What This Means for the Ambulance Industry 

The Bonuses:  Until December 31, 2017, the Medicare fee schedule amount for ground ambulance services will continue to be increased by:

• 3% for transports originating in rural areas;
• 2% for transports originating in urban areas; and
• 22.6% for transports originating in super-rural areas.

No gap in bonus payments.  The ambulance bonuses expired back on March 31, 2015.  But, the Bill makes the bonus extensions effective on April 1, 2015.

Minimal claims reprocessing.  Medicare contractors have been holding claims for dates of service (DOS) on or after April 1, 2015 to eliminate the need to reprocess claims.  MACs have been instructed to implement the bonuses immediately.  However, CMS cautioned that a small number of claims may be processed without the bonus payments. For these claims, CMS stated that the MACs will automatically reprocess the claims at the updated payment rate and no further action is necessary from providers who have already submitted claims.  The bottom line is that most of your claims for DOS on or after April 1, 2015 should be processed with the bonuses and for those claims that are not, your MAC should automatically reprocess them.

PWW Tip: Pay close attention to your Medicare EOBs for dates of service on and after April 1, 2015 to make sure they are being paid with the bonus amounts and are being properly reprocessed by your MAC if they need to be reprocessed.  

The Prior Authorization Program:  The Bill also expands the existing model prior authorization program for scheduled, repetitive non-emergency ambulance transports.  Currently, ambulance suppliers in Pennsylvania, New Jersey and South Carolina must obtain prior authorization from their respective MACs for scheduled, repetitive NE transports.  This Bill would continue the program in these states and then expand the model program as follows:

• More States in 2016
  • ​No later than January 1, 2016, HHS must expand the model program to cover: Delaware, DC, Maryland, North Carolina, West Virginia and Virginia starting January 1, 2016.
• Nationwide in 2017
  • The Bill calls for the expansion of the prior authorization program to all states beginning  January 1, 2017, provided HHS determines that the initial model programs have met all appropriate criteria.

PWW Tip: Ambulance services, especially those in states where the program is expanding in 2016, should take a look at the current model prior authorization program.  You can click HERE to read more information from PWW about the program.

What Else Should We Know About the Bill?

The “Doc Fix”:  The media has focused a lot of attention on the repeal of the Medicare Sustainable Growth Rate (SGR).  The SGR is a cost control formula put into place in 1997, aimed at controlling Medicare payments for physician services.  But, Congress has regularly suspended the SGR through various “doc fix” bills because applying the SGR would have resulted in big Medicare reimbursement cuts to physicians (21% this year if the SGR was applied).

Ambulance industry advocates have been successful at getting ambulance bonus extensions included in “doc fix” bills over the past several years.  But with the repeal of the SGR, the ambulance industry will have to look to other legislation to extend bonus payments in the future.

The “Integrity” Provisions:  The Bill also includes provisions aimed at protecting the integrity of Medicare, such as:

• A requirement that HHS establish policies and claims edits to prevent improper payments for services furnished to individuals who are incarcerated, deceased, or not legally present in the U.S.;
• A requirement that MACs establish an “improper payment outreach and education program” for providers; and
• A directive to HHS to develop a plan to revise the incentive reward program to enhance rewards for individuals reporting Medicare fraud and extending the program to Medicaid.

Join us at abc3 this spring for much more about the prior authorization program, new fraud and abuse initiatives, and how you can be prepared in 2015, 2016 and beyond.