This month, On Time Ambulance President John Bush and Director of Customer Care Susan Delsandro traveled to Dallas to give a presentation to the Texas Ambulance Association on the Novitas Prior Authorization Program.
An active group of ambulance providers operating throughout the Lone Star State, the Texas Ambulance Association is committed to protecting the integrity of emergency medical care and transportation. Their philosophy is that continuing education and a proactive approach is more effective and important to providers than a reactive and crisis-oriented one.
They provide a forum for private and public ambulance providers to discuss issues, collaborate, and share information to improve care for their customers. The providers that make up the association also lobby their state legislature on issues related to financial stability and efficiency in EMS.
Pictured from left to right: David M. Werfel, Esq., Gail Atnip of Novitas Solutions, Susan Delsandro & John Bush.
Below is a quick a look at the presentation we gave on Prior Authorization for repetitive Medicare patients. It explains how to comply with the new regulations, and what specifically CMS looks for.
A look at the room at the TAA Conference 2016
What is Prior Authorization?
Before the December 2014 Prior Authorization mandate, improper billing for ambulance services was the norm rather than the exception. CMS claimed that only 1 out of every 10 patients transported by stretcher actually needed the service.
Novitas (The Medicare Administrative Contractor for NJ, PA, and SC) used to pay out an average of $18.9 million per month. Since the program began, Novitas now spends average of $5.4 million per month. That represents a 71% decrease in spending on ambulance services.
CMS now requires that ambulance companies receive prior approval to transport non-emergency patients before the trip starts. A doctor's signature is no longer sufficient. Prior Authorization did not create new clinical documentation requirements. Instead it requires the same information necessary to support Medicare payments, just earlier in the process.
The new rule affects repetitive stretcher patients covered by Medicare. Repetitive means someone who needs ambulance transportation three times a week or once a week for more than three weeks.
Submission must be repeated on a monthly basis for the duration of the patient's transport. The need for cooperation between physician, facility, and ambulance service provider has increased in order to collect all the necessary documentation.
What documentation is needed?
Documentation used to prove medical necessity must include specific information on the following:
- Mobility (is the patient capable of sitting in a chair?)
- Wounds & wound care
- Oxygenation (w/ titration of oxygen rates & delivery method)
- Pain scales
- Interventions & post intervention assessments
To substantiate patient need for ambulance transport, Medicare needs:
- The Physician Certification Statement (PCS)
- The Physician Mobility Assessment (PMA)
- Copies of sections of the medical record may include but are not limited to:
- Physician's History & Physical (H&P)
- Physician's Progress Notes
- Nurse's Notes
- Physical Therapy Notes
- Respiratory Therapy Notes
- Wound Care Notes
- Prescriptions for Pain Medications
All paperwork that is submitted must be dated and completely legible. A single illegible word can lead to a submission rejection.
- 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 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 are they looking for?
Accuracy --- no contradictions
Objective clinical data --- that does not come from the billing party
Legibility --- names, signatures & dates; typed when possible
Mobility assessments and pain assessments must be included.
In New Jersey, these new stricter rules led to the closure of 65 ambulance companies in just the first year. Some firms haven't been able to keep up with the record keeping requirements.
We are always happy to share our knowledge with other providers and help bring the industry up to speed. We even got a great letter of recommendation from the President & Vice President of the TAA, Fidel Balzado and John Brian:
John Bush and Susan Delsandro of On Time Ambulance recently visited our organization here in Dallas to teach us about complying with new Medicare regulations regarding Prior Authorization of ambulance trips.
New, more strict rules are rolling out across the country on how Medicare approves and pays for rides. John and Susan have extensive experience in this area and I am certainly grateful for their willingness to come and share their expertise.
I heard about their Compliance Training Program through a colleague and eagerly reached out to learn the details of how they've been handling these new rule changes. We're already implementing many of the tips, tricks, best practices, and other recommendations that John and Susan taught us.
In my opinion they are true leaders in the field of EMS and ambulance transportation. The experience and skill they bring to the table puts them a cut above the rest. The fact that they're willing to travel to help others in the industry is a testament to their philosophy of transparency, leadership, and quality of service.
The TAA published a look at the conference on their website here.
As many of our facility partners know, we take great pride in keeping our clients up to speed on regulatory changes in our industry. New laws that have forced others to close their doors have made us even stronger.
If you handle transportation for a medical facility in New Jersey and would like a free compliance seminar, give us a call and we can schedule a visit. We'll help bring you up to speed on Medicare requirements for repetitive transports.