An ambulance company in Virginia is blaming its demise on a CMS pilot program that requires prior authorization for non-emergency services.
Mid-Atlantic Regional Ambulance in Virginia Beach, Va., had less than 10% of its services for regular dialysis patients reimbursed by the CMS. The company had 55 dialysis patients.
The state of Virginia participates in the CMS' pilot program that involves ambulatory suppliers or beneficiaries in eights states submitting prior authorization for repetitive, scheduled non-emergent ambulance transportations. The states are Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia and West Virginia, as well as the District of Columbia.
The states were selected because they have large numbers of Medicare enrollees frequently taking non-emergency ambulance trips, according to the CMS. Seniors often need transportation multiple times a week to receive dialysis or cancer treatments.
The CMS processes prior authorization requests within 10 business days and 20 days for repeated requests. In response to Mid-Atlantic’s claims, CMS spokeswoman Lorraine Ryan said that 20% of non-emergent transporters didn’t meet Medicare’s coverage requirements in 2006. The CMS prior authorization program is expected “to reduce these improper payments,” she said.
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 released in September 2015.
The CMS is testing the model to analyze whether prior authorization dropped costs while maintaining quality of care. The program began in 2014 with three states and was expanded to six states in January 2016. It will expand nationwide in 2017 if it's successful in the test markets.
Michael Hall, president of the American Ambulance Association, which represents 485 ambulance companies, said it's rare for ambulatory services to close due to lack of Medicare reimbursement funds because they account for such a small percentage of service fees, like cost for transport, which can range from $224 to $2,204.
The association suggested the CMS implement the prior authorization program in an attempt to tackle fraud among non-emergent ambulatory companies, which account for less than 10% of ambulance services.
“We wanted to tackle fraud so legitimate providers were not made to look bad,” Hall said.
