medicare update

MEDICARE

UPDATEBrian S. Werfel, Esq.

September 17, 2014

2013 Medicare

Payment Data

NATIONAL DATAFY 2013

Description 2013Allowed #

2013Allowed $

2013Paid $

A0425 Ground Mileage 140,891,705 1,099,189,084 864,339,277

A0426 ALS Non-Emergency 325,531 85,189,084 66,422,692A0427 ALS Emergency 4,974,507 2,076,931,30

41,615,499,54

1A0428 BLS Non-Emergency 6,833,969 1,509,979,92

51,182,578,45

3A0429 BLS Emergency 2,726,768 976,470,132 758,337,761A0430 Fixed Wing 10,820 45,337,204 35,462,990A0431 Helicopter 56,200 258,426,685 201,690,114A0432 Paramedic Intercept 3,153 1,183,491 908,676A0433 ALS-2 111,789 67,358,827 52,420,103A0434 Specialty Care

Transport 104,605 77,832,279 61,021,808

A0435 Fixed Wing Mileage 1,972,269 23,203,089 18,185,274A0436 Helicopter Mileage 3,309,845 104,479,754 81,690,492Totals

161,321,063 6,325,760,889

4,938,557,181

NATIONAL DATAFY 2013 vs. FY 2012

Description 2013Allowed #

2012Allowed #

%Change

A0425 Ground Mileage 140,891,705 139,251,814 1.18%A0426 ALS Non-Emergency 325,531 315,322 3.24%A0427 ALS Emergency 4,974,507 4,984,105 - 0.19%A0428 BLS Non-Emergency 6,833,969 6,685,824 2.22%A0429 BLS Emergency 2,726,768 2,687,644 1.46%A0430 Fixed Wing 10,820 10,074 7.41%A0431 Helicopter 56,200 58,308 - 3.62%A0432 Paramedic Intercept 3,153 3,067 2.80%A0433 ALS-2 111,789 111,723 0.06%A0434 Specialty Care

Transport 104,605 103,315 1.25%

A0435 Fixed Wing Mileage 1,972,269 1,858,117 6.14%A0436 Helicopter Mileage 3,309,845 3,390,550 - 2.38%

Totals 161,321,063 159,459,862 1.17%

NATIONAL DATA FY 2013 VS. FY 2012

Description 2013Paid $

2012Paid $

%Change

A0425 Ground Mileage 864,339,277 $861,277,845 0.36%A0426 ALS Non-Emergency 66,422,692 $64,860,566 2.41%A0427 ALS Emergency 1,615,499,54

1$1,630,257,4

05 - 0.91%

A0428 BLS Non-Emergency 1,182,578,453

$1,178,364,961 0.36%

A0429 BLS Emergency 758,337,761 $753,395,553 0.66%A0430 Fixed Wing 35,462,990 $33,298,889 6.50%A0431 Helicopter 201,690,114 $211,489,526 - 4.63%A0432 Paramedic Intercept 908,676 $894,878 1.54%A0433 ALS-2 52,420,103 $52,855,918 - 0.82%A0434 Specialty Care

Transport 61,021,808 $60,263,801 1.26%

A0435 Fixed Wing Mileage 18,185,274 $17,090,963 6.40%A0436 Helicopter Mileage 81,690,492 $84,621,519 - 3.46%

Totals 4,938,557,181

$4,948,671,824

- 0.20%

NATIONAL DIALYSISFY 2013

Description 2013Allowed #

2013Allowed $

2013Paid $

A0425 Ground Mileage 24,042,444 $182,660,653

$143,820,280

A0426 ALS Non-Emergency 9,058 $2,348,337 $1,844,296A0427 ALS Emergency 36,644 $15,107,658 $11,824,080A0428 BLS Non-Emergency 3,441,190 $753,980,36

