This morning, President Donald Trump signed into law a Continuing Resolution (CR) that included a five-year renewal of the ambulance Medicare add-ons. 

The specific provisions included are:

• 5 year extension of the ambulance Medicare add-ons through December 31, 2022, retroactive to January 1, 2018.
• The American Ambulance Association's preferred method of Cost data collection that provides flexibility to the Secretary of HHS in developing the system. Consultation with the industry is required so that it strikes the appropriate balance between obtaining meaningful data while not overly burdening or onerously penalizing the ambulance services.
• The penalty for failing to report required data would be a reduction in payment up to 10% for the year following the year in which the data should have been submitted. American Ambulance Association objected to the house proposed penalty of up to a year of Medicare payments clawback or withholding of payments. A clause is included to wave the penalty in cases of hardship.
• A “pay-for” for the 5-year extension of the add-ons with a 13% cut to non-emergent dialysis transports – the American Ambulance Association had objected to the offset and pushed for a cut targeted to just those entities which abuse the dialysis transport benefit. We were successful in reducing the initial cut from 22% to 13%. The American Ambulance Association is actively working on other pay-for options that would replace the 13% cut with something targeting dialysis fraud and abuse.

This week, President Sechler testified before the legislature on behalf of PAAW in support of grants for students interested in EMS. He also participated in the American Heart Association Hill Day advocating for dispatcher-assisted CPR.

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.  

New for 2018, PAAW is proud to bring you a revamped podcast featuring a new host, Samantha Hilker!  Please take a few moments to vote on your favorite new name for the monthly show! 

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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.  

We Need Your Help to Renew the Ambulance Medicare Extenders

By:
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:

1. Uncertainty over whether the temporary add-ons will be extended.
2. To the extent legislation is passed extending the temporary add-ons, uncertainty as to whether the higher rates will be made retroactive to January 1, 2018.
3. To the extent legislation is passed extending the temporary add-ons, uncertainty as to how quickly CMS will implement the revised rates for new claims and adjust claims paid at the original, lower rates.
4. Uncertainty over how the various secondary payers will handle their adjustments.

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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