2. 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.

3. TODAY

4. ACCREDITATION –
Impact on EMS
Reimbursement

5. CURRENT
REIMBURSEMENT
ISSUES

6. Accreditation
A process whereby a professional
association or non-governmental agency
grants recognition to a school or healthcare
institution for demonstrated ability to meet
pre-determined criteria for established
standards such as accreditation of hospitals
by the Joint Commission on Accreditation of
Healthcare Organizations.

7. Certification
A process in which an individual, an
institution, or an educational program is
evaluated and recognized as meeting certain
pre-determined standards. A Certification is
usually made by a non-governmental
agency.

8. Accreditation
Example:
National Academy of
Ambulance Coders (NAAC)
Certification

9. Accreditation
Example:
National Academy of
Emergency Dispatch (NAED)
Accreditation

10. Accreditation
Example:
Commission on Accreditation
of Ambulance Services (CAAS)
Accreditation

11. Accreditation
Example:
Commission on Accreditation of
Medical Transport Systems (camts)
Accreditation

12. Accreditation
Today’s discussion
Focus:
CAAS
camts

13. Accreditation
CAAS
Primary Focus:
Ambulance/Ground Transportation
(ALS & BLS)

14. Accreditation
Camts
Primary Focus:
Fixed Wing and Rotary Transportation as
well as Critical Care Ground Transport

15. Accreditation
camts
Will also provide accreditation for
ALS and BLS Ground Transportation
when related to a Critical Care
Transport Service that is accredited.

16. Accreditation
CAAS & camts
Primary Focus:
CAAS: Business processes
camts: Patient care and safety

17. Accreditation
CAAS & camts
Both CAAS and camts
evaluate reimbursement processes
within the organization as part of
accreditation.

18. Accreditation
CAAS & camts
When asked about reimbursement
being tied to accreditation…

19. Accreditation
CAAS
...CAAS does not place a lot
of emphasis on accreditation
being a key part of reimbursement

20. Accreditation
CAAS
...This was confirmed in discussions
with a former CAAS board member
and attorney at law

21. Accreditation
Camts
...camts is currently working
with CMS to explore having
reimbursement tied to accreditation.

22. Accreditation
Camts
In discussions with industry experts:
there seems to be some in-fighting
among air transportation providers at
this time with disagreements about who
should regulate the air ambulance
industry (FAA vs State)

23. Accreditation
camts
Other disagreements include:
Elevated reimbursement for more
sophisticated air transport systems
i.e., better equipment
and enhanced staffing

24. Accreditation
MedPac
MedPac =
Medicare Payment Advisory Commission

25. Accreditation
MedPac
Independent Agency established
by the BBA to advise the
U.S. Congress on issues
affecting the Medicare program.

26. Accreditation
MedPac
MedPac is currently studying
ambulance reimbursement

27. Accreditation
MedPac
MedPac may be brought in to
the fold of discussing larger
reform for the ambulance
industry including
quality of care issues.

28. Accreditation
Jerry’s Crystal Ball
Ground Ambulance
Transportation

29. Accreditation
Jerry’s Crystal Ball
The next five years:
not much change for ground
ambulance in relationship to
accreditation and its
impact on reimbursement

30. Accreditation
Jerry’s Crystal Ball
Over five years:
????????????

31. Accreditation
Jerry’s Crystal Ball
Air Ambulance
Transportation

32. Accreditation
Jerry’s Crystal Ball
Next five years:
Accreditation could have
impact on reimbursement

33. Accreditation
My Two Cents Worth
Regulate ourselves before we
are regulated by CMS

34. Accreditation
Accredited 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

35. Accreditation
CAAS
Wisconsin CAAS Accredited Services
•Rib Mountain Fire Department Wausau, WI
•Wisconsin Rapids Fire Department WI Rapids, WI

36. Accreditation
CAMTS Accredited Services
Wisconsin
•MedLink Air – La Crosse, WI
•Flight For Life – Milwaukee, WI
•Mayo Medical Transport – Minnesota
•Gold Cross Ambulance - Minnesota

37. Accreditation
Resources
www.caas.org
www.the-aaa.org
www.medpac.gov
www.pww.emslaw.com

38. Current Reimbursement Issues

39. Reimbursement Issues
2013 Medicare Rates
•CPI-U is estimated to be 1.7%

40. Reimbursement Issues
2013 Medicare Rates
• 2013 Ambulance Inflation Factor
•Calculated by taking CPI-U
minus the MFP = AIF

41. Reimbursement Issues
2013 Medicare Rates
• MFP = multi-factor productivity
index (10 year moving average of
private non-farm businesses)
For 2013, estimated to be 1.1 to
1.2%

