is that you would have to repay that single claim. It will not result in a large extrapolated overpayment. Nor is the denial of that claim likely to trigger a larger postpayment review. Therefore, other than being sure to respond to the record request in a timely fashion, there is little to fear from CERT.

I hope this helps put your mind at ease!

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

Government Affairs Update: Protecting the Ambulance Add-ons

Written by Tristan North on . Posted in Advocacy Priorities, Government Affairs, Legislative, Member Advisories, Member-Only, Reimbursement.

Medicare Ambulance Relief and Reform

The top legislative priority this year for the American Ambulance Association is to extend, or hopefully make permanent, the temporary Medicare ambulance add-on payments. The temporary increases of 2% urban, 3% rural and the super rural bonus expire at the end of this year. The 2% urban and 3% rural increases have been in place since 2008 and the super rural bonus payment since 2004. While the AAA and our members have been successful in getting the payments extended numerous times, 2017 is not a typical year and we need everyone to be prepared to help push to make the increases permanent or extended for the longest possible duration.

The other top priorities for the AAA are for the Centers for Medicare and Medicaid Services (CMS) to recognize ambulance services more like providers of medical services instead of merely suppliers of transportation. In addition, it is critical that Congress direct CMS to collect cost data from ambulance service providers using a method, which will result in usable and meaningful data from everyone, but also not be overly burdensome on extremely low volume providers. Finally, Congress needs to target fraud and abuse with the transport of dialysis patients through a prior authorization program instead an arbitrary payment cut that impacts all providers.

The AAA is pushing its agenda again through a version of the Medicare Ambulance Access, Fraud Prevention and Reform Act which we hope to have introduced in the next few weeks. We are working with our champions on Capitol Hill on a different approach to being treated more like providers to mitigate issues raised about the provision last Congress. Instead of being listed in the Social Security Act as having provider status, we are looking to a hybrid model similar to dialysis facilities. This will clarify that we are not seeking to be treated like providers to achieve Medicare coverage because we are already reimbursed under the Medicare program. It will however still set the foundation for future legislative and regulatory changes to the Medicare fee schedule such as reimbursement for transporting to an alternate destination or treat and referral.

We are also making potential modifications to the House bill on our proposed data collection system. These changes would help with possible Committee consideration of the provision but still hopefully achieve or goal of obtaining useable data that is not overly burdensome to 73% of our industry which is composed of providers that do less than 1,000 Medicare transports a year of less. It is vital that we have meaningful data to make data-driven decisions as to changes to the Medicare ambulance fee schedule.

Ambulance Advocacy Webinar

We will let you know as soon as the revised legislation is introduced for the new Congress. In the meantime, we encourage you to register for the upcoming AAA webinar on the Ambulance Advocacy Action Plan with AAA Senior Vice President of Government Affairs Tristan North and AAA Government Affairs Coordinator Aidan Camas. Tristan and Aidan will provide you the latest information on our advocacy efforts and let you know how you can help. To register for the webinar which is free to AAA members, please go to: https://ambulance.org/product/ambulance-advocacy-action-plan/.

Also read Tristan and Kathy Lester’s recent Member Advisory on ACA Repeal & Reform:

ACA Repeal & Reform – What It Means for Ambulance Services (Pt. 1)
ACA Repeal & Reform – What It Means for Ambulance Services (Pt. 2)

Administration’s Proposed Rule on Marketplace Stabilization

Written by Kathy Lester on . Posted in Government Affairs, Medicaid, Medicare, Member Advisories, Member-Only, Private Insurance, Regulatory.

The Centers for Medicare & Medicaid Services (CMS) has released the “Marketplace Stabilization Proposed Rule” (Proposed Rule). Overall, the rule proposes a series of modifications to the Marketplaces that align with requests made by issuers in an attempt to keep them in the Marketplaces. The background section of the Proposed Rule emphasizes the concerns of issuers and the Agency’s interest in making sure that consumers have more plan options for 2018. Comments are due March 7.

