Reimbursement

Medicare Advantage Primer: What You Need to Know
By Barbara Davenport
In Medicare reimbursement for ambulance services, one size does not fit all. For non-emergency transports, knowing whether a patient’s coverage is traditional Medicare or Medicare Advantage can mean the difference between getting paid and eating the cost.

Hospital Invests in EMS CPAP and Saves Money
EMS agencies are reimbursed for medical transportation based on the patient’s condition at pick-up and the medically necessary level of service provided to the patient before and during the ride to the hospital. Once at the hospital, patients are assigned a code called a DRG (for Diagnosis Related Group) based on their medical diagnosis. The DRG imposes limitations on the reimbursement that the hospital can receive for that patient’s care. Services considered unrelated to the DRG are not covered under Medicare and Medicaid.

How Hospital Reimbursement Rules Brought ALS to Rural Nebraska
By Karen Edwards
Before CAH designation, the ambulance service run by the 20-bed Nemaha County Hospital in Auburn, Nebraska, was typical of many rural EMS operations: It relied on volunteer EMTs to staff its ambulances. With only 120 to 140 transports a year, its EMTs struggled to maintain their skills. Tougher education requirements demanded more time to maintain certification; yet, even if volunteers could find more time, employers were increasingly unhappy about paying employees who were gone from their jobs for hours or even an entire day transporting patients close to 140 miles round-trip to hospitals in Omaha and Lincoln.

AAA Opposes Proposed Medicare Rules
The American Ambulance Association (AAA) has sent at least two letters to the Centers for Medicare and Medicaid Services (CMS) recently opposing proposed changes to rules governing reimbursement for ambulance transport.

Compassionate Billing Demands A Written Financial Hardship Policy
The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) in June withdrew a proposed rule that would have established a federal statute regarding discounting and waiving ambulance transport fees for un- and under-insured patients. Should the withdrawal of the proposed rule make ambulance providers nervous about their financial hardship policies? Not necessarily.

CMS Proposes Changes
The Centers for Medicare and Medicaid Services (CMS) published a lengthy Proposed Rule in July that, if adopted, would result in some significant changes in how EMS providers document ambulance transport for Medicare beneficiaries.

Feds Flip-Flopping on Medicare Rules
Two rulings issued this summer by federal agencies will likely result in confusing changes to the way in which Medicare reimburses EMS providers for ambulance transportation.

Medicare Fees Insufficient
Average Medicare payments within 36 months will not be sufficient to cover the cost of ambulance transport for as many as 61 percent of EMS services. The shortfall will be an average of 6 percent and as high as 35 percent in “super-rural” areas.

A Lesson for States Implementing Electronic Patient/Run Record Systems
Ambulance reimbursement of the future is likely to follow current trends in other healthcare sectors that are moving to pay-for-performance, which means that EMS will no longer be compensated based solely on treatment interventions or transport to a hospital, but also on performance. In order to be paid, EMS services will need to provide evidence that their medics performed to a certain standard.

Cash Flow: Are You a River or a Swamp?
If any one aspect of your emergency ambulance service can cause you to go out of business, it is poor cash flow. Especially during the Fee Schedule transition when payers may be particularly slow in processing claims, money may be coming in, but if it’s not coming in fast enough, you can’t pay your bills. Cash flow concerns may be compounded for those ambulance services whose carrier is yet to transition to the Multi-Carrier-System (MCS). (See Sidebar.) Think of the difference between a river and a swamp – both have water, but because of the current, the river water will fill up a reservoir a lot faster than waiting for the swamp to drain into it.

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