42. Reimbursement Issues
2013 Medicare Rates
• 2013 Ambulance Inflation Factor
estimated:
CPI-U at 1.7% minus 1.1% = an
Ambulance Inflation Factor 0.5 to
0.6%

43. Reimbursement Issues
Sequestration
• 2% reduction in Medicare
payments
•(eff: January 1, 2013)
•Result of “Super Committee”
failing to reach an agreement on
spending cuts

44. Reimbursement Issues
Sequestration
•This will likely not be resolved
prior to the elections.

45. Reimbursement Issues
Next Factor: Expiration of
Temporary Adjustments
Scheduled to expire on December 31, 2012
•2% increase for urban
•3% increase for rural
•22.6% increase for super rural

46. 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 rates
based on loss of urban adjustments

47. 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

48. Reimbursement
Permanent Ambulance Relief
Current Proposed Legislation
Medicare 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

49. Reimbursement
Payment Data
Fiscal Year 2010
•Total spent on ambulance transport including air
ambulance:
$4,589,990,960

50. Reimbursement
Payment Data
That was a 1.66% increase from
the year before (2009)

51. Reimbursement
Payment Data
Problem Areas:
Big surprise –
DIALYSIS

52. Reimbursement
Payment Data
•Houston, TX area – 9 out of 10 patients
transported for dialysis go by ambulance.
•Nationwide the average is 1 in 10

53. Reimbursement
Payment Data
•Puerto Rico recently on a per capita basis were
transporting more patients by ambulance for
dialysis than the entire state of New York

54. Reimbursement
Overpayments
•Sixty day requirement to report and return
overpayments
•Significant false claim act liability
•Overpayments must be returned 60 days after
it’s been identified
•There was some discussion about clarifying
when an overpayment has been “identified”

55. 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

56. Reimbursement
Revalidation
•CMS is requiring all Medicare providers and
suppliers to “revalidate” their Medicare
enrollment information
•Current target date is March of 2015
•Contractors have been given the discretion I
went to revalidate each provider group

57. Reimbursement
Revalidation
•Every service will require a site inspection
•There is one company in the US providing these
inspections – don’t expect this any time soon
•No advance notice provided

58. Reimbursement
PECOS
Provider 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”

59. Reimbursement
ANSI 5010
•Initial implementation date – 1/1/2012
•Enforcement delays through 6/20/2012

60. Reimbursement
Wisconsin Carrier
•WPS
•Appealing CMS decision
•Currently in dispute
•Wisconsin could end up in Region 6 and
potentially be administered by Noridian

61. Reimbursement
Co-Insurance Waivers
•Opinion issued 6/20/2012
•Permitted a non-profit ambulance service to
waive co-payments due from county residents
that had paid an EMS user fee
•Membership/user fee must exceed the amount
being waived

62. Reimbursement
ICD-10 Codes
•Implementation date now pushed to October
1st, 2014

63. Reimbursement
Healthcare Reform
•Court held that individual mandate was a
valid exercise of congress’ power to levy
taxes
•That was a 5 to 4 decision

64. Reimbursement
Affordable Care Act (ACA)
•ACA will require all states to expand their
Medicaid program to include all individuals with
incomes up to 133% of the federal poverty level
•Federal govt will pick up 100% of initial cost
and 90% of the costs in 2020
•Penalty for failing to meet this mandate would
be forfeiture of all Medicaid dollars

65. 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”

66. 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

67. Reimbursement
Healthcare Exchanges
•ACA requires states to establish state exchanges

68. Reimbursement
Exchange Timeline
• 2010 – Passage of ACA
• 2011 – Release of exchanged propose rule
• 2011 – Release of essential healthcare benefit
guidance
• 2012 – Release of final exchange rule
• 2014 – Exchange is implemented

69. Reimbursement
Accountable 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

70. Reimbursement
Fraud
Texas Dialysis
•Trailblazer in Texas now requires pre-payment
review after patient’s twelfth transport per year
•90+% denial rate

71. Reimbursement
Fraud
Puerto Rico Dialysis
•2008 Medicare data – estimated that Puerto
Rico has 620,000 Medicare beneficiaries
•They had 407,000 dialysis transports
•Comparatively, CA, FL, and NY combined have
an estimated 11 million Medicare beneficiaries
and 356,000 dialysis transports
•The answer...

72. Reimbursement
Fraud
Pre-transport
analysis

73. New this week

74. Membership Programs
Waiving Co-Pays for Residents

75. ALS/BLS Joint Billing
Intercepts

77. Questions?