While ambulance services are not directly mentioned, the Proposed Rule could affect the ability of individuals in the marketplace to enroll and remain enrolled in plans. Another provision that could impact the ambulance industry is the proposal to rely more upon the States to enforce the network adequacy requirements of the ACA.  

Changes to Open Enrollment/Special Enrollment Periods

CMS proposes to tighten the enrollment rules in several ways. First, the Proposed Rule would change the open enrollment period to November 1 – December 15 to “increase the incentives for individuals to maintain enrollment in health coverage and decrease the incentives for individuals to enroll only after they discover they require services.”[1]  Individuals may still be eligible for a special enrollment period that would allow them to enroll outside of these dates.

CMS would increase the States’ pre-enrollment verification from 50 percent to 100 percent beginning June 1, 2017, and require consumers’ enrollment requests to be “pended” until verification is complete. CMS encourages State-based Exchanges to adopt a similar policy. The Proposed Rule would also limit the ability of existing Exchange enrollees to change plan metal levels during the coverage year.  It would allow Exchanges to require enrollees that qualify for a special enrollment period because of a dependent to be add only to the current Qualified Health Plan (QHP) or allow the enrollee and the new dependent to enroll in another QHP within the same level of coverage.[2]

The Proposed Rule would also require that if an enrollee or the dependent is not enrolled in a silver level QHP and becomes newly eligible for cost-sharing reductions and qualifies for the special enrollment periods, the Exchange may allow the enrollee and dependent to enroll in only a QHP at the silver level.[3] CMS also proposes a new restriction that would allow the Exchange only to allow an enrollee and dependents who qualify for remaining special enrollment periods to make changes to their enrollment in the same QHP or to change to another QHP within the same level of coverage, if other QHPs at that metal level are available.[4]

CMS would allow consumers to start their coverage one month later than their effective date would ordinarily have been, if the special enrollment period verification process results in a delay in their enrollment such that they would be required to pay two or more months of retroactive premium to effectuate coverage or avoid termination for non- payment. [5]

Additionally, CMS would permit the issuer to reject an enrollment for which the issuer has a record of termination due to non-payment of premiums unless the individual fulfills obligations for premiums due for previous coverage.

The Proposed Rule also expresses concern that some consumers not seeking coverage until they are married. CMS proposes that if consumers are newly enrolling in QHP coverage through the Exchange through the special enrollment period for marriage, at least one spouse must demonstrate having had minimum essential coverage for 1 or more days during the 60 days preceding the date of marriage. There is a special rule for individuals who may not have been living in the United States prior to their marriage.[6]

The Proposed Rule would also significantly limit the use of the exceptional circumstances special enrollment period. In previous years, this special enrollment period has been used to address eligibility or enrollment issues that affect large cohorts of individuals where they had made reasonable efforts to enroll, but were hindered by outside events. If the proposal were adopted, CMS would apply a more rigorous test for future uses of the exceptional circumstances special enrollment period, including requiring supporting documentation where practicable. It would grant this special enrollment period only if provided with sufficient evidence to conclude that the consumer’s situation was truly exceptional and in instances where it is verifiable that consumers were directly impacted by the circumstance, as practicable.[7]

CMS is also exploring ways to incentivize consumers to maintain continuous coverage.

These proposed special enrollment changes would not apply to special enrollment periods under the Small Business Health Options Program (SHOP).[8]

Network Adequacy

CMS proposes changes to the oversight of network adequacy requirements to “affirm the traditional role of States in overseeing their health insurance markets while reducing the regulatory burden of participating in Exchanges for issuers.”[9]

CMS proposes to rely on State reviews for network adequacy in States in which an FFE is operating, provided the State has a sufficient network adequacy review process, rather than performing a time and distance evaluation. Beginning in plan year 2018, it would defer to the States’ reviews in States with the authority that is at least equal to the “reasonable access standard” and means to assess issuer network adequacy, regardless of whether the Exchange is a State-based Exchange or federally facilitated, and regardless of whether the State performs plan management functions.

