Medicare Prior Authorization Expansion- What Does It Mean for You?

By Chuck Humphrey, B.A., CAC, CACO, CADS, EMT-B*

The Time Has Come

Unless you are Rip Van Winkle and you’ve been snoozing for a long, long winter’s nap, I’m hoping by now that you are aware that the Centers for Medicare and Medicaid Services (CMS) is expanding the Prior Authorization of Repetitive, Scheduled Non-Emergency Ambulance Transports (RSNAT) across the entire United States.

If you are reading as an ambulance administrator in Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, or West Virginia and you provide RSNAT services then you are very much aware of this program. It is you who has been the guinea pig dating back a few years as CMS tested its theory using a demonstration model which has saved the Medicare program approximately $550 million, so far.

But for the rest of you, the time has come!

Timeline

Beginning on December 1, 2021, those of you with ambulance services garaged in Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas were invited to the “party.”

On February 1st, ambulance services in Alabama, American Samoa, California, Georgia, Guam, Hawaii, Nevada, Northern Mariana Islands, and Tennessee will be included. No earlier than April 1st, if you operate in Florida, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, Puerto Rico, Wisconsin, or the U.S. Virgin Islands Prior Authorization will come to you.

Late this year and no earlier than June 1st, all of the New England states plus New York, Indiana, and Michigan will begin with the process and rounding out the year but no earlier than August 1st, the states of Alaska, Arizona, Idaho, Kentucky, Montana, North Dakota, Ohio, Oregon, South Dakota, Utah, Washington, and Wyoming will be included.

Medicare Prior Authorization Expansion

What’s this mean?

So, you’re operating an ambulance service in one of the program expansion states. What’s this mean for you?

Well, keep in mind that in the demonstration states, the Prior Authorization program resulted in a reduction of ambulance transports for these patients by 63 percent, and Medicare payments plummeted by 72 percent.

What this means for you and your ambulance service, if you are heavily involved in RSNATs as part of your operating model with patients that are potentially, marginally, medically necessary for ambulance transport; you will see a tightening of your cash flow from Medicare Fee-for-Service and no “slam dunk” in getting these transports paid for common RSNAT transport reasons such as dialysis, wound care and even radiation treatments for cancer.

We highly recommend that you take a deep dive look into your budget and then cross-reference the frequency and number of patients who fall into the RSNAT category and who may be on the medical necessity fence. Using the government’s own numbers from their review, factor out 72 percent of the reimbursement dollars you derive from these transports and ask yourself the critical question about what life will be post-Prior Authorization implementation.

How to prepare?

We’ve been asked, as a billing company; “How can I prepare for this?”

The answer, on the surface, is simple and yet not so simple.

On the surface, may we suggest that you begin immediately to re-assess each and every RSNAT patient you transport? To assess properly, you’ll need to establish a dialogue with the patients’ primary physician and collect every single piece of medical necessity evidence you can get your hands on.

It is this medical necessity information that you’ll ultimately be required to submit to Medicare along with your written request to receive a provisional affirmation of coverage (note, this is not a guarantee of payment) for prior authorization of your series of transports (40 round trips over 60 days or 80 one-way trips.) It’s important to note this because we are accustomed in EMS to relying on the physician’s certification statement (or certificate of medical necessity) and the patient care report (PCR) from the field as the definitive documentation.

However, the prior authorization process requires that we collect other collaborating medical necessity documentation to make a case as to why the Medicare Administrative Contractor (MAC) should issue the provisional affirmation. Without this documentation, there will be no Prior Authorization issued by the MAC which will result in your RSNATs being suspended in the adjudication process pending pre-pay review.

The word is PRIOR

Having said all of this, I want to close out this discussion by simply stating and make clear note that this is a PRIOR Authorization. In the dictionary, prior is defined as “coming before in time, order or importance.”

So, as you are intaking potential RSNAT requests to move patients repetitively begin immediately to map out how you will gather the necessary information and then submit the Prior Authorization request to the MAC. Each MAC has a form and either an electronic or fax or snail mail avenue to submit the request form for consideration.

This process must be completed PRIOR to beginning the transport and then after each 60-day period. If you miss, it can result in your completing multiple RSNATs with no means of collecting from Medicare Fee-for-Service for these transports which over time adds up to potentially large amounts of lost reimbursements dollars.


*Chuck Humphrey is the Senior Director of Compliance and a Territory Sales Manager for Quick Med Claims. He is one of our industry experts with over 30 years of experience in the EMS industry.

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