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By Samantha Hilker
On Tuesday, January 23rd, the EMS Live in Wisconsin podcast featured two guests who, on the surface, were entirely different. Dr. Suzanne Martens, the EMS Medical Director for the State of Wisconsin, spoke to the Physician Advisory Committee’s (PAC) work and plans for 2018 during the shows first segment. In the second half, Joe Kachelski, CEO of Wisconsin Statewide Health Information Network (WISHIN), talked about the new use case for EMS that allows EMS agencies to access the Health Information Exchange for billing purposes. After listening to each guest share their work, the resources now available for EMS, and future plans, it became clear they were sharing a mission: to remove barriers in the delivery of quality patient care.
Dr. Martens and the PAC are working to remove barriers for EMS services across the state by cleaning up language and ensuring resource documents, like the combined scope of practice and paramedic medication list, are up to date and accessible on the Wisconsin EMS website (https://www.dhs.wisconsin.gov/ems/licensing/scope.htm). They are also taking a critical look at the national scope of practice compared to the current scopes of practice for all levels in Wisconsin; in some areas Wisconsin is ahead of the curve while other areas there is room to grow. She also talked about the importance of accessing information and resources on the EMS website, including contact information for all PAC members and meeting dates for the EMS Advisory Board and committees. Provider and service level involvement is vital to the continued progression of EMS in Wisconsin, and the meetings can even view the sessions remotely! All of this information can be found here.
Joe Kachelski and the entire WISHIN team have been working to remove information barriers by building a robust Health Information Exchange in Wisconsin. Care providers, like hospitals and healthcare systems, can access medical history and patient information that may aid them in clinical decision making, particularly in emergency situations when patients may be unable to share the information. They are now expanding access and use of that network to EMS agencies. While EMS agencies may not have the luxury of time and resources to access an electronic health record and review medical history at the time of care, they can certainly benefit from accessing the network and gathering FACE sheet data for billing purposes after the fact. Organizations do have to be registered users to gain access to the health information exchange, but Joe assured us the process is straightforward and he and his team are there to help by giving demonstrations, answering questions via phone or email, and supporting you through the process. You can find more information on the WISHIN network on their website.
Barking dogs aside, the podcast was full of information and is worth 30 minutes of your time. Be sure to check back in February for the next episode featuring Scott Moore, Esq. where we'll be talking about employee incentive programs.
P.S.— Don't miss the next episode February 20 at 9am CT. Scott Moore, Esq will share with listeners the good, the bad, and the ugly about employee incentive programs.
by Samantha Hilker, Hilker PSM
PAAW’s first podcast of the new year was scheduled with James Newlun, then EMS Section Chief for the Wisconsin EMS Office. The goal of the podcast was to facilitate a discussion with a representative of the State EMS office about staffing and what, if anything, could be done at a state level to help alleviate the burden services are feeling. As you may remember, PAAW mailed a letter to the state office outlining several concerns and potential solutions to the staffing shortage last year (you can read the letter here). Unfortunately, we were unable to secure an alternative representative from the state office as a guest after James announced his exit in late December, and the podcast was subsequently canceled. With the Section Chief role vacant the day to day duties are keeping those remaining at the state office quite busy, and they were unable to provide a comment on the subject.
Without the opportunity to engage a representative of the state office, I engaged friends and colleagues across the country and combed through an endless number of articles about staffing in EMS published over the years. Specifically, articles about the difficulties EMS agencies are having when it comes to finding reliable, committed and loyal EMTs and paramedics. Although it feels as though this topic has consumed discussions over the past year in Wisconsin, the dates on the available articles reveal that finding the right people (or any people, in some cases) is not a new problem for EMS.
In September 2015, EMS Insider published an article in JEMS titled Critical Staffing Shortages that discusses the ongoing decline of volunteerism along with difficulty in retention due to the overall demands of the EMS profession. The article cites research done in North Carolina as early as 2008. Another interesting article published in June of 2014 is an editorial piece by Arthur Hsieh where he calls out the lack of a real identity for the EMS industry as the leading cause of recruitment and retention issues. If we don’t know who we are, after all, how do we go about convincing other people to join?
I’ve spent some time asking people who have voluntarily exited the EMS industry why they decided to leave. While this was not a scientific poll by any means, the answers I received came from across the country as well as right in our own backyard; some I know personally as well as some I have never met in person. The low rate of pay was the most common answer I received while working conditions including the length of shift, the state of equipment, condition of quarters and the ability to get along with their co-workers was a typical answer as well. Supportive leadership, or lack thereof, was comfortably third in the ranking of most common responses right along with a lack of advancement opportunities. Many of you reading this, I am sure, are not surprised by this information. So then, how do we fix it? What can be done to stop, or at least slow, the leak?
