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PSOW 2012 - Quality & Reimbursement


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PSOW 2012 - Quality & Reimbursement

  1. 1. About Your Presenter: Jerry Miller, NREMT-P CEO/President – LifeQuest Services Jerry has been actively involved in the EMS and fire industry for 33 years.
  2. 2. TODAY
  3. 3. ACCREDITATION – Impact on EMS Reimbursement
  5. 5. AccreditationA process whereby a professionalassociation or non-governmental agencygrants recognition to a school or healthcareinstitution for demonstrated ability to meetpre-determined criteria for establishedstandards such as accreditation of hospitalsby the Joint Commission on Accreditation ofHealthcare Organizations.
  6. 6. CertificationA process in which an individual, aninstitution, or an educational program isevaluated and recognized as meeting certainpre-determined standards. A Certification isusually made by a non-governmentalagency.
  7. 7. Accreditation Example: National Academy ofAmbulance Coders (NAAC) Certification
  8. 8. Accreditation Example: National Academy ofEmergency Dispatch (NAED) Accreditation
  9. 9. Accreditation Example: Commission on Accreditationof Ambulance Services (CAAS) Accreditation
  10. 10. Accreditation Example: Commission on Accreditation ofMedical Transport Systems (camts) Accreditation
  11. 11. AccreditationToday’s discussion Focus: CAAS camts
  12. 12. Accreditation CAAS Primary Focus:Ambulance/Ground Transportation (ALS & BLS)
  13. 13. Accreditation Camts Primary Focus:Fixed Wing and Rotary Transportation as well as Critical Care Ground Transport
  14. 14. Accreditation camts Will also provide accreditation forALS and BLS Ground Transportation when related to a Critical CareTransport Service that is accredited.
  15. 15. Accreditation CAAS & camts Primary Focus: CAAS: Business processescamts: Patient care and safety
  16. 16. Accreditation CAAS & camts Both CAAS and camtsevaluate reimbursement processes within the organization as part of accreditation.
  17. 17. Accreditation CAAS & camtsWhen asked about reimbursement being tied to accreditation…
  18. 18. Accreditation CAAS ...CAAS does not place a lot of emphasis on accreditationbeing a key part of reimbursement
  19. 19. Accreditation CAAS...This was confirmed in discussions with a former CAAS board member and attorney at law
  20. 20. Accreditation Camts ...camts is currently working with CMS to explore havingreimbursement tied to accreditation.
  21. 21. Accreditation Camts In discussions with industry experts: there seems to be some in-fighting among air transportation providers atthis time with disagreements about who should regulate the air ambulance industry (FAA vs State)
  22. 22. Accreditation camts Other disagreements include: Elevated reimbursement for moresophisticated air transport systems i.e., better equipment and enhanced staffing
  23. 23. Accreditation MedPac MedPac =Medicare Payment Advisory Commission
  24. 24. Accreditation MedPacIndependent Agency established by the BBA to advise the U.S. Congress on issuesaffecting the Medicare program.
  25. 25. Accreditation MedPacMedPac is currently studying ambulance reimbursement
  26. 26. Accreditation MedPacMedPac may be brought in to the fold of discussing larger reform for the ambulance industry including quality of care issues.
  27. 27. AccreditationJerry’s Crystal BallGround Ambulance Transportation
  28. 28. Accreditation Jerry’s Crystal Ball The next five years:not much change for groundambulance in relationship to accreditation and its impact on reimbursement
  29. 29. AccreditationJerry’s Crystal Ball Over five years: ????????????
  30. 30. AccreditationJerry’s Crystal Ball Air Ambulance Transportation
  31. 31. Accreditation Jerry’s Crystal Ball Next five years: Accreditation could haveimpact on reimbursement
  32. 32. Accreditation My Two Cents WorthRegulate ourselves before we are regulated by CMS
  33. 33. AccreditationAccredited Center of Excellence (EMD)•Dane County Public Safety Communications Madison WI •Camts MedLink Air across Wisconsin •Flight for Life Milwaukee WI •Mayo Medical Transport Minnesota •Gold Cross Ambulance Minnesota
  34. 34. Accreditation CAAS Wisconsin CAAS Accredited Services •Rib Mountain Fire Department Wausau, WI•Wisconsin Rapids Fire Department WI Rapids, WI
  35. 35. Accreditation CAMTS Accredited Services Wisconsin •MedLink Air – La Crosse, WI •Flight For Life – Milwaukee, WI•Mayo Medical Transport – Minnesota •Gold Cross Ambulance - Minnesota
  36. 36. Accreditation Resources
  37. 37. Current Reimbursement Issues
  38. 38. Reimbursement Issues 2013 Medicare Rates•CPI-U is estimated to be 1.7%
  39. 39. Reimbursement Issues 2013 Medicare Rates• 2013 Ambulance Inflation Factor •Calculated by taking CPI-U minus the MFP = AIF
  40. 40. Reimbursement Issues 2013 Medicare Rates• MFP = multi-factor productivityindex (10 year moving average ofprivate non-farm businesses)For 2013, estimated to be 1.1 to1.2%
  41. 41. Reimbursement Issues 2013 Medicare Rates• 2013 Ambulance Inflation Factorestimated:CPI-U at 1.7% minus 1.1% = anAmbulance Inflation Factor 0.5 to0.6%
  42. 42. Reimbursement Issues Sequestration• 2% reduction in Medicarepayments •(eff: January 1, 2013)•Result of “Super Committee”failing to reach an agreement onspending cuts
  43. 43. Reimbursement Issues Sequestration•This will likely not be resolvedprior to the elections.
