Friday, June 27, 2014

Understanding the Medicare Prior Authorization Demo Project

Repetitive Scheduled Non –Emergent Ambulance Transports
The Centers for Medicare and Medicaid Services (CMS) just announced that they will pilot a demonstration project to pre-authorize Repetitive Scheduled Non-Emergent Transports.

Authorized Stamp
Repetitive Scheduled Non-Emergent Transports are defined when the same patient is transported three or more times over a ten-day period or at least once each week for three weeks. The large majority of these transports are to and from dialysis facilities and also for radiation treatments. Other types of transports can also qualify if they meet the frequency criteria.

Targeting Dialysis in NJ, PA,SC

This trial program will target three States. It will be conducted in New Jersey and Pennsylvania by the Medicare Administrative Contractor (MAC) Novitas Solutions Inc. The program will also include South Carolina where Palmetto GBA is the MAC.

These three States were targeted for the demonstration program as they were identified in a recent MedPAC Committee study as being at the top of a list of six States that had significantly higher dollars paid annually for dialysis transports.

Been There, Done That…

Palmetto already has had experience successfully conducting such a program when they were the Part B MAC for the State of Ohio. The Palmetto program, at the time, was very effective and provided the ambulance service with continual feedback regarding their determination of medical necessity before the ambulance service invested into multiple transports.

Plus, with the MAC pre-auth in hand it gave the Ohio ambulance providers relative peace of mind they would not see these highly audit-able claims fall under any type of review down the road.

Ambulance Administrator- what’s it mean to you?

If you are an ambulance administrator and your ambulance department is physically located in one of the three trial States and your department provides these types of transports begin to prepare now for this trial to begin (CMS has not announced a start date and has only stated the program is coming soon.)

Once implemented, you will need to submit documentation to the MAC on or before the fourth transport provided to the same patient in a 30-day period because if you submit claims for your patient the fourth claim will automatically put those trips into pre-payment review.

CMS has indicated that the MACs will be required to accept documentation via fax and a secure internet method called Electronic Submission of Medical Documentation (esMD). The commitment will be for the MAC to issue (or deny to issue) a prior authorization within ten business days from that point. If the health and well-being of the patient is at risk, there will be an expedited process provided for the MAC to quickly consider the disposition of the trip but only if the patient’s condition meets certain urgent criteria.

So, for a dialysis patient who typically requires three round-trip transports per week, you could technically find yourself taking as many as six to maybe nine round-trip transports (twelve to eighteen individual trip legs) before the MAC decides if you’re ultimately going to be paid for these trips.

CMS did indicate recently that a supplier can elect to allow the trips to go into pre-payment review without obtaining a prior authorization which will take a lot longer for the review and slow up cash flow considerably. However, doing so will allow for the normal appeal rights to come into play whereas the prior authorization determination will be the final word.

For the administrator, what this boils down to is that you should have been already pre-screening these patients to make sure that the medical necessity and reasonableness of each trip is solid before submitting a single claim. In our opinion, this program- while admittedly adding an additional layer to the process- will give you the peace of mind knowing that the MAC has weighed-in, up-front regarding their determination for your patient. Plus CMS stated that these claims should reasonably not come back around in a future review process, with the exception of the random CERT reviews or if a provider/supplier find themselves on the radar screen for larger fraud and abuse issues.

Our advice, as it’s always been, is to remind each of you to employ the basics.

  • Have an excellent call-intake process in place and pre-screen each new repetitive patient.
    • Consider using face-to-face visits for each patient BEFORE you commit to transport them.
    • Open communication lines between your department and referring facilities and physicians.
Ambulance Staff Members- What’s it mean to you?
Staff members, the only thing this means to you is that you must continue to nail the documentation for these patients following each transport. Be certain that you are writing Patient Care Reports that adequately describe the patient’s medical condition and support that the patient is medically necessary and the trip itself is reasonable.

If you don’t feel that you can do so, then you must communicate your doubts to the administrator(s) you report to.

Everyone in your ambulance department must work together to weed out the patients who definitely require ambulance transport to separate them from those patients who can be transported safely by other means. Those who can be transported safely by other means should be provided alternate transportation methods other than in an ambulance and certainly those transports will not be billed to Medicare.

Bottom line…

Because we have worked within the Ohio process with Palmetto in the past, Enhanced has the experience and understanding to assist our clients with meeting the demands of this new process.

Even without seeing the actual program in play as it will evolve under these new rules, we are cautiously optimistic about this program. We believe this to be a positive step taken by CMS as it is proactive rather than reactive and is not punitive.

Of course, time will tell as we watch the program unfold.

The bottom line is, Enhanced has this covered. We’re ready to help our clients comply.

Current Enhanced clients, watch for more information upon program implementation.

Not an Enhanced client? You NEED a billing office that has the know-how to help you navigate these new prior authorization waters. Contact Enhanced today by visiting our website at or call us at (800) 369-7544 and ask for Chuck Humphrey. You can e-mail him at
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