PMC is committed to helping ambulance providers cope with the complex requirements of Medicare’s “ambulance prior authorization” program. The good news is, this program is not going to roll out nationwide on January 1 as expected. Phase III was expected to implement the first of this year, making the requirement universal across the country.
The ambulance prior authorization program requires ambulance companies to request a prior authorization before the fourth transport of a repetitive patient. The prior auth request also has to be accompanied by documentation to support medical necessity for the ambulance transport. The emphasis is on the patient’s medical condition but the types and sources of documentation that can be used are not always straight forward. Medicare carriers are likely to be elusive and specific at the same time about what records can be used to prove medical necessity. A PCS and patient care report from your EMT will not be enough. You will probably need medical records from the ordering physician as well.
These changes apply to several states already included in the new prior authorization requirement. If your state already requires a prior authorization, the process is going to continue for you. If your state was not included in the 2015 or 2016 roll out, (Phase I & II), your state’s roll out has been delayed. Pay close attention to announcements from your local Medicare Part B carrier for up coming changes.
This delay does not relieve providers of the requirement to maintain adequate documentation on file to demonstrate medical necessity for their ambulance transports. For repetitive patients, supplemental medical records must be on hand from the ordering physician or facility. Those records must support the need for an ambulance as well, just like those produced by the transporting EMT. Obtaining an approval for your prior authorization can be difficult, depending on the patient’s condition and the condition of your documentation. Medicare carriers have worked extensively in some regions to educate nephrologists, case managers and facilities, but the push back is still being felt by ambulance companies.
Ambulance prior authorization policies were designed to combat fraud and waste in the ambulance industry. But that does not mean we should not transport these patients. Medicare expects ambulance companies to take good care of these patients, building relationships with facility case managers and even physicians will make that task easier. Case managers can be more eager to work with ambulance companies when they understand the case manager’s needs. Having a solution in hand for your customer is marketing 101.
Ambulance prior authorization issues are forcing companies out of business, mergers and lay offs are common EMS news these days. As the business model shifts away from fee-for-service toward value based reimbursement, providers need to give serious consideration to how this change fits into their overall business model and strategy.
PMC is a medical billing and reimbursement consulting company. We are solely focused on the issues facing EMS providers and ambulance companies. If you would like to discuss your billing needs with one of our experienced account representatives, feel free to drop us a line or give us a call. We are here to serve the EMS community and enjoy doing just that. Give us a call today!!! 1-800-635-7577