It may be time to get creative with staffing in EMS instead of relying on the same practice to yield different results. The days of long-term employment, it seems, have been replaced with habits of “job hopping” as the newer generations begin to enter the workforce. Maybe we are asking too much or setting our expectations too high regarding the length of employment. In a recent article on Business Insider by Becky Peterson lists the average period of employment for the 10 biggest companies in tech and the highest is just over two years even though many of the dissatisfiers identified by EMTs and paramedics are not present. Perhaps the best way to keep employees on your roster for longer is to provide them a career path that can be laid out for them on day one of orientation; show them you believe in their future at your organization, and maybe they will believe in it, too.
Congress is heading toward a possible partial shutdown of the federal government without taking action on our expired Medicare add-on payments. While PAAW, the American Ambulance Association, and other industry stakeholders have pressed hard for Congress to immediately pass a five-year extension of the ambulance add-ons, our message is not being heard loud enough amongst all the other noise. We need you to contact your members of Congress today in support of extending the 2% urban, 3% rural and 22.6% super rural increases! Please share with your staff and encourage them to write letters as well.
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Last night, the House of Representatives mostly along party lines passed a Continuing Resolution to fund the federal government through February 16. The fate of the bill in the Senate is uncertain. If Congress does not pass by midnight tonight a measure extending funding for the federal government, there will be a partial government shutdown.
The AAA had pushed for Congress to attach a Medicare provider extender package including a five-year extension of the ambulance add-ons to the Continuing Resolution. Since the extender package was not included in the Resolution, we are pressing Congress to consider a separate extenders only package including the five-year ambulance extension or attach the package to another moving legislative vehicle. We are also pushing Congress to at the very least pass a short-term extension retroactive to January 1 until a Medicare extender package can move.
It is critical that we get the Medicare ambulance add-ons reinstated as soon as possible. So please write your members of Congress today!
Brian S. Werfel, Esq. &
Rebecca Williamson, Chair, AAA Medicare Regulatory Committee
Reprinted with Permission from the American Ambulance Association
Ambulance suppliers face an important decision at the start of every calendar year on whether to hold their Medicare claims for the first few weeks.
This decision historically revolved around the patient’s Medicare Part B deductible ($183 in 2018). The argument in favor of holding claims was that a brief claims hold would allow time for the patient’s deductible to be satisfied by another health care provider, thereby relieving the ambulance supplier of the time and expense involved in billing the patient (or their secondary insurance) for the deductible. Ambulance suppliers that hold claims believe that this ultimately results in higher collections. The argument against holding claims is that any increase in overall collections is likely to be minimal, and that the resulting disruption to the company’s cash flow more than offsets any potential benefits from those higher collections.
This year, the debate is complicated by the events surrounding the expiration of the temporary add-ons for urban, rural, and super-rural ground ambulance transports on December 31, 2017. These temporary add-ons increased the Medicare allowables by 2%, 3%, and 22.6%, respectively. Congress failed to act upon these temporary add-ons prior to its adjournment. However, there remains strong bipartisan support for reinstating these add-ons – – and Medicare extenders for other types of Medicare providers – – early in the 2018 Legislative Calendar. The AAA’s political consultants believe these Medicare extenders will likely be included in the next government funding legislation, which must be passed by January 19, 2018.
Assuming our temporary add-ons are reinstated, they are likely to be made retroactive to January 1, 2018. This would require CMS to retroactively adjust claims previously paid at the current (lower) rate. This may also require secondary payers, including State Medicaid Programs, to retroactively adjust their payment amounts to reflect increased cost-sharing amounts. There is precedent for these sort of retroactive adjustments. Most recently, the Affordable Care Act, which was enacted on March 23, 2010, provided for a reinstatement of these same temporary add-ons, retroactive to January 1, 2010.
In this inaugural edition of the Great Medicare Debate, AAA Medicare Regulatory Committee Chair Rebecca Williamson and AAA Medicare Consultant Brian S. Werfel, Esq. debate the merits of holding claims pending a resolution of the add-on issue vs. submitting claims.
Ambulance suppliers would likely benefit from holding their claims for some period of time pending clarity on the status of our temporary add-ons.
