Medicare Prior Authorization for the Ambulance Industry

Transcription

1 Medicare Prior Authorization for the Ambulance Industry

2 ABOUT Us Wayne The On Time Companies provide ambulance, wheelchair van, and medical car service, 24 hours, 7 days a week. On Time has been in business for 26 years and currently has: 3 locations throughout New Jersey 250 Employees 120 Vehicles, ½ are Wheelchair Vans 24,000 Ambulance calls 143,000 Transport calls Roselle Headquarters Voorhees

3 MEDICARE Transport Why Dialysis? In September 2013, the Office of Inspector General published a report including a detailed analysis of Medicare Part B ambulance transports between 2002 through The number of beneficiaries who received transport increased 34% compared to the increase of 7% in the number of new beneficiaries enrolled in the Medicare fee-for-service program. During this same time the transports for ESRD grew by 269% There were a number of fraud schemes and questionable billing practices uncovered. The OIG provided CMS with recommendations to remediate vulnerabilities to program integrity.

4 MEDICARE Transport Why New Jersey? According to Medicare statistics, transports in New Jersey for dialysis alone jumped from $74 million to $87 million from That s an increase of more than 17 % in 1 year, at a time when the rate of people with end-stage kidney failure has leveled off, according to the National Institutes of Health. Per the Local Coverage Determination and the OIG report, Medicare asserts that 1 out of every 10 patients transported by stretcher actually required the service prior to the December 2014 change.

5 MEDICARE Transport The Results Are In CMS Is Saving Money! Spending on repetitive scheduled non-emergent ambulance transports in PA, NJ and SC dropped significantly during the Pilot Program. Prior to the PA Program Novitas paid out: An average of $18.9 million per MONTH Since the PA Program began Novitas now pays out: An average of $5.4 million per month 71% Decrease on Expenditures Get ready, Prior Authorization will be coming to a state near you!

6 MEDICARE Transport What s the Difference? Documentation 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.

7 How The PA Process Stole Christmas for Many Patients and Providers December 15, 2014 Novitas rolled out the new Medicare Prior Auth Program. Education to doctors, caregivers, and facilities was poor. Initially almost all patients in the state were denied authorization. We were crashing Christmas parties to get doctors to finish documenting the patient files. Soon after the media caught wind. The story hit the front pages of NJ major newspaper s Sunday edition TWICE.

8 New Jersey Ambulance Companies Make the Papers When was the last time ambulance provider issues invoked the power of the media? Were the reporters on the provider s side? Do you want to be a headline?

9 Medicare Fraud Crackdown In New Jersey Ensnaring More Patients And Ambulance Companies The federal government's four-month crackdown on ambulance companies that fraudulently bill Medicare to take patients to non-emergency dialysis, chemotherapy and wound care is continuing to have a dual impact: reducing the number of ambulance carriers and confounding patients and their families. The New Jersey Department of Health this week reported that 11 ambulance providers have given up their licenses since the beginning of the year, although surviving operators say the actual number of shuttered businesses may be twice that or more. "What I keep hearing is it's 20 to 25 that are closed," said John Bush, owner of On Time Ambulance in Roselle. "I think there's a few more that are on their heels right now." Still, even 11 closures are well above levels from recent years, when health department officials said at the most three closures a year would be the norm. Ambulance companies and patients complain that the sweep of the program entangles legitimate operators and patients who truly need their services, as well as those gaming the system. The decision to shut down can happen abruptly to patients and caregivers. Prior authorization regulation by Medicare is stressing ambulance companies, patients. By Tim Darragh NJ Advance Media for NJ.com on April 10, 2015 at 6:30 AM, updated April 15, 2015 Holy Name Medical Center in Teaneck heard one day in late March that Aaron Ambulance in Hackensack would not make its scheduled runs the following day. That following day, it called to say it was closing for good, spokeswoman Katherine Emmanouilidis said. She said the hospital worked with another company out of Hackensack to cover Aaron's former patients. Phone numbers for Aaron have been disconnected. Health department spokeswoman Dawn Thomas said the 11 companies that have closed since Jan. 1 reported that Medicare's pre-authorization requirements, instituted in New Jersey in mid-december, are the primary reason for the closures. Medicare began the crackdown after a government audit of New Jersey revealed that from 2002 to 2011 the growth in ambulance transports was nearly twice the national average and the number of trips per patient was up about 60 %. Overall, Medicare during that period saw billing for nonemergency transportation increase 130 percent to $4.5 billion a year nationally. Medicare pays for non-emergency transportation only when a patient must be carried on a stretcher. If the patient can be moved in a wheelchair or can walk, Medicare does not pay. The pre-authorization program has clamped down, according to patients and ambulance companies. Throughout 2015, patients and ambulance companies have said that people whose doctors determined that they qualified for stretcher service found the Medicare program administrator for New Jersey, Novitas Solutions, routinely denying authorization. Applications continue to be denied for any number of reasons, including illegible doctor's notes, ambulance companies say. Page 1 of 2

