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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”.
>> Click to download podcast and listen now!
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/#
This change is in response to requests from ambulance and EMS providers, who are often not in a position at the time of transport to collect all t he information necessary to bill for their services. They typically follow up days later to seek "face sheet" (encounter) information from the hospital to which they have transported a patient.
According to Nate Hunstiger, Communication and Engagement Specialist, Wisconsin Statewide Health Information Network, "WISHIN recently approved a new use case granting EMS and ambulance providers access to clinical face sheet data in the WISHIN Pulse Community Health Record for billing purposes."
Ambulance and EMS providers often make multiple contacts with hospitals before they receive the face sheet from the encounter. This new use case relieves the hospitals of the burden of responding to these requests and allows ambulance and EMS organizations to more promptly bill for their services.
Assembly Bill 151 (AB 151) authored by Rep. Amy Loudenbeck (R-Clinton), Rep. Katrina Shankland (D- Stevens Point) and Sen. Terry Moulton (R- Chippewa Falls) was signed into law by Governor Walker on November 27 after passing both legislative chambers with unanimous bipartisan support.
Community EMS Bill Signing, Governor's Office, November 27, 2017
AB 151 advances opportunities for non-emergency health care services in Wisconsin by creating and defining community paramedics (CPs) and community emergency medical technicians (CEMTs). It also creates the framework allowing hospitals, private ambulance companies, and municipal EMS providers to develop new strategies for delivering quality care, in the right place, at the right time.
“The Wisconsin EMS Association commends Reps. Loudenbeck and Shankland and Sen. Moulton for their tireless effort and commitment to the safety and continuum of care for all patients in Wisconsin. Today EMS and Fire unite as one voice by utilizing their skills and talents to improve patient outcomes while reducing costs of healthcare to individuals, hospitals, insurance providers and communities, said Marc Cohen, Executive Director of the Wisconsin EMS Association
“I am pleased the Governor is signing this important public health legislation into law. Community EMS promises greater flexibility and room for innovation to lower healthcare costs and meet any number of local healthcare goals,” said Sen. Moulton.
Greenfield Fire Chief Jon Cohn, President of the Wisconsin Fire Chiefs Association stated, “The future of health care is to be proactive instead of reactive. The Wisconsin Community EMS Bill achieves this by optimizing health system performance, improving the patient care experience, improving the health of populations and reducing the per capita cost of health care. Thanks to our Legislators for recognizing the need to shift and allow these expanded services.”
“Wisconsin has many challenges in the health care workforce, including an aging population,” said Rep. Shankland. “Community EMS helps bridge this gap by expanding patient-centered care, especially in regions that are underserved, rural, or have high health care demands. This bill will offer local communities a new innovative tool to improve public health outcomes and serve at-risk patients, and I’m excited to see the positive impact it will have.”
“The Professional Fire Fighters of Wisconsin are energized to promote Community EMS to our most medically at risk citizens. Fire Fighters and EMS Professionals are experts in prevention, and the impact of this legislation will be felt by those in need of better access and more help throughout rural and urban Wisconsin, said Mahlon Mitchell, President of the Professional Fire Fighters of Wisconsin.
Patrick Ryan, owner of Ryan Brothers Ambulance Service and Past-President of the Professional Ambulance Association of Wisconsin (PAAW) said, “PAAW is extremely proud to be a part of this collaborative effort from all across EMS in Wisconsin to pass this enabling legislation for CEMS. Because of this bill, services throughout the state will be able to develop and implement CEMS programs that will improve the health and well-being of our citizens.”
“Pilot programs have already demonstrated that community-based, mobile integrated health produces improvements in health outcomes and medical cost savings. I hope to continue to hear stories about the life-changing impacts on CEMS in the communities across the state,” said Rep. Loudenbeck.
>> Read Wisconsin Act 66 (AB151) signed into law.
On Friday, November 17, President Trump signed H.R. 304, the Protecting Patient Access to Emergency Medications Act of 2017, into law.
H.R. 304 will improve the Drug Enforcement Administration (DEA) registration process for emergency medical services (EMS) agencies, and clarify that EMS professionals are permitted to administer controlled substances pursuant to standing or verbal orders when certain conditions are met.
Authored by committee member Rep. Richard Hudson (R-NC), H.R. 304 initially passed the House by a vote of 404-0 in January. It passed the Senate, as amended, by unanimous consent, in October. H.R. 304 passed the House, as amended by the Senate, sending it to President Trump earlier this month.
“This is an important bill that will help equip our first responders in the most unpredictable and urgent situations,” said Energy and Commerce Committee Chairman Greg Walden (R-OR). “The clarifications in this bill will translate to more detailed accounts of how registered agencies can administer controlled substances.”
“I’m thrilled to see this important fix signed into law,” said Rep. Hudson. “This is an example of how to get things done — finding common ground and advancing bipartisan solutions to get results people deserve.”
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