Rebecca Williamson, Chair of the AAA’s Medicare Regulatory Committee:
According to CMS, 73% of all ambulance service suppliers bill less than 1,000 Medicare covered transports per year. Additionally, 54% of ambulance suppliers bill less than 250 Medicare covered transports per year. Assuming an average claim amount of $400.00 per call (base rate plus mileage), an ambulance supplier with 1,000 Medicare covered transports per year could collect approximately $320,000.00 per year in a best case scenario ($400,000.00 X 80%). This leaves the service with copays of $80,000.00 to be collected from patients. By adding $183.00 as a deductible for each of these 1,000 patients, the collection from Medicare decreases to only $173,600.00. This means the service now must collect an additional $43,400.00 . In other words, if the patient has not met the deductible, the deductible is applied first and a $400.00 allowable becomes a $217.00 allowable. Medicare now pays 80% of $217.00 which is $173.60. Multiplied by 1,000 claims, Medicare pays a total of $173,600.00 and the balance owed to the supplier is the deducible of $183,000.00 and copayments of $43,400.00.
By holding claims for a brief period, usually thirty days, ambulance services increase the likelihood that another provider, often a hospital, will file claims with Medicare first, meaning collecting patients’ deductibles becomes the facilities’ responsibility.
Of course these numbers are only examples and many factors affect the actual billing and collection process. Some Medicare beneficiaries will promptly pay the deductible, many will have secondary payers or insurances, and a certain percentage will be dually eligible for Medicare and Medicaid, all of which results in higher collection ratios for the ambulance service. However, in plain terms, collecting $320,000.00 versus $173,600.00 can make a very real difference in the viability of a small service. Each service should look carefully at its own payer mix, patient statistics, and demographics to determine individual service projections.
Another good reason to hold claims, this year in particular, is the almost certainty of Congress reinstating the extenders. For those of us who have been in this industry for a long time, the expiration of the add-ons this year is a painful reminder of 2010 when the extenders expired and were not reinstated until March 23, 2010. It wasn’t until July 2010 that CMS even began the process of correcting previously processed claims , and by January 2011 many claims were still outstanding and had not been completely reprocessed. Also by that time, which could have been as long as a year after the date of service, many secondary payers were either unwilling or unable to retroactively correct the reprocessed claims. Some Medicaid states, such as Oklahoma, simply did not have the manpower or ability to even attempt it.
The administrative burden imposed on ambulance suppliers by having claims retroactively reprocessed by CMS, then reprocessed again by secondary payers – potentially incorrectly, if at all – along with the many manual adjustments required in-house, make it even more attractive to advocate and advise holding claims for as long as financially feasible. Of course not every service has the cash reserve to be able to do this, and I would generally not advise holding claims for as long as it may take for Congress to reinstate the extenders and for CMS to implement the correction for services who cannot afford to, but for those who can, not only will they almost certainly increase the amount of payments collected, they will decrease overhead administrative costs.
I am very optimistic that Congress will include the ambulance extenders in legislation as well as being optimistic that it will be sooner rather than later. I know others disagree, but the higher likelihood of it happening versus not, make this a good bet to take.
Ambulance suppliers should disregard the status of the temporary add-ons when making their decision on whether to hold claims for some period of time
By: Brian S. Werfel, Esq.:
Rebecca makes a strong argument about the benefits of holding claims. Moreover, I have long advocated in favor of holding claims for the patient’s deductible. For these reasons, I would understand if ambulance suppliers elect to hold claims for the patient deductible. However, I would question the wisdom of holding claims pending further clarity on the status of the temporary add-ons.
My argument against holding claims for that reason boils down to a single word: uncertainty. In this context, I am referring to four specific types of uncertainty:
With respect to the extension of the add-ons, I agree that they are likely to be included with other Medicare adjusters in the budget resolution that must pass before January 19, 2018. Likewise, at this point, there is no reason to think that these add-ons will not be made retroactive to January 1, 2018. However, there are no guarantees. It is possible that the Republicans and Democrats fail to reach agreement on the larger budgetary issues, including the status of the so-called “Dreamers”, and a government shutdown results.
My larger concern relates to how quickly CMS revises its fee schedule, and implements instructions to its contractors. As Scott noted above, the last time we faced this issue was in 2010. The Affordable Care Act was signed into law on March 23, 2010. However, CMS didn’t issue a transmittal to its contractors until May 21, 2010, and even then, didn’t instruct its contractors to start paying the higher rates until July 6, 2010.
In other words, if you elected to hold claims to avoid having them paid and then reprocessed, you would have needed to hold claims for more than 6 months.
To me, the strongest argument for holding claims is not how Medicare would handle the adjustment. I recognize the administrative burden created by having to post and then re-post the same claim once it was adjusted. However, I trust that CMS will eventually get it right (emphasis on eventually).
