Medicare Ambulance Prior Authorization – Nationwide Rollout

October 07, 2020
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Medicare Ambulance Prior Authorization – Nationwide Rollout

September 22, 2020

CMS announced today that “repetitive, scheduled, non-emergency ambulance transports” (RSNAT) will soon require prior authorization nationwide.  Up to now, the prior authorization model has been limited to just a few states, however that is about to change.  Ambulance providers will now be required to submit a request for authorization before dialysis patients can be approved for transport payments.  If the model used in the pilot project is duplicated in other regions, and we expect it will be, ambulance providers will need an approval after the third transport leg in any ten day period.  The fourth transport will not be covered until a prior authorization is issued by your local Medicare carrier.  Once approved, the patient’s transports should be covered for a sixty day period in most cases.

Medicare ambulance coverage guidelines gain another layer of complexity when you begin transporting repetitive patients.  For example, once a patient has been transported often enough to be considered “repetitive”, typically three load fees in ten days, a different set of rules apply to the Physician Certification Statement.  For example, after the patient becomes a “repetitive patient”, the PCS can be signed by the attending physician only, and the form must be obtained “prior to dispatch”.  In other words, you can not use a PCS to support billing a repetitive transport if that PCS was obtained after the transport was provided.  It must be obtained prior to the patient’s fourth transport leg.  In the case of the repetitive patient, backdating a physician’s signature on a PCS could have a material effect on whether or not a transport is covered by Medicare.  If that signature date is falsified, the resulting claim(s) could be considered fraudulent.  The bottom line is, ambulance providers should evaluate their documentation now to make sure it compliant with Medicare’s guidelines.  Repetitive ambulance transport billing has always been a target for regulators, this change will give medicare’s medical review staff a chance to look at your patients much more closely than before.

Ambulance companies who provide these transports should be aware that their local medicare carrier will be checking to see if all the Medicare program requirements are met before an authorization is issued.  Prior authorizations will be conducted in much the same way as any medical review process.  They can take a little time, and the carrier can look at documents other than those presented by the ambulance provider.  They will do this by reviewing field crew documentation from the ePCR, Billing Signature Forms, Physician Certification Statements and possibly physical therapy, dialysis center, social worker and nephrologist’s notes.  If there was ever a time to open up a good line of communication with your local healthcare facilities, this is it.  Gathering documentation can be difficult at times, dialysis centers and social workers will need to be educated and assured that their patients will continue getting the medically necessary services they need.

The implementation timeline will be worked out by your local Medicare carrier.  If you operate in a state where prior authorizations are already the norm, you probably wont see a big change.  For the rest of the nation, you will want to work closely with your billing staff and monitor your local Medicare carrier’s activity closely.  There is very little time to prepare for this change, if this is new to you, it might be a good idea to get the support of an experienced partner.  The more important repetitive patients are to your cashflow, the more significant the risk to your business.

Priority Medical Claims has been working with the ambulance prior authorization model since it was first introduced as a pilot program in Pennsylvania, West Virginia and Virginia.  No matter where you operate, you do not have to navigate this change alone.  We are a full service, ambulance billing agency with over twenty five years experience.  Whether you need a simple consultation or you are considering a change to a more robust billing solution, we are just a phone call away. Toll free 1-800-635-7577.


Thank you,

Keith A. Waycaster, CEO

Disclaimer: Priority Medical Claims is not a law firm and the author of this post is not an attorney.  Nothing in this post or on this website should be relied on as legal counsel.  We are simply a medical billing agency who has helped numerous ambulance and EMS providers succeed in the modern ambulance business during the last twenty five years.  We have experience working with a few different attorneys who specialize in ambulance issues.  If you need legal advice, we would be happy to share the names of those firms with you during a confidential consultation.

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