About Your Presenter:

Jerry Miller, NREMT-PCEO/President – LifeQuest Services

Jerry has been actively involved in the EMS and fire industry for 33

years.

TODAY

ACCREDITATION – Impact on EMS Reimbursement

CURRENT REIMBURSEMENT

ISSUES

Accreditation

A process whereby a professional association or non-governmental agency grants recognition to a school or healthcare institution for demonstrated ability to meet pre-determined criteria for established standards such as accreditation of hospitals by the Joint Commission on Accreditation of Healthcare Organizations.

Certification

A process in which an individual, an institution, or an educational program is evaluated and recognized as meeting certain pre-determined standards. A Certification is usually made by a non-governmental agency.

Accreditation

Example:

National Academy of Ambulance Coders (NAAC)

Certification

Accreditation

Example:

National Academy of Emergency Dispatch (NAED)

Accreditation

Accreditation

Example:

Commission on Accreditation of Ambulance Services (CAAS)

Accreditation

Accreditation

Example:

Commission on Accreditation of Medical Transport Systems (camts)

Accreditation

Accreditation

Today’s discussion

Focus:CAAScamts

Accreditation

CAAS

Primary Focus:

Ambulance/Ground Transportation (ALS & BLS)

Accreditation Camts

Primary Focus:

Fixed Wing and Rotary Transportation as well as Critical

Care Ground Transport

Accreditation camts

Will also provide accreditation for ALS and BLS Ground Transportation

when related to a Critical Care Transport Service that is accredited.

Accreditation

CAAS & camts

Primary Focus:

CAAS: Business processes

camts: Patient care and safety

Accreditation

CAAS & camts

Both CAAS and camts evaluate reimbursement processes within the organization as part of

accreditation.

Accreditation

CAAS & camts

When asked about reimbursement being tied to accreditation…

Accreditation

CAAS

...CAAS does not place a lot of emphasis on accreditation

being a key part of reimbursement

Accreditation

CAAS

...This was confirmed in discussionswith a former CAAS board member

and attorney at law

Accreditation

Camts

...camts is currently working with CMS to explore having

reimbursement tied to accreditation.

Accreditation

Camts

In discussions with industry experts:

there seems to be some in-fighting among air transportation providers

at this time with disagreements about who should regulate the air

ambulance industry (FAA vs State)

Accreditation

camts

Other disagreements include:

Elevated reimbursement for more sophisticated air transport systems

i.e., better equipment and enhanced staffing

Accreditation

MedPac

MedPac =

Medicare Payment Advisory Commission

Accreditation

MedPac

Independent Agency established by the BBA to

advise the U.S. Congress on issues affecting the Medicare

program.

Accreditation

MedPac

MedPac is currently studying ambulance reimbursement

Accreditation

MedPac

MedPac may be brought in to the fold of discussing

larger reform for the ambulance industry

including quality of care issues.

Accreditation

Jerry’s Crystal Ball

Ground Ambulance

Transportation

Accreditation

Jerry’s Crystal Ball

The next five years:

not much change for ground ambulance in relationship to

accreditation and its impact on reimbursement

Accreditation

Jerry’s Crystal Ball

Over five years:

????????????

Accreditation

Jerry’s Crystal Ball

Air Ambulance

Transportation

Accreditation

Jerry’s Crystal Ball

Next five years:Accreditation could have impact on reimbursement

Accreditation

My Two Cents Worth

Regulate ourselves before we are regulated by CMS

Accreditation

Accredited Center of Excellence (EMD)

• Dane County Public Safety Communications Madison WI

• Camts MedLink Air across Wisconsin• Flight for Life Milwaukee WI

•Mayo Medical Transport Minnesota• Gold Cross Ambulance Minnesota

Accreditation

CAAS

Wisconsin CAAS Accredited Services

• Rib Mountain Fire Department Wausau, WI

•Wisconsin Rapids Fire Department WI Rapids, WI

Accreditation

CAMTS Accredited ServicesWisconsin

•MedLink Air – La Crosse, WI• Flight For Life – Milwaukee, WI

•Mayo Medical Transport – Minnesota•Gold Cross Ambulance - Minnesota

Accreditation

Resources

www.caas.orgwww.the-aaa.orgwww.medpac.gov

www.pww.emslaw.com

Current Reimbursement Issues

Reimbursement Issues

2013 Medicare Rates

•CPI-U is estimated to be 1.7%

Reimbursement Issues

2013 Medicare Rates

• 2013 Ambulance Inflation Factor

•Calculated by taking CPI-U minus the MFP = AIF

Reimbursement Issues

2013 Medicare Rates

• MFP = multi-factor productivity index (10 year moving average of private non-farm businesses)For 2013, estimated to be 1.1 to 1.2%

Reimbursement Issues

2013 Medicare Rates

• 2013 Ambulance Inflation Factor estimated: CPI-U at 1.7% minus 1.1% = an Ambulance Inflation Factor 0.5 to 0.6%

Reimbursement Issues

Sequestration

• 2% reduction in Medicare payments• (eff: January 1, 2013)

•Result of “Super Committee” failing to reach an agreement on spending cuts

Reimbursement Issues

Sequestration

•This will likely not be resolved prior to the elections.

