CMS says prior authorization has reduced ambulance transportation

CMMI chose New Jersey, Pennsylvania and South Carolina to participate in the first year because of its spend on these services was much higher than in other states. Congress later sent Delaware, Maryland, North Carolina, Virginia and West Virginia to join the experiment in 2016 because their spending was too high.

A 2015 report from the HHS Office of the Inspector General found that Medicare paid $ 54 million in the first half of 2012 for regular non-emergency ambulance transportation that did not meet or meet Medicare requirements. with Medicare-covered services. That followed a 2006 report that found that 25% of ambulance claims did not meet the Medicare requirement, including a large portion of payments for dialysis transportation or other non-emergent services. In addition, the use of land ambulance services grew by 33% from 2004 to 2010, according to the Government Accountability Office.

CMS banned new ambulance service providers in several areas in 2013, saying there was a high risk of fraud, waste or abuse associated with regular non-emergency ambulance transportation in those parts of the country.

Researchers observed that prior authorization had no apparent effect on quality or access to care, that beneficiaries were no longer prone to use emergency services, to go to hospital or to die. . But some providers have reported that some beneficiaries may have experienced delayed or missed treatments because ambulance service providers may not be able to gather their documentation quickly enough.

“A large majority of ambulance providers have reported difficulties in obtaining supportive information from physicians and treatment facilities,” the report said.

According to the report, several ambulance services and doctors thought the medical necessity criteria were too strict, unclear and not well understood, and were sometimes applied too rigidly by Medicare Administrative Contractors. MAC staff said it was probably because the rules had not been strongly enforced or applied before the start of the experiment. In addition, physicians did not receive much notice or education about the new prior authorization requirements before they came into effect.

The researchers found that refusal claims increased immediately after the start of the experiment, but returned to pre-authorization rates within two years. MACs attributed the trend to a better understanding of medical needs guidelines and documentation requirements among ambulance services.

An amazing 45% of ambulance companies it went out of business after prior authorization went into effect in New Jersey, Pennsylvania and South Carolina. However, that figure was only 13% in the states that Congress added to the experiment.

“Outgoing providers tend to be small, relying heavily on RSNAT to earn and serve primarily urban beneficiaries,” the report said.

There was no effect on rural ambulance service providers.

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