10 Medicare Fraud Crackdown In New Jersey Ensnaring More Patients And Ambulance Companies "We have found that one of the hardest things is the notes that are required now to substantiate medical necessity are poorly written or you can't read them," Bush said. "Legibility is a huge one." Without authorization, patients and ambulance companies are left with a choice: Find another way to get to life-sustaining treatment, use the same provider and hope to gain authorization on appeal or pay out of pocket. Watchung resident Eunice Aridi said Medicare has declared that her father qualifies for Medicare-covered transport to get to his thrice-weekly dialysis, but still has been denied because his documentation lacks details. "It has gone unbelievably terrible," she said. "I have all kinds of doctor certification statements, therapist notes, hospital records describing the reason my father needs a stretcher transport and Medicare has not given the approval." She said she's paying $300 a week to transport him while she waits on appeals. Without dialysis, Aridi said, "he will surely die within weeks." Bush said that he has hired a nurse full-time to educate patients and doctors about the requirements for authorization. The goal of pre-authorization is not to put companies out of business, said William Polglase of the office of communications at the U.S. Centers for Medicare and Medicaid Services. It's to tighten oversight, he said. He also said CMS has no plans at this point to expand the program past New Jersey and the other two states that had excessive billing, Pennsylvania and South Carolina. Another ambulance operator, who did not want NJ Advance Media to use his name because he fears retribution, said most of his Medicare authorization requests have been denied and eventually end up before an administrative law judge, who he said approves them "I have a ton of claims that have to go through this process," he said. "We're basically hanging on by a thread." Page 2 of 2

11 Industry Aftershock Less Providers Initially companies closed 1 year later 35 companies closed 2 years later 65 companies closed

12 Bankruptcy Auction Complete Inventory of Multi-State Medical Transportation/EMS Business 275+ Ambulances/Vans/Buses & 1,500+ EMS Support Devices The Assets are being sold AS IS WHERE IS, WITH ALL FAULTS, without any representations, covenants, guarantees or warranties of any kind or nature, and free and clear of any liens, claims, or encumbrances. By delivering their respective Deposits, all Bidders acknowledge that they have had the opportunity to review and inspect the Assets and will rely solely on their own independent investigations and inspections of the Assets in making their bids. Neither Maltz, the Trustee, the Attorney for the Trustee nor any of their collective representatives makes any representations or warrantees with respect to the use or condition of the Assets. All Bidders acknowledge that they have conducted their own due diligence in connection with the Assets and are not relying on any information provided by Maltz, the Trustee, the Attorney for the Trustee, or their professionals. All prospective bidders are urged to conduct their own due diligence prior to participating in the Public Auction. Bid rigging is illegal and suspected violations will be reported to the Department of Justice for investigation and prosecution. Details: Complete Inventory of Multi-State Medical Transportation/EMS Business Assets Sold Individually or in Small Groupings 230+ Type I, Type II & Type III Ambulances 45+ Invalid Coaches, Passenger Buses, Wheelchair Accessible Vans & Full Size Vans 25+ SUVs 28 MDT s Radios & Communication Equipment 1,500+ Pieces of Ancillary Ambulance/EMS Support Equipment: ALS/BLS Kits Defibrillators IV Pumps LSUs Monitors Miscellaneous: EMT Training Supplies Mechanical Maintenance Equipment, Tools & Parts Medical Supplies Telecom Equipment Stretchers, Scoops, Boards & Splints Stair Chairs Ventilators Wheelchairs And Much More Communication Devices Computers Office Furniture Sonim Phones I-Pad Minis Medications: List Coming Soon Office Equipment: Servers Mobile Data Terminals with Voice Radios XT 5000 Motorola Portable Radios

