Medicare Ambulance Prior Authorization
RSNAT – Repetitive Scheduled Nonemergency Ambulance Transport
[Revised July 2, 2023]
CMS now requires your local Medicare contractor to authorization repetitive ambulance transports in advance. Billing of transport claims can not commence until this process is complete and an approval code has been issued to the provider. The carrier will review the patient’s condition carefully and then issue an approval or a denial based on Medicare policies for covering non-emergency ambulance transportation. A successful prior authorization request can be a challenge, but there are a few things you can do to improve your success rate.
The first step is understanding who your patients are (and who they are not). A careful read of the CMS Ambulance Benefit Policy Manual will help you understand key phrases like, “Medical Necessity” and “Appropriate and Reasonable”. Transport by ambulance is only covered when the patient’s medical condition is such that transportation by any other means is contraindicated. In other words, Medicare will pay for an ambulance, if other forms of transportation are not safe for the patient. This all revolves around the patient’s medical condition and how that condition affects their ability to ride in other types of vehicles. Availability of those less expensive forms of transportation are not relevant. Medicare does not pay for ambulances just because there is no public transportation available. It is important to understand, an ambulance is the most expensive form of medical transportation. It is reserved for patients who are severely debilitated. And it is generally understood in the industry, a patient who is that severely debilitated, should make enough of an impression on an EMT that his or her secondary assessment should identify enough abnormalities that the EMT documentation supports medical necessity. That a third party reading the chart can see why an ambulance was the appropriate and the most reasonable choice.
As a provider of non-emergency ambulance transportation services, it is your job to make sure you are paying attention to what your EMTs are finding when they transport these patients. This requires reading their charts and talking to them about the patient. You should be making sure the patient truly needs an ambulance when you agree to transport them, the EMT is your second source of information, to help you determine if the patient told you the truth when they requested the transport. Consider also carefully, how the patient referral made it’s way to you in the first place.
Patients who require ongoing, repetitive care, will be under the watchful eye of nurses and technicians on a very regular basis. If the patient was debilitated to the point that an ambulance was needed, they would have acted immediately. For this reason, it is our experience that when a patient or a family member refers themselves to an ambulance provider, the case is usually more about finding a ride the patient can afford than reacting to sudden and severe downturn in the patient’s medical condition. Not that it is impossible, but it is up to you to ask enough questions up front, to determine what caused the caller to reach out in the first place. If the patient rode in a private automobile last week to dialysis, and there was not a major change in condition since then, odds are, you will be transporting them at your own expense, in an ambulance that should be reserved for someone who truly needs it.
The chances of ending up with a patient who you can truly help are much better if you wait for referrals from a patient’s healthcare practitioner. Someone who is a trained medical professional, directly involved in the patient’s ongoing care. Physicians, dialysis clinics and hospitals have all been aggressively educated by CMS on the subject of when it is appropriate to consider an ambulance for a patient. If you want to recruit business, letting those people know that you have an ambulance available is your best approach. The other side of this issue is, repetitive patients are usually suffering from illnesses that make it dangerous for them to wait too long for a transport team. Blood glucose levels drop, painful conditions just get more painful and people who are sick, do not do well when left waiting for long periods. Nurses caring for them, really care about them, and the despise transport delays. If your competitor is overwhelmed, patients suffer, so your chance will come, if the right people know you are available.
Too much competition in the ambulance business is not a good thing. There is nothing wrong with a little friendly competition, but when the market gets saturated, providers take too many chances on borderline patients. Patients who have a serious medical history, but none of it makes a good argument for an ambulance. Providers get scared that they will not be able to make payroll and buy fuel and they start thinking too much about the short term factors in the billing process. How they can convert a patient transport into income. Insurance companies and programs do not have the ability to review every claim in deep detail. Providers in this country have an obligation to self regulate to some degree. Even with Medicare’s prior authorization system, there are still ways to bill claims to some payers, whether the underlying transports are medically necessary or not. This is one of the primary reasons that CMS believes competition in the ambulance industry encourages fraud, waste and abuse.
As an ambulance billing service, we care about all of the patients behind the claims we work with. And we care about our providers, our clients. But we also care about our nation’s healthcare system. Medicare and Medicaid are strained systems at best. Abusing them by transporting patients who could be transported safely by another means, is not the answer to anyone’s problem. But I would also offer, as an alternative, Medicare does not always react to provider claims and prior auth requests fairly. This is why it is important to work with a qualified partner for your billing. A company small enough to care about you and your company, but large enough to make sure you always have a team of professionals in your corner.
If you need help with your repetitive ambulance patients, give us a call today… 1-800-635-7577.
The PMC Team
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 with more than two decades of ambulance and EMS billing experience. Get the help and support you need at 1-800-635-7577.
RSNAT – Repetitive Scheduled Nonemergency Ambulance Transport