Friday, April 24, 2015

H.R. 2 and You

Last Week
Last week Congress passed the “Medicare Access and CHIP Reauthorization Act of 2015.” The Bill, H.R. 2, contained an important provision for the ambulance industry and it passed on the brink of allowing the Medicare ground ambulance bonus payments to expire.

The extension effected by H.R. 2 allows them to remain in place until December 31, 2017. This is a welcomed measure as we won’t find ourselves on the brink of losing those payment extensions for another generous thirty-three months.

There’s always a but…
That was the good news. But there’s always a but.

The but here is that Congress working together with the industry now must find a permanent fix and pass it within that 33-month period. The reason why this is now so important is because the ambulance industry lobbyists, most notably the American Ambulance Association, has been able to connect the bonus payments to something called the “Doc Fix.”

The “Doc Fix” is officially termed the Sustainable Grown Rate (SGR). SGR was a cost control formula incepted in 1997 and it was meant to control physician payment rates. Had the SGR been allowed to do its thing last week, it would have meant that physicians across the United States would have realized a Medicare reimbursement loss of 21%.

So, every year when it came time for SGR to take effect, Congress delayed its inception. Wisely, ambulance industry lobbyists were successfully able to slide in the Medicare ground ambulance bonus payments extension at the same time as Congress was acting on the delay in implementation of the SGR.

However, H.R. 2 now effectively repeals SGR so there will be no further, upcoming extension for the bonus payment decision to ride along with through Congress.

All this means that someone in Washington needs to get moving to find a permanent repair to the less than adequate Medicare Ambulance Fee Schedule.

Prior-Authorization Program Extended
Along with the good comes the not-so-good.

H.R. 2 will usher in an extension of the Prior Authorization demonstration program. Right now, scheduled, repetitive non-emergency ambulance transports must be prior authorized in the states of New Jersey, Pennsylvania and South Carolina.

The bill will now mandate that the program extend to include the states of Delaware, Maryland, North Carolina, West Virginia and Virginia beginning January 1, 2016. The following year, beginning January 1, 2017 the program will then be mandated for all States starting January 1, 2017.

Talk to any EMS agency representative that is experiencing this Prior Authorization program currently and they will quickly tell you it has had a major impact on the EMS agency’s bottom line. At the beginning nearly all of the prior-authorization requests had been denied and even now, several months into the program there is a majority failure to obtain Medicare prior authorizations for schedule, repetitive, non-emergency transports.

The result has left patients without a transport option and entire ambulance services folding and going out of business in the affected states.

Now is the time to plan. Learn all you can about the requirements to obtain a prior authorization and work together with your billing office to develop a plan to meet those requirements. Plus, develop a dialogue now with other healthcare providers outside of EMS as you’ll be needing their assistance to obtain the necessary patient medical necessity documentation in order to make your case for a prior authorization to be issued.

New Requirements on the Horizon
Finally, H.R. 2 calls for the Department of Health and Human Services (HHS) to put in place integrity controls to protect the Medicare program form improper payments due to fraud and abuse.

Payments have been found to be flowing to incarcerated persons, persons who are deceased and to persons not legally present in the United States. Congress is mandating that HHS make controls to stop these payments.

HHS must also implement an educational program to reach out to providers about the damage those improper payments due to fraud and abuse causes to the fragile Medicare system.

Congress also is calling upon HHS to make the incentive reward program sweeter to greater encourage individuals to report Medicare fraud and also expand the program into Medicaid.

All of this means that our industry is going to continue to be on the Fed’s radar screen in increasing amounts and it means that we are all going to see new requirements, potentially, in increased audit activity and great compliance controls.

We’ve been talking about this for a long time. The day is here. Our industry is going to need to adapt and meet the demands of even greater scrutiny in order to maintain a healthy bottom line.

Everyone in the ambulance industry, from crew member to administrator is responsible for the outcome for not only your EMS agency individually, but the integrity of the entire American EMS systems as a whole.

The Ambulance Billing Services blog is provided as an educational tool by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is an all-EMS, third-party billing contractor serving Fire/EMS agencies across the United States. To learn more about our company, please visit our website at and click on the “Get Started” link on any landing page.
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