13 MEDICARE Industry Effects What Has Really Changed? By the end of December 2015, 35 ambulance companies throughout NJ closed their doors. By December 2016, that number has escalated to over 65. Many others have had to make drastic changes to their daily operations. On Time s Customer Care and Clinical Services departments have been screening our patients for years to ensure medical necessity, enabling us to minimize the impact felt throughout the industry. Our field staff is trained to report situations where a patient may not meet necessity criteria for various reasons to prevent potential fraud.

14 Repetitive Setup - Zoll helps make it easy Doing More for Less. A significant amount of repetitive patient transports are for dialysis. The Medicare reimbursement is reduced by 10% of the regular non-emergency reimbursement. Is your setup as automated as it should be?

15 Repetitive Setup - Zoll helps make it easy Make Sure The Charges Are Right From The Start In New Jersey, for a dually eligible Medicare Medicaid recipient, providers/suppliers are obligated to accept Medicare reimbursement as payment in full. So let s do the math 10% less for dialysis patients and now no copayment either! You always want the revenue to be as accurate as possible. Setting up repetitive trips with the wrong contractual allowances will give you the wrong picture. All of your KPI reports may be off as a result of a few repetitive patients. Zoll allows for the set up of 2 (or as many as you need) Medicare payers to set the correct contractual allowances. Our Medicare-Medicaid payer reduces the revenue from the start, ensuring the revenue is accurate when the trip is entered. No write off is necessary after payment is made.

16 Repetitive Setup - Zoll helps make it easy Add More Non-Emergency Charges Dialysis Load & Mileage charges should be entered in addition to regular Non- Emergency Load & Mileage charges to compensate for the lower reimbursement. By adding the Dialysis specific Load and Mileage charges your revenue numbers will be accurate from the time the trip is entered, providing a cleaner daily/weekly/monthly revenue figure. This also saves the biller time if all of the charges are set correctly.

17 Repetitive Setup - Zoll helps make it easy Default Charges Now that the additional charges are entered, you can set up Default Charges for your Repetitive Trips. Add specific Priorities that you can link to Dialysis Load and Mileage Charges in Default Charges in Billing/Charges in Administration.

18 Zoll Reporting Auto Reports Since submissions need to be repeated approximately every month, there is a Zoll canned report called Standing Order (Short) that you can have ed or printed as often as you need. The report can be found in General/Trip Related/Lists. We had a few modifications made to the report to include the pick up and drop off location. We have the Custom Report ed 2 weeks prior to the expiration and every day until the new PCS is updated.

19 Facility Education Developed Our Own Compliance Program We provide the folders for the facility staff. It helps organize the patient documentation.

20 Facility Education Developed Our Own Compliance Program The folder includes a simple handout that provides a summary of the process. It also includes contact information for follow up questions.

21 MEDICARE Transport Who Is Affected? All repetitive claims billed to Medicare on a CMS-1500 and or a HIPAA compliant ANSI X12N 837P electronic transaction must have a Prior Authorization. Part B claims billed by suppliers not providers. Repetitive is defined as 3 times per week or 1 time per week for more than 3 weeks. Patients that are involved with one time transports such as discharges and emergencies as well as non- Medicare patients are not affected by this change.

22 MEDICARE Industry Effects In the Prior Auth Wake According to the new rules, Medicare is requiring ambulance operators to receive approval to transport repetitive patients before the trips start. It has changed the way patients are accepted into healthcare facilities. Submission needs to be repeated on a monthly basis for the duration of the patient s transports with documents 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.

