It's been a year and a half since Prior Authorization went into effect here in New Jersey. There have been some unintended consequences, but for the most part it seems that the program has been successful. As one of the state's largest ambulance and medical transportation companies, we have gained plenty of experience in complying with these new regulations.
To assist our various partners, we've put together a list of explanations and key terms that health care workers can use to increase chances of approval. This list is by no means exhaustive, but we think it's a good start. If you have questions that are more in-depth or specific to your organization, we'd be happy to schedule a compliance consultation visit.
SCTU Ambulances charging outside of our Roselle, NJ Headquarters
What's changed?
The Centers for Medicare & Medicaid Services (CMS) now require that ambulance operators receive approval to transport non-emergency patients before the trip starts. A doctor’s signature is no longer enough to qualify a patient for stretcher transportation. This has changed the way patients are accepted into health care facilities.
Submission needs to be repeated on a monthly basis for the duration of the patient’s transports with documentation submitted within the prior 60 days. The need for cooperation between physician, facility, and ambulance service provider has increased in order to collect all needed documentation for Medicare approvals.
As a result, due to cost, many facilities are rethinking the way that they accept Medicare patients that will require repetitive transportation. Hospitals are having trouble finding accepting facilities for these patients. Many more patients will be traveling by wheelchair van instead of by stretcher.
Documentation needed to prove medical necessity now needs to include specific information on:
- Mobility (is the patient capable of sitting in a chair?)
- Wounds and wound care
- Oxygenation (with titration of oxygen rates and delivery method)
- Pain scales
- Interventions and post intervention assessments
By the end of December 2015, after just one year of prior authorization, 35 ambulance companies throughout NJ had closed their doors. Many others have been forced to make drastic changes to their daily operations.
Prior to the December 2014 change, improper billing for ambulance services in New Jersey was the norm rather than the exception. CMS actually claimed that only 1 out of every 10 patients transported by stretcher actually needed the service.
Records showed that transports in New Jersey for dialysis alone jumped to $87 million in 2013, up from $74 million a year earlier. That represented an increase of more than 17% in a year. Meanwhile, according to the National Institutes of Health, the rate of people with end-stage kidney failure leveled off during that time. Something didn’t add up.
Who's affected?
Patients involved with one time transports like discharges and emergencies, as well as non-Medicare patients are NOT affected by this change.
However, repetitive stretcher patients who have Medicare are. Repetitive is defined as 3 times per week or 1 time per week for more than 3 weeks.
EMTs lifting a stretcher-bound patient using proper technique
Key terms and ideas
- Physician Certification Statement (PCS) aka Necessity Form
The document that certifies the patient medically needs stretcher transportation and cannot travel any other way
- Clinical Data
Objective, quantifiable data about the patient’s condition obtained during patient assessment and recorded in the clinical record
- Bed-Confined
Patient is unable to get up out of bed without assistance, unable to ambulate, AND unable to sit in a chair or wheelchair
- Mobility Assessment
Objective, clinical data about the patient’s abilities (ambulation, transfers, standing, sitting in chair, etc.)
- Pain
Such that is not relieved completely by medication and rates at least 7/10 on a 10 point scale
- Transport Benefit
Necessity is determined by the patient’s inability to be transported in a wheelchair, NOT the inability to transfer to and from it
Required medical records and clinical documentation
To substantiate patient need for ambulance transport, Medicare needs:
- Physician Certification Statement (PCS)
- Physician Mobility Assessment (PMA)
- Copies of sections of the medical record which may include but is not limited to:
- Physician’s History and Physical (H&P)
- Physician’s Progress Notes
- Nurse’s Notes
- Physical Therapy Notes
- Respiratory Therapy Notes
- Wound Care Notes
- Prescriptions For Pain Medications
**REMEMBER: ALL PAPERWORK SUBMITTED MUST BE COMPLETELY LEGIBLE AND DATED. LEGIBILITY IS IMPERATIVE AS AN ENTIRE SUBMISSION CAN BE REJECTED DUE TO A SINGLE WORD BEING ILLEGIBLE**
One of our Medicare Prior Authorization packets containing required paperwork
What's covered?
The CMS Local Coverage Determination (LCD) specifies that the following is covered:
- Pain causing bed-confinement
- Transportation of psychiatric patients requiring restraints due to danger to self or others
- Stage 3 or greater decubitus ulcer on sacrum or buttocks requiring transportation of 60+ minutes of sitting
- Lower extremity contractures that are sufficient degree to prohibit sitting in a wheelchair
- Unstable joints
- Severely debilitating chronic neurological conditions
- Morbid obesity causing the patient to meet the regulatory definition of bed-confined.
What is CMS looking for?
Accuracy – no contradictions
Objective clinical data – does not come from the billing party
Legibility – names, signatures, dates; typed when possible
Mobility must be included in assessments. Physicians often leave out information on the patient’s mobility.
Pain assessments must include pain scales and medication if given. Pre and post administration pain assessments must also be present.
What's at stake?
- Choosing a reliable and informed medical transportation provider is critical for proper patient care. If an unprepared company quickly closes, patients are at risk of losing access to transportation and missing treatment.
- If a company is not aware of Medicare requirements, patients can be wrongly denied coverage and risk inappropriate medical care.
- Inability to properly assign mode of transportation according to CMS standards could result in unnecessary costs.
- Overall patient experience can be compromised.
- Have questions specific to your facility?
- Want to arrange a free compliance consultation visit?
- Looking for a new transportation partner?
Contact us online or call (908) 298-9500.
We’d love to visit you to share our expertise.
For more information and related coverage documentation, visit CMS's page on Prior Authorization for Repetitivetive Schedule Non Emergent Ambulance Transport.
