The CMS will soon require prior authorization for regular non-emergency ambulance transportation in order for it to be covered under Medicare.
The changes, which start next year, affect seniors living in Delaware, Maryland, North Carolina, Virginia, West Virginia and the District of Columbia. The six areas have large numbers of Medicare enrollees frequently taking non-emergency ambulance trips, according to the CMS. Those seniors often need transportation three or more times a week to get to dialysis, cancer or wound treatment appointments.
In 2012, Medicare Part B paid $5.8 billion for ambulance transports, almost double the amount it paid in 2003, according to an Office of Inspector General report (PDF) released in September.
The number of ambulance transports reimbursed by Medicare Part B increased 69% between 2002 and 2011, according to a 2013 OIG report (PDF).
A 2010 OIG report indicated that 20% of the agency's spending on non-emergency ambulance trips were improper because ambulance companies overbilled Medicare or transported people who didn't need or qualify for the service.
Finally, a June 2013 Medicare Payment Advisory Commission report found that the volume of ambulance transports to and from a dialysis facility increased 20% between 2007 and 2011, more than twice the rate of all other ambulance transports combined.
“The purpose of this model is to test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care,” the CMS said in a federal notice.
The initiative is the expansion of an effort that began last year in New Jersey, Pennsylvania and South Carolina.
The Medicare Access and CHIP Reauthorization Act of 2015, which Congress passed earlier this year to replace the sustainable growth-rate formula, mandated the expansion. If the ambulance pre-payment model ultimately proves successful in these markets, the law stated that the initiative should be expanded nationwide in 2017.
Prior to the launch of the requirement in 2014, some worried that the policy would have negative consequences.
“This new process may cause cash and workflow interruption for independent ambulance suppliers in the affected states, as well as an interruption to essential healthcare for many fragile patients,” PYA, a healthcare consulting firm, said in its analysis of the policy.
However, on a call with ambulance suppliers on Tuesday, the CMS said few issues have been reported to the agency from stakeholders in New Jersey, Pennsylvania and South Carolina, and anecdotally called the effort a success thus far.
Senior advocates in the three states also noted they haven't heard of any consumer complaints tied to the policy. Some also noted that they support the prior-authorization requirement.
"Particularly in southeastern Pennsylvania, there has been a lot of well-documented ambulance fraud, so there should be a policy that works to prevent these fraudulent practices," said Kathy Cubit, director of advocacy initiatives at the Philadelphia-based Center for Advocacy for the Rights and Interests of the Elderly.
Physicians reportedly had not been providing the necessary documentation to prove the ambulance rides were medically necessary, but agency officials said that was because they were unaware that they should do so. The CMS has since posted a form letter to physicians on its website that ambulance companies can give to providers.