23 MEDICARE Policy Throwing It All The Way Back Medicare Policy Concerning Bed-Confinement (Rev. 1, ) Medical necessity is established when the patient s condition is such that the use of any other method of transportation is contraindicated. Contractors may presume this requirement is met under certain circumstances, including when the beneficiary was bed-confined before and after the ambulance trip (see 20 for the complete list of circumstances). A beneficiary is bed-confined if he/she is: Unable to get up from bed without assistance; Unable to ambulate; and Unable to sit in a chair or wheelchair. The term "bed confined" is not synonymous with "bed rest" or "nonambulatory". Bedconfinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary's condition that may be taken into account in the intermediary's/carrier's determination of whether means of transport other than an ambulance were contraindicated.

24 MEDICARE Speak Physician Certification Statement (PCS) AKA Necessity Form The document that certifies the patient medically needs stretcher transportation and cannot travel any other way. Must be signed by an M.D. or D.O. with a valid NPI. 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 Frequently Used Terms 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

25 CMS Explanation Letter

26 MEDICARE Coverage Requirements Medical Records & Clinical Documentation **ALL PAPERWORK THAT IS SUBMITTED MUST BE COMPLETELY LEGIBLE AND DATED. LEGIBILITY IS IMPERATIVE AS AN ENTIRE SUBMISSION CAN BE REJECTED DUE TO A SINGLE WORD BEING ILLEGIBLE** 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

27 MEDICARE Determination It is important to note that when submitting to the MAC you must confirm the credentials your MAC will accept on your PCS: In NJ we found that Novitas will not accept Nurse Practioners as a signor for repetitive transport. Include the appropriate credentials, MD or DO on the form. The PCS MUST have a legible name under the signature. Printed, typed or stamped names all work, but if it is illegible the entire submission may come back. The doctor that signs the PCS MUST have an NPI number or the submission will come back. The date of the PCS will dictate the date of the Prior Authorization. Use a separate Doctor Only PCS Physician Certification Statement

28 MEDICARE Determination Zoll PCS Expiration Report In order to track when your patient s PCS will expire, Zoll has a canned report under Billing/Trip Related/ PCS Expiration Report by Physician. There are a number of selectors on the report that will allow you to narrow your search, including trip date and PCS Expiration Date. You can also create a script and have the report sent to your printer or your or group .

29 MEDICARE Ambulance Provider Choosing Who Is Right For The Job Companies are frequently closing due to Medicare s new Prior Authorization program. Your patient could be at risk of having no transportation and miss treatment. If a company is not aware of Medicare requirements, patients could be wrongly denied coverage and risk appropriate medical care. Inability to properly assign mode of transportation according to Medicare standards could result in unnecessary cost. Patient experience can be compromised On Time is equipped to combat all of these negative possibilities through preparation and ensuring that the patient s experience is never compromised.

30 MEDICARE Requirements What is CMS Looking For? Accuracy no contradictions Objective Clinical Data does not come from the billing party Legible names, signatures, dates; typed when possible

31 MEDICARE Coverage Requirements Repetitive Non-Emergent Transportation The CMS Local Coverage Determination (LCD) specifies that the following is covered: Pain causing bed-confinement Transportation of psychiatric patient 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 bedconfined.

32 BEFORE You Submit The Documentation Said Chair.. If the patient file says chair or wheelchair ask questions. Sometimes the term wheelchair is overused in facilities. All chairs are not created equal: A Geri Chair cannot be secured in a moving vehicle but a patient can be Hoyer lifted into one during the day. Bed confined patients must be repositioned to avoid skin breakdown. Wound care patients must reposition in order to promote healing. Specialized wheelchairs that facilitate feeding and respiratory function are often used for bed confined patients.

