PSOW 2012 - Quality & Reimbursement
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Transcript of PSOW 2012 - Quality & Reimbursement
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?