In States without the authority or means to conduct sufficient network adequacy reviews, CMS would rely on an issuer’s accreditation (commercial or Medicaid) from an HHS-recognized accrediting entity. HHS has previously recognized 3 accrediting entities for the accreditation of QHPs: the National Committee for Quality Assurance, URAC, and Accreditation Association for Ambulatory Health Care. An unaccredited issuer would have to submit an access plan.

Interpretation of the Guaranteed Availability Requirement

CMS proposes revising the interpretation of the guaranteed availability requirement to allow issuers to apply a premium payment to an individual’s past debt owed for coverage from the same issuer enrolled in within the prior 12 month. CMS argues this change is necessary to “remov[e] economic incentives individuals may have had to pay premiums only when they were in need of health care services and to encourag[e] individuals to maintain continuous coverage throughout the year and prevent gaming.”[10]

De Minimis Variation in the Actuarial Values

CMS proposes increasing the de minimis variation in the actuarial values (AVs) used to determine metal levels of coverage for the 2018 plan year to “allow issuers greater flexibility in designing new plans and to provide additional options for issuers to keep cost sharing the same from year to year.”[11]

Essential Community Providers

CMS proposes allowing issuers to use a write-in process to identify essential community providers (ECPs) who are not on the HHS list of available ECPs for the 2018 plan year; and lower the ECP standard to 20 percent (rather than 30 percent).[12] 

[1] CMS Patient Protection and Affordable Care Act; Market Stabilization Proposed Rule.

[2]Id.

[3]Id.

[4]Id.

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[12]Id.

The Future of Prior Authorization

Written by Brian Werfel on . 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.

New Membership Referral Program!

Written by Amanda Riordan on . Posted in AAA HQ, Member-Only.

No one knows better than an AAA members the incredible value of membership. Consider sharing your AAA membership experience, and get rewarded for doing so!

Through our new Membership Referral Program, receive a free webinar registration for each new member organization you refer that successfully joins the association. Successfully sign up 6 new member organizations, and you’ll receive a free registration to the AAA Annual Conference & Trade Show! To participate, simply copy ariordan@ambulance.org on emails you send to colleagues inviting them to join. AAA staff will answer questions and help with follow up.

Not quite sure what to write? Here’s a sample email to get you started!

Dear Colleague’s Name,
I hope your year is off to a great start. I wanted to send a quick note to ask if Colleague’s Ambulance Servicemight be interested in membership to the American Ambulance Association?

My service is a proud member of AAA, and the advocacy work they do on behalf of our industry is more important now than ever. In addition to working toward fair reimbursement, AAA now offers free counseling and CISM for your staff, access to experts on operations and Medicare, and much more. I especially enjoy the sessions and networking at Annual Conference, as well as the ability to recognize my top field staff at Stars of Life. I have copied AAA’s membership staff on this message in case you have any questions about benefits or dues.

I hope that you’ll consider supporting the American Ambulance Association. Thanks for considering, and have a great one.

Your Name

Medicare Relief and Reform Letter by President Postma

Written by Mark Postma on . 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 115th 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 – 114th 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 . 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 . 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 . 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).

Free Post-Election Analysis Webinar for Members

Written by Aidan Camas on . Posted in Elections, Events, Government Affairs, Member-Only, Webinars.

Post-Election Analysis Webinar – Thursday, November 17th, 2:00pm EST

post-election-analysis

The recent elections resulted with Republicans taking control of the White House and retaining a majority in the House and Senate. In the first 100 days of the Trump Administration, we will see a major shift from the policy positions of the current administration. It is likely that there will be immediate efforts toward the repeal, amendment, and replacement of the Affordable Care Act as well as tax reform and infrastructure improvement. Join us for this free webinar, and hear former Members of Congress Bill Paxon (R-NY) and Vic Fazio (D-CA), whom both served in their respective party leadership, give their analysis of the elections and of where the new Administration and Congress go from here.

Register Now

Unable to Attend?

No problem! All webinars will be recorded and available to stream On-Demand. Register now and watch on your own time!

Questions?

Please contact Colleen Crowley at ccrowley@ambulance.org.

CMS SMR Contractor Audit Error

Written by Brian Werfel on . 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 . 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

 

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