0$592,925,70

9A0429 BLS Emergency 23,564 $8,407,654 $6,576,810A0430 Fixed WingA0431 HelicopterA0432 Paramedic InterceptA0433 ALS-2 884 $522,505 $409,976A0434 Specialty Care

Transport 8,048 6$,406,502 $5,049,534

A0435 Fixed Wing MileageA0436 Helicopter Mileage

Totals 27,561,831

$969,433,669

$762,450,685

NATIONAL DIALYSISFY 2013 VS. FY 2012

Description 2013Allowed #

2012Allowed #

%Change

A0425 Ground Mileage 24,042,444 22,663,118 609%A0426 ALS Non-Emergency 9,058 7,568 19.69%A0427 ALS Emergency 36,644 34,111 7.43%A0428 BLS Non-Emergency 3,441,190 3,228,449 6.59%A0429 BLS Emergency 23,564 22,762 3.52%A0430 Fixed Wing  A0431 Helicopter    A0432 Paramedic Intercept  A0433 ALS-2 884 1,158 - 23.66%A0434 Specialty Care

Transport 8,048 8,058 - 0.12%

A0435 Fixed Wing Mileage  A0436 Helicopter Mileage    

Totals 27,561,831

25,965,224

6.15%

NATIONAL DIALYSISFY 2013 VS. FY 2012

Description 2013Paid $

2012Paid $

%Change

A0425 Ground Mileage $143,820,280 $139,759,810.40 2.91%

A0426 ALS Non-Emergency $1,844,296 $1,540,337.52 19.73%

A0427 ALS Emergency $11,824,080 $11,058,719.32 6.92%

A0428 BLS Non-Emergency $592,925,709 $572,920,033.98 3.49%

A0429 BLS Emergency $6,576,810 $6,397,094.89 2.81%

A0430 Fixed Wing  A0431 Helicopter    A0432 Paramedic Intercept  A0433 ALS-2 $409,976 $538,990.19 - 23.94%A0434 Specialty Care

Transport $5,049,534 $4,880,874.31 3.46%

A0435 Fixed Wing Mileage  A0436 Helicopter Mileage    

Totals $762,450,685

$737,095,860.61

3.44%

WISCONSIN – FY 2013Description 2013

Allowed #2013

Paid $

A0425 Ground Mileage 1,812,421 $11,517,681A0426 ALS Non-Emergency 5,098 $1,043,709A0427 ALS Emergency 72,900 $23,411,393A0428 BLS Non-Emergency 37,285 $6,255,057A0429 BLS Emergency 60,366 $16,287,358A0430 Fixed Wing 11 $29,828A0431 Helicopter 487 $1,842,283A0433 ALS-2 1,965 $936,947A0434 Specialty Care Transport 1,975 $1,104,787A0435 Fixed Wing Mileage 1,358 $9,992A0436 Helicopter Mileage 26,679 $659,368Totals 2,020,546 $63,098,403

WISCONSINFY 2013 vs. FY 2012

Description 2013Allowed #

2012Allowed #

%Change

A0425 Ground Mileage 1,812,421 1,760,695 2.94%A0426 ALS Non-Emergency 5,098 4,397 15.95%A0427 ALS Emergency 72,900 71,694 1.68%A0428 BLS Non-Emergency 37,285 34,201 9.02%A0429 BLS Emergency 60,366 61,653 -2.09%A0430 Fixed Wing 11 6 85.17%A0431 Helicopter 487 482 1.00%A0433 ALS-2 1,965 2,027 -3.04%A0434 Specialty Care

Transport 1,975 1,339 47.46%

A0435 Fixed Wing Mileage 1,358 837 62.26%A0436 Helicopter Mileage 26,679 26,946 -0.99%