Reimbursement Issues

Next Factor: Expiration of Temporary Adjustments

Scheduled to expire on December 31, 2012

•2% increase for urban•3% increase for rural•22.6% increase for super rural

Reimbursement Issues

Let’s Do the Math2013 Medicare Rates

•0.5 – 0.6% inflation (AFI)•Minus temporary adjustments•Minus additional 2% (sequestration)•Approximately 3.5% loss in MC rates based on loss of urban adjustments

Reimbursement

Legislative UpdateMedPAC

•MedPAC to study ambulance reimbursement• Study appropriateness of temporary

adjustments• The need to affirm current payment structure• Including permanent ambulance relief

• Expected to show the same results as the last report from 2007

2007 GAO Report• Medicare pays an average of 6% below cost

• 17% below cost in super rural areas

Reimbursement

Permanent Ambulance Relief

Current Proposed LegislationMedicare Ambulance Access Preservation Act (MAAPA)• 6% increase for urban and rural transports• 22.6% increase for super rural• This is for 2012-2016• Still pending; building support from legislature

Reimbursement

Payment Data

Fiscal Year 2010• Total spent on ambulance transport including air ambulance:

$4,589,990,960

Reimbursement

Payment Data

That was a 1.66% increase from the year before (2009)

Reimbursement

Payment Data

Problem Areas:

Big surprise –DIALYSIS

Reimbursement

Payment Data

•Houston, TX area – 9 out of 10 patients transported for dialysis go by ambulance.

•Nationwide the average is 1 in 10

Reimbursement

Payment Data

•Puerto Rico recently on a per capita basis were transporting more patients by ambulance for dialysis than the entire state of New York

Reimbursement

Overpayments

•Sixty day requirement to report and return overpayments•Significant false claim act liability•Overpayments must be returned 60 days after it’s been identified•There was some discussion about clarifying when an overpayment has been “identified”

Reimbursement

Overpayments

•AAA is asking that overpayment not be “identified” until the latter of:

• Exhaustion of appeal rights• Expiration of time to appeal under the next level

Reimbursement

Revalidation

• CMS is requiring all Medicare providers and suppliers to “revalidate” their Medicare enrollment information• Current target date is March of 2015• Contractors have been given the discretion I went to revalidate each provider group

Reimbursement

Revalidation

•Every service will require a site inspection

•There is one company in the US providing these inspections – don’t expect this any time soon

•No advance notice provided

Reimbursement

PECOS

Provider Enrollment, Chain &Ownership System

•Medicare’s electronic enrollment database• CMS wants all providers and suppliers enrolled in PECOS by the end of the year• If Medicare sends you a request to revalidate, you have 60 days• Failure to respond can result in termination of your billing privileges with a potential one year band on “re-enrollment”

Reimbursement

ANSI 5010

• Initial implementation date – 1/1/2012• Enforcement delays through 6/20/2012

Reimbursement

Wisconsin Carrier

•WPS• Appealing CMS decision• Currently in dispute•Wisconsin could end up in Region 6 and potentially be administered by Noridian

Reimbursement

Co-Insurance Waivers

•Opinion issued 6/20/2012•Permitted a non-profit ambulance service to waive co-payments due from county residents that had paid an EMS user fee•Membership/user fee must exceed the amount being waived

Reimbursement

ICD-10 Codes

• Implementation date now pushed to October 1st, 2014

Reimbursement

Healthcare Reform

• Court held that individual mandate was a valid exercise of congress’ power to levy taxes• That was a 5 to 4 decision

Reimbursement

Affordable Care Act (ACA)

• ACA will require all states to expand their Medicaid program to include all individuals with incomes up to 133% of the federal poverty level• Federal govt will pick up 100% of initial cost and 90% of the costs in 2020• Penalty for failing to meet this mandate would be forfeiture of all Medicaid dollars

Reimbursement

Affordable Care Act (ACA)

• By a 5 to 4 margin, the court held that any constitutional problem could be remedied by rewriting “the law to

allow any state that opted out of the Medicaid expansion to keep existing

Medicaid funding”

Reimbursement

Effects of Court Decision

• ACA implementation will go forward• States will have the option to:• Expand their Medicaid programs and accept federal money to cover cost for these additional recipients• Elect not to expand their programs and keep only the money they currently receive from the federal government

Reimbursement

Healthcare Exchanges

• ACA requires states to establish state exchanges

Reimbursement

Exchange Timeline

•2010 – Passage of ACA•2011 – Release of exchanged propose

rule•2011 – Release of essential healthcare

benefit guidance•2012 – Release of final exchange rule•2014 – Exchange is implemented

Reimbursement

Accountable Care Organizations (ACO)

• A network of hospitals, physicians that will share responsibility for providing care to

patients• ACO would be responsible for pre-hospital,

inpatient acute care, and post-acute care patients

• Goal is to replace insurance company as the gatekeeper

• Ultimately a capitated payment program

Reimbursement

Fraud

Texas Dialysis• Trailblazer in Texas now requires pre-payment review after patient’s twelfth

transport per year• 90+% denial rate

Reimbursement

Fraud

Puerto Rico Dialysis• 2008 Medicare data – estimated that Puerto Rico has 620,000 Medicare beneficiaries• They had 407,000 dialysis transports• Comparatively, CA, FL, and NY combined have an estimated 11 million Medicare beneficiaries and 356,000 dialysis transports• The answer...

Reimbursement

Fraud

Pre-transport analysis

New this week

Waiving Co-Pays for Residents

Membership Programs

ALS/BLS Joint Billing

Intercepts

Questions?