I have far less confidence in how the secondary payers, including State Medicaid Programs, will handle the adjustments. When this happened in 2010, we had numerous reports from A.A.A. members of secondary payers incorrectly processing the adjustment. For example, some State Medicaid Programs didn’t simply issue a supplemental check for the higher copayment. Instead, the Medicaid Program took back its initial payment, and then reprocessed the claim in its entirety. Unfortunately, in some instances, the Medicaid rates changed in the interim, and Medicaid then repaid a lower amount. In other instances, they failed to repay the patient’s deductible. Similar issues were noted with commercial secondary payers, Medicaid managed care organizations, etc.
In sum, if your company has historically held claims during the first few weeks of the year for the patient’s deductible, I see no reason to discontinue that practice. If, however, you historically submitted claims without regard to the patient’s deductible, I see little benefit to holding claims pending action by Congress on our add-ons.
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Great news! Early bird rates for the #MidwestEMSExpo are still available! Register your team today to learn from top national and regional experts in La Crosse May 2–3. Register now►
According to PAAW President Dana Sechler, “The Midwest EMS Expo conference offers a platform for the exchange of ideas and information among ambulance leaders of all levels. Given the constantly changing nature of EMS, it is critical to bring this educational and networking opportunity to our region.”
In addition to powerful educational content, the Midwest EMS Expo will offer attendees the opportunity to experience the best in products, services, and vehicles for EMS providers. Gold Sponsor Savvik Buying Group will be joined by Silver Sponsor Cindy Elbert Insurance Services, Bronze Sponsor eCore, and dozens more exhibitors on the show floor. For a complete list of current vendors, please visit www.midwestemsexpo.com/exhibitors.
Conference registration is now open, with member early-bird rates as low as $200 per attendee. Sponsorship, booths, and vehicle spaces are also available online at low introductory rates. To register for the Midwest EMS Expo or view the complete schedule of events, please visit www.midwestemsexpo.com.
PAAW is a member-based organization dedicated to healthy, sustainable ambulance service delivery in Wisconsin.
President - Dana Sechler
Vice President - Chris Anderson
Secretary - Cody Doucette
Treasurer - Tom Tornstrom
Board of Directors
Government / Municipal Ambulance Services
Jay Steuer, Director, Valders Ambulance, Valders, WI
Mark Fredrickson, Executive Director, Gold Cross / Brillion Ambulance Service, Menasha, WI
*Dana Sechler, EMS Chief / Director, Baraboo District Ambulance, Baraboo, WI
For Profit Ambulance Services
Patrick Ryan, President, Ryan Brothers Ambulance, Madison, WI
*Chris Anderson, Operations Director, Bell Ambulance, Milwaukee, WI
Larry Knuth, Vice President, Paratech Ambulance, Milwaukee, WI
Not-For-Profit / Nonprofit Ambulance Services
David Rae, Operations Director, Gold Cross / N.E.W. Paramedic Service, Menasha, WI
*Tom Tornstrom, Executive Director, Tri-State Ambulance, La Crosse, WI
*Cody Doucette, Operations Manager, Divine Savior EMS, Portage, WI
* Denotes Executive Officer
Amanda Riordan, PAAW Senior Director of Marketing and Membership
Samantha Hilker, PAAW Content and Podcasts
Dr. Mark Westfall, Medical Director Consultant
Attorney Thomas Shorter, Healthcare and Legal Consultant, Godfrey & Kahn Law Firm, Madison, WI
Michael Brozek, Government Relations and Registered Lobbyist, Midwest Strategies, Madison, WI
EMS Live in Wisconsin Podcast
By Joe Covelli, PAAW Executive Director
With the stroke of a pen on the morning of November 27, Governor Scott Walker officially ushered into the state the skeletal framework of Community EMS by signing Assembly Bill AB 151 (Act 66) into law. For PAAW and other EMS stakeholders who worked collaboratively to make this reality, it was a five-year effort.
Community EMS Bill signing, November 27, State Capitol, Madison
This podcast was recorded live on Tuesday, December 12 and went 35 minutes. Our guests included PAAW President Dana Sechler and Pete Carlson and Dr. Pete Tenghe, both with North Memorial Medical Center, Minneapolis.
We discussed the Wisconsin Community EMS law, administrative rules that need to be written by the Wisconsin EMS Section before ambulance and healthcare providers can use these programs, funding sources, staff training considerations, completing a community assessment and more. Minnesota has been using Community Pararmedicine programs the past five years and is credited with giving Wisconsin the framework to start from.