WISCONSINFY 2013 vs. FY 2012

Description 2013Paid $

2012Paid $

%Change

A0425 Ground Mileage $11,517,681 $11,275,829 2.14%A0426 ALS Non-Emergency $1,043,709 $904,080 15.44%A0427 ALS Emergency $23,411,393 $23,144,136 1.15%A0428 BLS Non-Emergency $6,255,057 $5,798,595 7.87%A0429 BLS Emergency $16,287,358 $16,772,646 -2.89%A0430 Fixed Wing $29,828 $18,190 63.98%A0431 Helicopter $1,842,283 $1,810,258 1.77%A0433 ALS-2 $936,947 $972,712 -3.68%A0434 Specialty Care

Transport $1,104,787 $751,382 47.03%

A0435 Fixed Wing Mileage $9,992 $7,203 38.72%A0436 Helicopter Mileage $659,368 $662,637 -0.49%

WISCONSIN DIALYSIS Description 2013

Paid $2012

Paid $%

Change

A0425 Ground Mileage $174,867 $154,524 13.17%

A0428 BLS Non-Emergency

$827,609 $644,086 28.49%

Totals $1,265,209 $1,047,456

20.79%

2015 INFLATION UPDATE• On August 29, 2014, CMS issued

Transmittal 3057, which contained the Ambulance Inflation Factor (AIF) for CY 2015

AIF = CPI-U – MFPCPI-U = 2.1%MFP = 0.7%

AIF = 1.4%

TEMPORARY ADJUSTMENTS• On April 2, 2014, the President

signed the Protecting Access to Medicare Act of 2014

• Extension of temporary adjustments through March 31, 2015– 2% urban– 3% rural– “super rural” bonus

• Does not provide for a suspension of 2% “sequester”!!!

PERMANENT REDUCTION FOR DIALYSIS

SERVICES• American Taxpayer Relief Act of 2012

mandated a permanent 10% reduction in Medicare’s payment for BLS non-emergency ambulance transports to/from dialysis

• Transmittal 2703 (May 10, 2013)– Reduction will be applied to any claim

submitted:• A0428• “G” or “J” modifier as either the origin or destination

FUTURE OF DIALYSIS

• Future Congressional Action– Further reductions to Fee Schedule

Payments• Nothing currently proposed for 2014

– Cap on number of covered ambulance trips• Per patient per year• Similar to physical therapy caps

– Possible expansion of dialysis payment bundle

– “Safe harbors” to induce dialysis facilities to transport their own patients

• Increase in Enforcement Activity

PART B PAYMENT DATA RELEASE

• On April 9, 2014, CMS released the Medicare Provider Utilization – Sortable database of FFS payments by

individual physician, ambulance supplier and other health care suppliers

– http://projects.wsj.com/medicarebilling/?mod=medicarein

– A.A.A. Press Release and Talking Points• See handouts

2013 MEDPAC REPORT

MEDPAC REPORTKey Findings:• In 2011, Medicare paid $5.3 billion for ambulance

services• 3 temporary adjustments for ground ambulanced

accounted for $192 million• 2 permanent adjustments accounted for $220 million

• 50% increase for rural miles 1 – 17• 50% increase for rural air ambulance

• Ambulance volume increased by 10% from 2007 to 2011• Most of increase in volume was from increase in BLS-NE• Dialysis in particular• Increase centered in urban areas

• Number of ambulance providers has grown steadily since 2007

MEDPAC REPORTConclusions:• Current adjustments for ground

ambulance are not good indicators of transports with relatively high costs• i.e., high costs with low volumes

• Medicare beneficiaries are not experiencing access to care problems

MEDPAC REPORTRecommendations:• Permit expiration of current temporary

adjustments• Decrease rate for BLS non-emergencies (5.7%)

• Increase base rates for ALS, ALS-2, SCT and BLS-E (2.8%)• Restructure existing adjustment for rural ground

miles 1 – 17• Better target isolated, low volume providers

• Implement new national claims processing edits

• Better define medical necessity requirement

NEW FROM THE OIG

OIG REPORT ON UTILIZATION

• Between 2002 – 2011: – 69% increase in Part B ambulance transports– 34% increase in number of beneficiaries

requiring ambulance transport– 26% increase in number of ambulance suppliers

• ~ 100% increase in number of BLS-NE suppliers– 269% increase in dialysis transports

