TEN MINUTES CAN SAVE THOUSANDS OF DOLLARS Presented by Alliance Ambulance, Inc. (713)

Transcription

1 TEN MINUTES CAN SAVE THOUSANDS OF DOLLARS Presented by Alliance Ambulance, Inc. (713)

2 FORMS OF PAYMENT FOR AMBULANCE SERVICES: MEDICARE MEDICARE HMO MEDICARE A MEDICARE A ONLY PPS PATIENT MEDICAID (TMHP) MEDICAID HMO CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) PRIVATE INSURANCE PPO PRIVATE INSURANCE HMO HOSPICE ADULT PROTECTIVE SERVICES VETERANS ADMINISTRATION HOSPITAL PAY PATIENT PAY PATIENT FAMILY PAY FACILITY PAY As you can see, facility pay should be the last one to have to pay for an ambulance transport. A few extra minutes of your time prior to arranging ambulance transport can save your facility thousands of dollars per year in transportation costs. Let s look at the various ways you can save money and still accomplish effective transportation of your patients.

3 MEDICARE Medicare is regulated by the Centers for Medicare and Medicaid Services (CMS) and falls under the direct control of federal law. Medicare B does have transportation benefits as part of its plan, but Medicare A does not. MEDICARE A: Must be billed to the facility. Ambulance companies can only bill for Medicare B services. Patients sent out for outpatient testing or other services and returned in the same 24 hour period fall under Medicare A and are the responsibility of the facility. MEDICARE PROSPECTIVE PAY SYSTEM: If a patient is under Prospective Pay System (PPS) and in A Skilled Nursing Bed, there are certain transports that can be billed to Medicare B Dialysis MEDICARE B: Possibly radiation therapy Medicare B will only pay for services if a medical necessity exists and the patient meets the criteria set by Medicare for medical necessity. Medicare B requires that all ambulance transport from a facility have a completed and signed Physician Certification Statement, also known as a Certificate of Medical Necessity (CMN) in order for an ambulance provider to even bill Medicare for transportation services.

4 Medicare says the following regarding ambulance transport: Nonemergency transportation by ambulance is appropriate if either: the beneficiary is bed-confined, and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or, if his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required. Thus, bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation. It is one factor that is considered in medical necessity determinations. For a beneficiary to be considered bed-confined, the following criteria must be met: (i) The beneficiary is unable to get up from bed without assistance. (ii) (iii) The beneficiary is unable to ambulate. The beneficiary is unable to sit in a chair or wheelchair. Bed confined is not the only criteria, and it does not have to exist if there are other medical reasons for ambulance transport. Other reasons for medical necessity can also include: Services are not available at the sending facility Emergency care not available at that time 42 C.F.R (d)(1) which states his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required. MEDICARE WILL NOT PAY FOR: HOSPITAL TO HOSPITAL TRANSPORT WHEN THE SENDING HOSPITAL IS ABLE TO TREAT THE PATIENT S CONDITION. MEDICARE DOES NOT RECOGNIZE THE FACT THE PATIENT S PHYSICIAN IS AT ANOTHER FACILITY AS A REASON FOR THE TRANSFER.

5 MEDICARE HMO: Medicare HMOs include: Texan Plus, Texas Healthsprings, Pacificare, Secure Horizons HMO s require either an authorization number or notification of transportation before transport. Contact Numbers: Texan Plus (888) Texas Healthsprings (832) Pacificare Secure Horizons MEDICARE A ONLY PATIENTS When patients have only Medicare A, no ambulance benefits are available to the patient. The patient or the facility is responsible for the ambulance transportation. Should be encouraged to enroll in Medicaid or some other plan that has ambulance transportation benefits. Transportation should be discussed with the patient or their family when they may be responsible for the ambulance bill. MEDICARE PATIENTS RESPONSIBLE FOR BILL: As with any Medicare patient, it is the responsibility of the facility to determine if the patient qualifies for ambulance transportation under the Medicare guidelines. Billing Medicare when the patient does not meet the medical necessity criteria is illegal.

6 If the patient does not meet the medical necessity criteria then they are responsible for payment of ambulance transport. Check with the patient or their family to see if there may be another means of transportation for them if they are going to be responsible for the ambulance bill.

7 MEDICAID The Texas Medicaid & Healthcare Partnership (TMHP) is a coalition of contractors headed by ACS that carries out the Medicaid claims payment and Primary Care Case Management administrator duties for the State of Texas, under contract with the Texas Health and Human Services Commission. All nonemergency ambulance transports require authorization before any transport occurs. MEDICAID: Your case workers and emergency room must obtain an authorization number prior to ambulance transport (except in emergency situation, then no authorization number is required). If the Medicaid claim is denied because of no prior authorization number, the facility or calling party is responsible for the ambulance bill according to state law. (Chapter Human Resources Code) The emergency room can fax an authorization request to Medicaid without including the patient s medical records to facilitate an authorization number. MEDICAID HMO: Medicaid HMOs include: Amerigroup, Evercare, Community Health Choice, Texas Children s CHIP Texas Health Network HMO s require either an authorization number or notification prior to ambulance transport. MEDICAID HMO CONTACT NUMBERS: Amerigroup (713) Evercare (713) Community Health Choice (713)

8 Texas Children s CHIP (832) Texas Health Network (888) MEDICAID (TMHP) CONTACT NUMBER (800) FAX (512) CHILDREN WITH SPECIAL HEALTHCARE NEEDS: A state and federal program for children that are acutely ill. Administered by TMHP. Requires prior authorization for ambulance transport. Telephone number (800)

9 PRIVATE INSURANCE PPO: PRIVATE INSURANCE Most do not require authorization, but many times the patient s benefits do not cover non-emergency ambulance transport. Check with the insurance to verify the patient does have ambulance benefits. PRIVATE INSURANCE HMO: Most private insurance HMOs require authorization prior to ambulance transport. If they do not require an authorization, they still require that they are notified prior to an ambulance transport occurring.

10 VETERANS ADMINISTRATION OTHER PAYORS When calling the Veterans Administration Hospital for a transfer to their facility, check with the travel department to see if the patient qualifies for travel benefits. The VA Hospital will pay for ambulance transportation if the patient qualifies through them and the Travel Department is notified. HOSPICE: Many times the patient will be under hospice care and hospice will pay for the ambulance transport. There are times the patient may be entering into hospice, but is not under hospice care until they arrive at the destination. In those cases the patient will be covered by Medicare, Medicaid, or another primary insurance for ambulance transport. PATIENT OR PATIENT S FAMILY PAY: If the patient or the patient s family will be responsible for the ambulance bill, they should be consulted to see if there may be another means of transportation they wish to utilize.

11 FACILITY PAY: THE ONLY AMBULANCE TRANSPORTATION THE HOSPITAL SHOULD BE RESPONSIBLE FOR WOULD BE THE INDIGENT, NON-RESOURCE PATIENTS. WITH CAREFUL EVALUATION OF, AND COMMUNICATION WITH, THE PATIENT OR THE PATIENT S FAMILY, THE HOSPITAL CAN DECREASE THE FINANCIAL RESPONSIBILITY OF UNNECESSARY AMBULANCE TRANSPORTS.

12 OTHER ITEMS TO ASSIST IN DECREASING COSTS Alliance Ambulance requires its medics to obtain a Certificate of Medical Necessity (CMN) on all transports originating from a facility. This is due to the number of other insurance companies other than Medicare utilizing the CMN as a means of determining medical necessity. Please provide a demographics sheet and a History & Physical (H&P) to the medics transporting as it assists in the billing for the transport.