Medicare Prior Authorization: Month 4

Posted by Kimberly Wellinger on 5/27/15 4:09 PM

Phillip Castillo, RN – Clinical Compliance and Education Coordinator

Elana Toboul, RN, BSN, CCRN – Director of Clinical Services

The kickoff to Medicare's Prior Authorization (PA) Program on December 15, 2014 has affected many facets of the healthcare industry and exposed some areas where standard protocols have become lax. Medicare's basic concept makes sense...

When a patient requires stretcher transportation on a regular basis, this means he or she must be quite ill. To say a patient cannot be transported in a chair and requires the supervision of two Emergency Medical Technicians in a fully-stocked ambulance is theoretically a big deal. So, if this is the case, prove it. Surely, there is evidence of this in the medical records. Just have the ambulance company send that over to us and there should be no issues.

Documentation practices – The Center for Medicare Services (CMS) did not change WHAT they cover, they changed how the need for transport is determined. The documentation they are looking for is very particular and there are very strict rules as to what qualifies a patient, but is it truly unrealistic? Clinical documentation from a patient's medical record is expected to be objective, accurate, detailed, and legible. Collecting these documents should be a simple matter of asking for paperwork that already exists.

The reality exposed by this process is that patient medical records are lacking sufficient detail. The picture painted by the documentation is not clear, or the existing documentation is illegible. Furthermore, computer documentation has allowed for inadvertent inconsistencies when a practitioner does not edit defaults in an electronic medical record. This compounds the list of non-affirmed patients by adding those whose medical conditions meet requirements but lack the supportive documentation. The collected documentation must agree with what the physician selects on the medical necessity form.

Healthcare providers and facilities continue to struggle with Medicare's strict coverage guidelines.  It is important that patients who meet Medicare's guidelines get the transportation they require.  This is frequently difficult to coordinate as documentation is either incomplete, illegible, or does not contain a sufficient assessment of the patient's mobility.  On Time has undertaken a mission to educate facilities and providers so that patients have an easier time getting authorization when needed.  On Time is dedicated to the partnership created with each of our facilities and focused on the patient when it comes to providing care.

Supply & demand – Medicare fraud on ambulance transports were not always a matter of criminal intent. There were many patients who benefitted from transport via stretcher as opposed to wheelchair but did not truly meet strict necessity guidelines. With the roll-out of the PA program, many patients were downgraded to wheelchair. Although safe, many patients and families were not happy with this change.  This resulted in a shift from stretcher to wheelchair and subsequently elevated the complexity of the standard wheelchair transport.

On Time's wheelchair trip count jumped from 1,571 occurring in the month of January 2014 to 2,508 occurring January 2015. Transfers to and from the wheelchair are not factored into stretcher necessity at all because this is a strict "transport-only benefit". Even if a mechanical lift is required and the patient is a bilateral leg amputee, the patient must go by chair if they are able to be transported in it safely. It is the responsibility of the facility staff to provide the means for the patient to transfer. Although this was not common practice in the past, it was always the responsibility of the facility to provide the means for a safe transfer. Since this change, without the two-person EMT team, facilities struggle to provide that critical transfer support.

On Time has acknowledged the need for our transport associates to be up-to-speed with these issues, trained, and given the proper, updated resources to execute a safe transport. Our interdisciplinary team, which includes field training and leadership staff and our clinical services department is on top of the dynamic state of the industry by researching and implementing best practices based on scientific, peer-reviewed data. Recommendations are also being made on a state level for adjustments to be made for certification training of Mobility Assistance Vehicle Technicians.

On Time's Success – For many years, On Time has been extremely mindful of medical necessity for stretcher transport. Our EMTs are trained to document medical necessity clearly and in detail. They are also instructed to notify leadership of any patients who may not require a stretcher and could possibly be transported by wheelchair. For this reason the PA program had a less severe impact. Our billing and clinical services teams began preparations for the PA Program's December 15th as soon as information became available. On Time's clinical services department has dedicated staff specifically to prior authorization requests, allowing for smoother transactions including more patient advocacy.

On Time Ambulance has held educational in-services for thirteen facilities so far and continues to offer this education on Medicare's Prior Authorization Program.  We partner closely with each facility to ensure that patients who meet Medicare's guidelines are authorized for stretcher transportation.

Statistics:

  • 9 patients authorized and counting...
  • 13 education in-services

COMING SOON....

  • Webinars
  • Education regarding additional changes to Medicare Stretcher Transportation ...

Tags: Medicare, Stretcher Transportation, Medicare Prior Authorization

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