Railroad Medicare Pre-Pay Review Upcoming

It’s coming…

In communication from Railroad Medicare (Palmetto GBA) last week, the ambulance industry was notified that the U.S. Railroad Retirement Board Office of Inspector General (RRB OIG) and the Office of Inspector General U.S. Department of Health and Human Services (HHS OIG) together with internal data analysts had ordered prepayment review of both Emergency BLS and Non-Emergency BLS Transports.

No specific timetable has been established.

Railroad Medicare Pre-Pay Review Upcoming

What is prepayment review?

A prepayment review is exactly what it says it is. It’s a review of the claims in that particular level of service/priority prior to Railroad Medicare making payment on the claims submitted for payment.

You may recall from previous blogs our educating about this process and how the Federal Government has previously advised that the auditing arms of Medicare would use this tactic in place of the traditional “pay and chase” model where payment is allowed and issued on the claim, only to be reviewed and potentially recovered after the fact.

When an ambulance claim is selected for prepayment review, a notification is sent out to the EMS agency via an ADR- Additional Documentation Request letter. The EMS agency has 45 days from the date of the letter to submit all application documentation for each claim requested.

It’s important to be on the lookout for any such requests and act in a timely fashion. If the documentation is received on the 46th day or after, Railroad Medicare will deny payment no the claim.

Who are the decision makers?

The Medical Review (MR) department at Railroad Medicare will review the documentation submitted to support the medical necessity and reasonableness of the claim with Medicare’s ambulance coverage guidelines as their guide.

When a claim is denied or is determined or paid at a lower level of service (for example, a claim submitted for ALS level payment is paid at BLS level because the MR review department deemed the patient did not require ALS services), appeal rights are afforded to the EMS agency. Railroad will also issue a determination regarding if the patient or the EMS agency submitted the claim is ultimately responsible for payment.

How to support the claim

The request has arrived at your office. Now what do you need to do?

First and foremost, hopefully you or your staff in the case of an EMS administrator will have written and reviewed the original patient care report. That document must now be generated and sent to Railroad Medicare. Of course, the patient care report should describe…

  • The reason for the transport
  • Explanation as to why the patient required ambulance transport and was unable to be safely transport by any other transportation option
  • The patient’s condition and functional status at the time of the transport
  • All pertinent assessments and clinical evaluations
  • All procedures and supplies provided
  • Specific monitoring and treatments administered

Also, it is necessary to have the following to present to Railroad Medicare…

  • A valid provider signature from the crew on the PCR
  • Crew identities (Name and Credentials)
  • A signature form containing the patient’s signature or that of his/her representative for purpose of assigning and submitting the claim to Medicare.
  • A Physicians Certification Statement (PCS) certifying that the medical necessity requirements have been met for your patient (follow the PCS rules regarding who can
  • sign and the timetable for obtaining the PCS to insure that you are following all necessary guidelines that pertain to this document.)

This is a priority!

We can’t stress enough how important it is to act quickly once the ADR has been received. While, for most ambulance services, Railroad Medicare payments are a limited number of the claims you submit and dollars you receive, all dollars are important and must be received.

Take time now to review the requirements with your staff. We recommend you stress to them that they be extra-detailed with the documentation they provide following all runs, but now especially patient who they know are Railroad Retirees and carry Railroad Medicare coverage for their healthcare needs.

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