CMS extends Medicare experiment to curb ambulance use

The CMS will continue its multi-state initiative to reduce ambulance use in the Medicare program, citing the program's success in lowering claims.

Under the initiative, Medicare beneficiaries need prior authorization for regular, non-emergency ambulance transportation in order for the rides to be covered. The CMS said Tuesday that the 4-year-old demonstration has led to fewer claims for ambulance services.

The program, which is now up and running in Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia and West Virginia was on track to end this month. Now, it will continue through Dec. 1, 2018.

The states involved in the initiative 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.

A CMS spokesman did not respond to a request for program use and savings data.

MACRA called for the demonstration to be expanded nationally if it was shown to be effective without curtailing access to care. The CMS has said it hopes to expand the model, but hasn't released a timeline or indicated when a formal evaluation will occur.

Ambulance providers have praised the program even though its goal is to reduce ambulance use. The providers argue that it has actually weeded out bad actors that were abusing Medicare.

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.

The number of ambulance transports reimbursed by Medicare Part B increased 69% between 2002 and 2011, according to a 2013 OIG report.

"Requiring a pre-authorization for repetitive non-emergency transports means that everyone, including the provider and the patient, knows upfront if it's a legitimately covered service," Deborah Ailiff, president and CEO of Procare Integrated Health and Transport, a Maryland-based ambulance company.

However, there have been some downsides to the experiment. Smaller ambulance providers who were not defrauding Medicare, but had business models centered around repetitive non-emergency transports, have closed.

"Some smaller providers couldn't handle the cash flow reduction," John Iazzetta, vice president and chief operating officer of Alert Ambulance Service, a New Jersey-based company. "Yes, there have been casualties, but by and large this policy is needed."

Others are hoping the CMS will tweak its management of the program in the coming year. Some ambulance providers experienced whiplash when the CMS initially announced the experiment was coming to an end, only to come back a few days later to say it would continue.

"The abrupt restart of the program, after being told the process was being stopped, has been frustrating," said Ryan Thorne, CEO of Thorne Ambulance Service in South Carolina.

Another issue is that ambulance providers have struggled with dialysis clinics since the beginning of the experiment to get the paperwork needed to prove that ambulance service was necessary to get to the appointments.

Some clinics cite HIPAA as the reason ambulance companies are unable to obtain the requested documentation, while others do not maintain the documentation in the first place, Thorne said.

He said the CMS could rectify the issue by expanding outreach efforts to providers in demonstration states.

"The more aware our healthcare partners are in how this process works, the better we can ensure compliance with the documentation requirements of prior authorization," Thorne said.