When Compassion and Compliance Collide

New initiatives

By now many of you, especially those of you who provide scheduled, routine, non-emergency transports (ie. Dialysis, radiation, etc.) are becoming aware of a new Medicare trial initiative for pre-authorizing approval for claims submitted for these types of transports.

The Centers for Medicare and Medicaid Services (CMS) chose the states of Pennsylvania, New Jersey and South Carolina to test this new program, due to the fact that these states were found to have the greatest sudden growth in the number of these transports. Plus some recent government fraud investigations have led to charges and even convictions of some unscrupulous EMS agency owners, primarily in the for-profit arena of the ambulance industry.

The new pre-authorization initiative has not gotten off to a very good start. EMS agencies in all three states are complaining loudly citing that almost all of the requests for pre-authorization have been returned denied. These denials have brought Medicare reimbursements to a screeching halt for many of the agencies that provide these types of transports; causing, in some cases, these EMS agencies to shut down or drastically decrease services while laying off dozens of EMS staff members.

The Results

So…here’s the discussion of the day.

First, let’s get something straight right up front. We agree that there were too many EMS agencies operating on shaky ground and an alarming number of them were billing for services that were questionably medically necessary and in some cases downright fraudulent.

We saw the undercover news videos of ambulances pulling up to dialysis centers, the doors to the ambulance opening and three or four patients exit under their own power into the facility. Then we even learned that these patients were receiving part of that reimbursement as a kick-back! There’s no room for this and something had to be done.

When Compassion and Compliance CollideBut, we also believe there is a fine line we’re approaching where compassion for people’s circumstances- some very ill people’s circumstances- can be compromised in the name of compliance and the almighty dollar. Fraud scenarios aside, there is a patient population out there that needs transportation to their treatments and who have special obstacles keeping them from that treatment and now EMS agencies who get those patient to and from those locations are stepping back to take a look at the overall picture because they are having problems obtaining the pre-authorization ahead of time.

Caring or Complying

In a recent article published in the Anderson (S.C.) Independent Mail newspaper (Transports of S.C. dialysis patients crippled by Medicare, February 1, 2015), reporter Kirk Brown chronicled that four ambulance companies in that state had already closed their doors since the pre-authorization program began in mid-December. The article cited claims of three dialysis patients who died when requests for pre-authorization for ambulance transportation to and from treatments were rejected and the EMS agency ceased providing the service.

The choice for EMS agencies, it appears, now weighs in as a decision to continue caring for patients that have used the service for literally years versus complying with Medicare’s increased scrutiny of these types of transports resulting in payment denials.

We all know that nothing’s black and white in EMS. While there are truly patients who are completely bed bound and so ill that there is no other way they can make it to their destination other than an ambulance, there are also patients who think they need EMS but really don’t. Whether we, in the industry, are doing a good job to separate those scenarios is where the rubber meets the road.

We agree that something has to change.

But, there are also those “grey” scenarios. Ill patients who are so close to the line between being compassionately cared for but could possibly be transported more comfortably lying on a stretcher versus sitting in a van or other vehicle where, in our opinion, there should be allowances. There are also those patients who have physical barriers in and out of their residences and all kind of special mitigating circumstances that we do not believe the Medicare rules do not allow adequate provision to cover.

And, thus the quandary that EMS providers are experiencing. What do you do in that scenario?

In most cases, it also means that providing the service without being reimbursed is not an option (we operate on tight budgets as it is…there’s no wiggle room.)

Is there an answer?

The rules are the rules. We’ve all known it all along. If the patient can be safely transported by any other means other than an ambulance without danger to the patient then Medicare will not pay.

But who made those rules? Who are the people who sit on the pre-authorization committee? Is there ample information being provided by the non-ambulance healthcare population (doctors and others) that will paint the picture of the patient’s condition? Will Congress, CMS, and folks in Washington ever take a good look at the overall EMS picture in the United States to come up with some reasonable formulas for including the “grey” patients and their overall needs?

Answer those questions and you win the prize.

All we know is this, there are some really sad situations being relayed to us here at the billing office. The tough part of all of this is we are seeing some very reputable ambulance providers stressing over their desire to be compassionate and compliant at the same time.

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