  44. 44. Reimbursement Issues Next Factor: Expiration of Temporary AdjustmentsScheduled to expire on December 31, 2012 •2% increase for urban •3% increase for rural •22.6% increase for super rural
  45. 45. Reimbursement Issues Let’s Do the Math 2013 Medicare Rates•0.5 – 0.6% inflation (AFI)•Minus temporary adjustments•Minus additional 2%(sequestration)•Approximately 3.5% loss in MC ratesbased on loss of urban adjustments
  46. 46. Reimbursement Legislative Update MedPAC•MedPAC to study ambulance reimbursement •Study appropriateness of temporary adjustments •The need to affirm current payment structure •Including permanent ambulance relief •Expected to show the same results as the last report from 2007 2007 GAO Report •Medicare pays an average of 6% below cost •17% below cost in super rural areas
  47. 47. Reimbursement Permanent Ambulance ReliefCurrent Proposed LegislationMedicare Ambulance Access Preservation Act (MAAPA) •6% increase for urban and rural transports •22.6% increase for super rural •This is for 2012-2016 •Still pending; building support from legislature
  48. 48. Reimbursement Payment DataFiscal Year 2010 •Total spent on ambulance transport including air ambulance: $4,589,990,960
  49. 49. Reimbursement Payment DataThat was a 1.66% increase from the year before (2009)
  50. 50. Reimbursement Payment Data Problem Areas:Big surprise – DIALYSIS
  51. 51. Reimbursement Payment Data•Houston, TX area – 9 out of 10 patientstransported for dialysis go by ambulance.•Nationwide the average is 1 in 10
  52. 52. Reimbursement Payment Data•Puerto Rico recently on a per capita basis weretransporting more patients by ambulance fordialysis than the entire state of New York
  53. 53. Reimbursement Overpayments•Sixty day requirement to report and returnoverpayments•Significant false claim act liability•Overpayments must be returned 60 days afterit’s been identified•There was some discussion about clarifyingwhen an overpayment has been “identified”
  54. 54. Reimbursement Overpayments•AAA is asking that overpayment not be“identified” until the latter of: •Exhaustion of appeal rights •Expiration of time to appeal under the next level
  55. 55. Reimbursement Revalidation•CMS is requiring all Medicare providers andsuppliers to “revalidate” their Medicareenrollment information•Current target date is March of 2015•Contractors have been given the discretion Iwent to revalidate each provider group
  56. 56. Reimbursement Revalidation•Every service will require a site inspection•There is one company in the US providing theseinspections – don’t expect this any time soon•No advance notice provided
  57. 57. Reimbursement PECOSProvider Enrollment, Chain &Ownership System •Medicare’s electronic enrollment database •CMS wants all providers and suppliers enrolled in PECOS by the end of the year •If Medicare sends you a request to revalidate, you have 60 days •Failure to respond can result in termination of your billing privileges with a potential one year band on “re-enrollment”
  58. 58. Reimbursement ANSI 5010•Initial implementation date – 1/1/2012•Enforcement delays through 6/20/2012
  59. 59. Reimbursement Wisconsin Carrier•WPS•Appealing CMS decision•Currently in dispute•Wisconsin could end up in Region 6 andpotentially be administered by Noridian
  60. 60. Reimbursement Co-Insurance Waivers•Opinion issued 6/20/2012•Permitted a non-profit ambulance service towaive co-payments due from county residentsthat had paid an EMS user fee•Membership/user fee must exceed the amountbeing waived
  61. 61. Reimbursement ICD-10 Codes•Implementation date now pushed to October 1st, 2014
  62. 62. Reimbursement Healthcare Reform•Court held that individual mandate was avalid exercise of congress’ power to levytaxes•That was a 5 to 4 decision
  63. 63. Reimbursement Affordable Care Act (ACA)•ACA will require all states to expand theirMedicaid program to include all individuals withincomes up to 133% of the federal poverty level•Federal govt will pick up 100% of initial costand 90% of the costs in 2020•Penalty for failing to meet this mandate wouldbe forfeiture of all Medicaid dollars
  64. 64. Reimbursement Affordable Care Act (ACA)•By a 5 to 4 margin, the court held that any constitutional problem could be remedied by rewriting “the law to allow any state that opted out of the Medicaid expansion to keep existing Medicaid funding”
  65. 65. Reimbursement Effects of Court Decision•ACA implementation will go forward•States will have the option to: •Expand their Medicaid programs and accept federal money to cover cost for these additional recipients •Elect not to expand their programs and keep only the money they currently receive from the federal government
  66. 66. Reimbursement Healthcare Exchanges•ACA requires states to establish state exchanges
  67. 67. Reimbursement Exchange Timeline• 2010 – Passage of ACA• 2011 – Release of exchanged propose rule• 2011 – Release of essential healthcare benefitguidance• 2012 – Release of final exchange rule• 2014 – Exchange is implemented
  68. 68. ReimbursementAccountable Care Organizations (ACO) •A network of hospitals, physicians that will share responsibility for providing care to patients •ACO would be responsible for pre- hospital, inpatient acute care, and post-acute care patients •Goal is to replace insurance company as the gatekeeper •Ultimately a capitated payment program
  69. 69. Reimbursement Fraud Texas Dialysis•Trailblazer in Texas now requires pre-paymentreview after patient’s twelfth transport per year •90+% denial rate
  70. 70. Reimbursement FraudPuerto Rico Dialysis•2008 Medicare data – estimated that PuertoRico has 620,000 Medicare beneficiaries•They had 407,000 dialysis transports•Comparatively, CA, FL, and NY combined havean estimated 11 million Medicare beneficiariesand 356,000 dialysis transports•The answer...
  71. 71. Reimbursement FraudPre-transport analysis
  72. 72. New this week
  73. 73. Membership ProgramsWaiving Co-Pays for Residents
  74. 74. ALS/BLS Joint Billing Intercepts
  75. 75. Questions?