In many ways, the emergence of Community EMS, Community Paramedicine and Mobile Integrated Healthcare is reminiscent of the early years in the late 1960’s and early 1970’s of another EMS industry changing dynamic – Paramedics. Oh yes, there were questions asked – to include training, funding, equipment, as well as state laws to be written, barriers to overcome and some uncertainty.
In May 2010, I had the great pleasure of serving on the committee that brought together in Los Angeles for a dinner and recognition program the five doctors credited with starting the first paramedic systems in the United States in the late 1960’s. I asked one of them, Dr. Eugene Nagel, how he knew he was at a moment in time of developing something great (i.e. a paramedic system)? His response to me went something like this, “We were trying to do the best we could for our community, and our program at the City of Miami Fire Department developed into what we could do at the time. We didn’t know there were other programs just starting out in Los Angeles and Seattle, too. I knew about paratroopers trained to drop in war areas to render first aid, so we called our trained fire personnel who received medical training 'Paramedics', and the name stuck”.
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by Samantha Hilker, PAAW Contributor
“Do not go where the path may lead, go instead where there is no path and leave a trail.”– Ralph Waldo Emerson
November 1, 2017 marks an unprecedented moment for EMS in Wisconsin. Four associations historically focused on their own specific agendas gathered at the Wisconsin State Capitol with a common goal: moving EMS in Wisconsin forward. Although they didn’t know it at the time Patrick Ryan (PAAW President), Jerry Biggert (Chair of Wisconsin EMS Board) and Mahlon Mitchel (PFFW President) set this into motion over 5 years ago.
“They sat down together and agreed to focus energy on the 90% of EMS related items we can all agree on, and let the other 10% go to another day” explains Dana Sechler, Legislative Liaison and President for PAAW. Over the next several years the change was subtle and the action slow. Legislation affecting EMS was passed without known consultation of the various stakeholder groups -- and instead of assuming the other was to blame, the leaders of the EMS associations and organizations started talking to each other and asking how and why this could happen. Last year, a legislative study committee was formed to address the decrease in volunteerism in both EMS and Fire. Additional relationships were forged and strengthened between the stakeholders. Eventually, someone had the audacity to ask what we can do now, in this moment, to ensure stakeholder groups are consulted on legislation that directly effects EMS in Wisconsin. John Eich, Director at the Wisconsin Office of Rural Health, asked the question and provided the leadership needed to unite these four organizations and make EMS at the Capitol Day a reality.
Stronger together was the message of the day. This was expressed in the ability to celebrate the Community EMS bill passing unanimously through the Senate just one day prior, and reiterated during the Legislator Panel with Representatives Loudenbeck, Kolste and Shankland. (The Community EMS Bill also unanimously passed in the Assembly earlier this year and the Governor recently signed into law.) Each of the three Representatives echoed the importance of getting to know your elected officials and the power of stakeholder groups working together and sharing a clear, unified message.
Wisconsin EMS Day, November 1, 2017, State Capitol, Madison
For some participants, the biggest takeaway of the day was seeing so many private, hospital based, county and fire based EMS services, as well as 3rd party service providers and leaders in the same room with a common goal. Many young EMS providers hungry for change were musing at the collection of people in the room, while providers and leaders who have been in EMS for 20 years or more were awestruck looking at something they never thought they would see. Although there was a hint of apprehension leading into the afternoon visits, it seemed to melt away and be replaced with a certain sense of pride. On more than one occasion I heard attendees say they never would have put themselves in a room with the 2 or 3 people they met legislators with. They continued to report their individual surprise that they really did agree on many of the issues discussed, and found themselves listening to understand…instead of listening to respond.
Others had a slightly different takeaway; they saw their years of leadership expressed in their colleagues and team members.
“I’ve increasingly challenged myself to seek others with differing views…those on the fringe, outside my typical group of colleagues and peers. This approach not only provides unfamiliar perspective but leads to building relationships and better outcomes. EMS Lobby Day is another example of relationship building that inspires me to continue stepping outside comfort areas and hopefully challenges others to be more inclusive and collaborative as well.” reflected Jon Cohn, Greenfield Fire Department Chief, President of Wisconsin State Fire Chiefs Association.
On the surface, a group of professionals with the same “job” shared a day at the Capitol talking to politicians. A deeper look reveals the power of a conversation; the willingness to let go of the past and turn our attention towards a future full of possibilities. An exciting change for the veterans of EMS who never thought they’d see the day -- and the newcomers to EMS who will grow up in a culture of collaboration instead of territorial limitations.
Interactive map: find your representatives http://maps.legis.wisconsin.gov/#
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