Friday, May 17, 2013

Payment Reductions Loom for Dialysis Transports

Section 637
Remember “Section 637.”

This is the section of the American Taxpayer Relief Act of 2012 that will require the Center for Medicare and Medicaid Services (CMS) to reduce Medicare payments for BLS Non-Emergency ambulance transports nationwide by 10% beginning on October 1, 2013.

Non-Emergency, Basic Life Support transports of individuals with end-stage renal disease (ESRD) to and from dialysis treatment facilities will be affected by the reduction.

Another blow…
Having just taken a hit from sequestration, the American ambulance industry now has to absorb yet another blow.

CMS Transmittal 2703, posted just last week to the CMS website spells out for the Medicare Administrative Contractors (MAC’s) how the reductions will be assessed in anticipation of the upcoming changes, now a little less than five months away.

The transmittal explains “The payment reduction affects transports to and from both hospital-based and freestanding renal dialysis treatment facilities for dialysis services provided on a non-emergency basis.”

How the Reduction Will Work
When your billing office submits your Medicare claims for payment, the MAC will calculate the normal payment rate, including any applicable add-on payments, per the national Ambulance Fee Schedule (AFS). After determining the allowable payment amount, the MAC will then reduce payment amounts for both the BLS Non-Emergency base rate and the associated Loaded Mileage reimbursement by 10%.

The reduction will be assessed on all claims that are billed using the A0428 and A0425 HCPCS codes combined with the applicable origin/destination modifier codes for either the hospital-based or freestanding dialysis treatment facility.

The 10% reduction only applies to payments for ambulance transports to and from renal dialysis treatment that are provided to ESRD patients. While it is possible that a non-ESRD patient can be receiving regular dialysis treatments, and also require ambulance transport to and from those treatments, it is highly unlikely.

But in the event a non-ESRD Medicare beneficiary patient requires dialysis treatments and is medically necessary requiring ambulance transport to and/or from those treatments, CMS has instructed the MAC’s that they have the ability to offset the payment reduction upon receiving an appeal from the ambulance provider/supplier containing supporting documentation proving the patient has not been diagnosed with ESRD.

Identifying ESRD a Must
So, now that we know it’s coming and we know how it will work, what comes next?

We think the first big step you can take is to identify what patients you are currently transporting to and from dialysis carry an ESRD diagnosis and what patients aren’t diagnosed with ESRD. That’s an important first step.

Second, it’s time to get tougher call-intake and screening measures in place.

When taking the next call requesting your service to add a new dialysis patient transport, get serious by adding extreme screening measures to first sift out medical necessity (i.e. obtain medical records, make site visits to vet out the patient’s overall condition, train call-takers to ask probing questions about the patient’s overall condition, etc.) 

Once, and if medical necessity has been established for the transport, develop a means to collect if the patient is or is not an ESRD patient. This information will be key for your billing department (in-house or outsourced) down the road.

Coming up…
We’ll disconnect here. In our next blog post we’ll offer a few suggestions on how to begin preparing for the financial hit and what you can do to maybe offset the payment reduction.

In the meantime, what can Enhanced do to help you prepare? The time to complain has come and gone. Now we’re all going to have to live with it. Enhanced provides reporting tools and experience in assisting our clients with obtaining the necessary knowledge and data to soften the blow of this latest hit to the EMS industry.

Be sure to stay tuned to this blog space. Re-read some of our former posts to gain insight on where our industry is heading with regards to reimbursements in light of the country’s new healthcare initiatives.

Looking for an EMS outsourcing solution? You’ve come to the right place. Contact our Business Development Manager, Chuck Humphrey, today. You can connect with Chuck by e-mail at or by phone at (800) 369-7544, Extension 108.
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