In December 2014, the Centers for Medicare & Medicaid Services (CMS) implemented a three-year pilot program, which requires a prior authorization for independent ambulance suppliers who provide “repetitive scheduled non-emergent ambulance transports” in New Jersey, Pennsylvania, and South Carolina. These states were selected because they have a higher rate of non-emergent transports compared to national averages. CMS believes that using a prior-authorization process will help ensure services are provided in compliance with applicable coverage and payment rules before services are rendered. This new process has the potential to cause workflow interruptions, resulting in delayed patient care and cash flow for private ambulance companies.
Definition of Repetitive Ambulance Services
A repetitive scheduled non-emergent ambulance service is defined as an ambulance transportation that is furnished three or more times during a 10-day period, or at least once per week for at least three weeks. Beneficiaries who usually require these services are often receiving dialysis, wound care, cancer treatment, or have other conditions that prohibit them from being able to use contemporary means of transportation.
Prior-Authorization Request
The ambulance supplier or the beneficiary may request the prior-authorization request and upon approval, CMS will grant up to 40 round trips per those requests in a 60-day period. An additional request will need to be submitted once the 40 round trips are exceeded, or if services need to be rendered outside of the 60-day period.
A listing of the required elements that must be included in the prior-authorization request from the ambulance supplier may be found here.
Prior-Authorization Timeframes – The Kink in the Chain
CMS states that it will make every effort to review requests and postmark decision letters within 10 business days for an initial prior-authorization request. If the initial request is denied, then the beneficiary or ambulance suppliers can resubmit their request; however, the timeframe for a decision is increased to 20 business days for subsequent requests. If the standard timeframe could jeopardize the life or health of the beneficiary, then providers should indicate that they are requesting an expedited request. In this situation, the Medicare Administrative Contractors (MACs) are supposed to make reasonable efforts to provide a decision within two business days.
The Physician’s Responsibility
Providers are required to supply the ambulance service or beneficiary the Physician Certification Statement, as well as any other documentation that supports medical necessity for repetitive scheduled non-emergent ambulance transports. There are no new documentation requirements. The ambulance provider and beneficiary must rely on the physician to ensure that this portion of the process is accurate and complete to ensure payment.
Conclusion
The initiation of the prior-authorization pilot program for repetitive non-emergent transports is an attempt to curb the rising volume of transports as one means to preserve the Medicare Trust Fund. However, this new process may cause cash and workflow interruption for independent ambulance suppliers in the affected states, as well as an interruption to essential healthcare for many fragile patients. Additional information regarding the Prior-Authorization Demonstration
For consulting assistance with regard to prior-authorization requests, contact the experts listed below at (888) 420-9876.
