Friday, May 8, 2015

CMS Releases Further Clarification and Guidance about Prior Authorizations

Here to Stay
The Centers for Medicare and Medicaid Services (CMS) Prior Authorization Demonstration Project is here to stay. Put in place by CMS as a pilot project in the States of New Jersey, Pennsylvania and South Carolina in December, 2014; the program requires that all Scheduled, Repetitive, Routine Non-Emergency Transports receive a prior authorization in order to be paid.

We’ve now blogged about this program a few times and we learn each and every day just how game-changing the project is. Just last month, legislation passed to extend the program to several additional States (Delaware, DC, Maryland, North Carolina, West Virginia and Virginia) beginning January 1, 2016 and then to all States effective January 2017.

MLN SE 1514

The Medicare Learning Network educational tool this week published bulletin SE 1514 with the intent of providing an overview of the Prior Authorization Model. As time moves on, CMS is learning slowly that there remains a lot of ambiguity and confusion over the program while they garner continued complaints about the number of rejections the ambulance provider community is receiving as a result of the project.

Using key articles like this, they are doing their best to educate all of us on how to provide the correct information in order to facilitate the Prior Authorization process positively.


Key Points

SE 1514 reminds us of several key points and focuses on answering some of the questions they’ve been receiving about the project.

Medical Necessity

We’re reminded that in any case where some other means of transportation, other than an ambulance, could be used without endangering the individual patient’s health and whether or not such other transportation is actually available, no payment may be made for ambulance service. The reason for the ambulance transport must be medically necessary and the transport must be to obtain a Medicare covered service or return from that service.

They specifically point out that Medicare may cover repetitive, schedule, non-emergency transportation by ambulance if…

  • The patient meets bed confinement criterial and/or medically required ambulance transport –and-
  • The ambulance provider/supplier obtains a written order from the patient’s attending physician BEFORE furnishing the service in order to certify that the medical necessity requirements are met.
    • This happens by way of the Physician’s Certification Statement (PCS) which must be signed by the physician and obtained no more than 60-days prior to the requested start date for the transports.
In addition to the PCS, the EMS agency requesting the Prior Authorization must provide relevant documentation from the ordering physician’s medical records that provides a clear picture of the patient’s current condition that requires ambulance transport and that documentation can’t be date more than 60 days from start of the transports.

This documentation can include but is not limited to:

  • Doctor’s progress notes
  • Nursing notes
  • History and Physical Exam
  • Physical or occupational therapy notes
Plus, we’ve learned that Skilled Nursing Facilities maintain a set of records known as the Minimum Data Set (MDS) which is a nursing home’s comprehensive resident assessment and care screening document. It contains a wealth of information that can be helpful to paint the medical necessity picture about the patient and his/her medical necessity.

These are the key documents that must be submitted to the Medicare Administrative Contractor (MAC) for consideration by the Prior Authorization project’s medical review team in order to successfully obtain the approval.


Focus on Wound Care Services 

We found SE 1514 to be particularly enlightening regarding wound care related transports. It is apparent that CMS is fielding questions and/or complaints about these transports’ being denied prior authorizations.

The transmittal specifically states that CMS believes that most wound care is managed in the home or SNF and requires only periodic clinic appointments. Right there, we’ve all been placed on notice, they’re watching for these transports!


But, the document goes on to state that if ambulance is required they reasonably expect the trips to be for the purpose of…

  • Debridement
  • Wound management –or-
  • Infection-related types of services.
Read between the lines and be careful about your agency’s upcoming transports for anything but these types of intensive, sterile environment wound care services as we can almost predict that prior authorizations will not be granted if the care falls outside of these lines.

The rule always is…if CMS takes the time to specifically mention one type of scenario they have a purpose for focusing on that line of business and that purpose is probably to deny payment for the related transport.


Keep us Posted

Let us know what you’re experiencing with the Prior Authorization process. When we all share information we continue to learn. We welcome your comments and questions

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