33 REVIEW PT & OT Notes Chair Concerns It is very important to also review the PT & OT notes. If the patient has no trunk control they may be able to be placed in wheelchair briefly but will not be able to maintain a seated position during transport. Review Static & Dynamic sitting from the patient s medical documentation. Even Fair sitting balance may qualify for ambulance transport if the patient cannot cross the midline to adjust themselves. Sometimes there is no testing under wheelchair in the PT evaluation. You will need that information. The physical therapist can assist in determining if while in a moving vehicle the patient will collapse on themselves when there is any kind of turn.

34 REVIEW PT & OT Notes The Reclining Wheelchair Is So Misunderstood Reclining wheelchairs present many challenges that regular chairs do not. They are made for patients who cannot hold up their own weight using the arm and leg rests. They are longer in length than standard wheelchairs. Most patients are Hoyer-lifted into their reclined wheelchair from bed & the chair is reclined to the appropriate angle for comfort & safety. Once reclined the center of gravity changes & creates a number of safety concerns related to securing the chair in a moving vehicle.

35 DOCUMENTATION From Home Who You Gonna Call? Patients from home can be a bit more challenging because there is no clinical record documenting the daily movements. First order of business is to thoroughly educate the primary care giver on what you will need. Most patients will have some kind of visiting nurse service. Educate them as well. All patients will have a doctor that either visits the patient or the patient goes there. Enlist the help of the office manager or in some cases the doctors themselves.

36 Ambulance Provider Education Experience Has Taught Us Review the documentation and ask questions. Review your submissions prior to sending. Get them to the MAC as soon as you can! You worked hard for the Affirmation, do NOT leave it off!!

37 MEDICARE Will Not Accept What Not To Send From time to time you may have a doctor that feels that a letter would more succinctly describe why a patient requires stretcher service. Do not submit an attestation statement. Do not submit the Patient Care Reports. While you may need to submit to prove the transport occurred, these documents are not seen as objective and will not be taken into consideration.

38 DOCUMENTATION Recap Paint Your Own Picture With each submission immediately following the required CMS cover sheet spell it all out. We include: Patient name, DOB, HICN Facility Name or resident s home address Date of the assessment per attached paperwork Assessment Summarize the assessment and point out the pertinent information Answer the question Why does this patient need to travel via stretcher?

39 MEDICARE Submissions What Is The Most Effective Way In NJ, PA and South Carolina there are currently 3 ways we can send our submissions to Novitas Mail Fax Submit through esmd Electronic Submission of Medical Documentation

40 MEDICARE Affirmation What Now?? You will receive a Unique Tracking Number. Make sure that number is on every claim! It will deny without it. Every 30 days get ready to resubmit a new submission. Make sure you use the correct UTN when sending a new date range of claims!

41 MEDICARE Affirmation How Do I Track It In The System? Add the UTN from your Affirmation letter in Modify Customer. Click on your Medicare Payer. At the bottom of the Payer page click Add Add the UTN in the Description Choose Re-Use the same approval number Restrict Quantity by # of transports affirmed Restrict Date Range to include the range affirmed Click Ok!

42 MEDICARE Affirmation Where Does It Go On The Claim? On Tab 3 in Call Taking always Hit the Prior Auth button to add the correct UTN. If you don t hit the Prior Auth button you may submit the wrong PA when the Standing Order trip carries over. If you have added it correctly in Modify Customer, the correct PA will occupy the Prior Auth box.

43 MEDICARE Financial Effects Medicare Approval & The Cost of Denial Misdiagnosing can result in unnecessary cost to the patient Medicare can take up to 10 business days for the initial submission decision If you would like to resubmit additional documentation, Medicare has 20 business days from resubmission to provide an approval or denial If a patient is determined as not truly needing stretcher transportation, but is assigned as such in an attempt to save money without affirmative response from Medicare, the patient may be responsible for 5 TIMES the normal cost. - 3 round trips can cost approximately $1500/week in an ambulance compared to $270/week in a wheelchair van

44 Don t forget your CEU Certificates! After Summit, please list of sessions attended to: Col-ProviderRelations@ZOLL.com

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46 CONTACT INFORMATION: For Billing inquiries: Susan Delsandro Director of Customer Care (908) x116 John Bush Owner/President (908) x112