• 85% increase in number of ESRD patients transported by ambulance

– 829% increase in transports to partial hospitalization programs

OIG STUDY ON APPEALS• The First Level of Medicare Appeals Process,

2008 – 2012: Volumes, Outcomes, and Timeliness• October 2013• MACs processed 2.9 million redeterminations in

2012– 33% increase over 2008– 233,941 appeals for ambulance

• 3% increase over 2008

• 51% of Part B appeals were favorable to providers– 43% for ambulance claims

PROPOSED RULE RE: CMPS• May 12, 2014 Proposed Rule• Expands OIG’s authority to impose civil

monetary penalties for certain misconduct– $15,000 per day for failure to grant

timely access to records in connection with an audit or investigation

– $10,000 per day for each day an overpayment is not returned following the 60th day after it has been “identified”

PROPOSED RULE RE: EXCLUSIONS

• May 9, 2014 Proposed Rule• Revises OIG’s exclusion authority to incorporate ACA

changes–Would give OIG right to exclude individuals

convicted for obstructing an audit or investigation– Expands OIG’s authority to exclude individuals for

failing to supply certain payment data to CMS–Would give OIG right to exclude individuals that

knowingly make false statements in connection with the submission of an enrollment application

OIG GUIDANCE ON EXCLUSIONS

• On May 8, 2013• Updated Special Advisory Bulletin on Effect of

Exclusion from Participation in Federal Health Programs

• Reiterates existing guidance on consequences of employing an excluded individual– Prohibition would extend to those not involved directly in

patient care• Management and billing• Driving an ambulance• Ambulance dispatch services• Referring physician or individual signing PCS form

EXCLUSION TESTING• Employees– IG recommends testing employees once a month

• Referring Sources– Repetitive Patients v. Non-Repetitive Patients

• Vendors– Contractual commitment to do testing on

employees of vendor that service your accounts– Indemnity?

OIG ADVISORY OPINIONS

• Billing Waivers & Waiver of Coinsurance– Opinion 13-17 – IG permitted a municipal ambulance

service to use tax revenues to cover out-of-pocket expenses due fro non-residents

– Opinion 13-14 – IG permitted the waives coinsurance and deductibles due from residents for EMS provided by a county EMS agency and several volunteer rescue squads.

– Opinion 13-11 – IG permitted a BLS ambulance supplier to accept payment from the town for cost-sharing amounts due from residents. The private ambulance service also agreed to waive cost-sharing amounts when responding under mutual-aid

– Opinion 13-08 – IG permitted a fire protection district to NOT bill residents or their insurance• Expansion of existing line of opinions that permitted taxpayer-supported

entities to bill only to the extent of a resident’s insurance

OIG ADVISORY OPINIONS

• Reimbursement for Dispatch– Opinion 13-05 – IG permitted a municipality to

require the winner of an RFP for 911 services to reimburse the municipality for a portion of dispatch costs

• County Health District– Opinion 13-04 – IG permitted a County Health

District to provide non-emergency ambulance services, which would include the provision of transports to/from County health facilities

OIG ADVISORY OPINIONS

• Opinion 13-18– RFP asked bidders to provide:

• Free ambulance transports to City employees• Free AEDs and other equipment• Free EMS training• 20% discount on ambulance transports to uninsured

seniors• Replenishment of supplies used by City first-responders

– OIG took issues with the proposal to provide free or below-market equipment to the City, and therefore refused to sign off on the arrangement as a whole

WHAT ELSE IS NEW?

2015 PROPOSED RULE• July 11, 2014

• Technical changes to reflect extensions of temporary adjustments through March 31, 2015• 2% Urban• 3% Rural• “Super Rural” Bonus

• Proposal to adopt recent OMB modifications to Rural-Urban Commuting Area (RUCA)– CMS estimates

• 122 zip codes go from Urban to Rural• 100 zip codes would go from Rural to Urban• No impact on super rural

– AAA estimates• 1,500 zip codes go from Rural to Urban

PROPOSED RULE ON

ENROLLMENT

AMBULANCE ‘BACK BILLING’

• CMS proposing to limit effective date of Medicare billing privileges to later of:–Date enrollment application is

filed–Date you begin providing

services at new practice location

REVOCATION OF BILLING PRIVILEGES

• CMS proposing to expand its authority to revoke billing privileges for providers that have engaged in “a pattern or practice” of abusive billing– Including high percentage of claim

denials

LIMIT ON USE OF CORRECTIVE ACTION

PLANS• CMS proposing to limit the use of

Corrective Action Plans (CAPs) to minor issues of non-compliance– e.g., failure to timely file revalidation

• CMS indicated that failure to disclose a “Practice Location” would not be eligible for CAP– Would require you to appeal

PATIENT SIGNATURE REQUIREMENT

• July 11, 2014• Transmittal 2984

• CMS removed the requirement that you must capture the address of anyone signing on the patient’s behalf

• The AAA had requested this change over 2 years ago

SNF RECOUPMENTS

• In 2013, CMS issued a transmittal instructing RACs to recoup ambulance transports between two SNFs–Indicated by use of Discharge

Status Code “03” on the SNFs claim–Effective April 7, 2014

ICD-10 CODES• Implementation delay until October 1, 2015• ICD-9 Codes: ~ 17,000• ICD-10 Codes: ~ 150,000

If you want to laugh:http://www.youtube.com/user/

findacode

ICD-10 CODES•AAA has published an ICD-10 crosswalk for the current CMS Medicare Condition Code List• See handout

MEDICARE REVALIDATION

• CMS is continuing its efforts to require all existing Medicare providers and suppliers to “revalidate” their Medicare enrollment information– Original target date: March 2013– Extension: March 2015

–2014 Enrollment Fee: $542•Medicare contractors given discretion on when to revalidate various provider groups• Failure to revalidate can result in 1 year ban on participation in Medicare!!

MEDICARE REVALIDATION

•List of all providers that have been asked to revalidate, arranged by calendar quarter•CMS Website:

–http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidationshtml

ALJ DELAYS• November 2013 – Office of Medicare

Hearings and Appeals (OMHA) announces substantial delay in assignment of new cases to ALS– 24 months for new case assignments– 6+ months for hearings to be held–Up to 3 years before a decision

should be expected!!

ALJ PILOT PROJECT –SETTLEMENT CONFERENCES

• On July 7, 2014, OMHA announced a new mediation program designed to reduce the ALJ backlog– Settlement Conference Facilitation (SCF)

• Eligibility requirements– 20 or more claims at issue– $100,000 or less at issue– Beneficiary must not have been

determined to be liable for

ALJ PILOT PROJECT –STATISTICAL SAMPLING

• Project for appeals involving large numbers of claims

• ALJ will review a sample of appealed claims, and extrapolate against larger universe of appealed claims

• Eligibility requirements– 250 or more claims at issue– No request for Settlement Conference – Beneficiary must not have been determined

to be liable for

MEDICARE ADVANTAGE PLANS

• CMS announced that it is suspending the “Payment Dispute Resolution Process” as of February 1, 2014–Used to resolve situations where MA

plan pays the claim, but at the incorrect rate–Lack of funding

A.A.A. MEDICAID RATE SURVEY

• In March 2014, the A.A.A. completed a survey of the current Medicaid rates in all 50 states– Includes information the payment of

Medicare crossovers– See handout

V.A. MILLENNIUM BILL

• V.A.’s payment for emergency ambulance services is contingent on V.A. paying for veteran’s care at hospital ED–Patient’s with Part A Medicare,

but not Part B–Must bill veteran

AIR AMBULANCE• On April 21, 2014, the FAA announced

delay in implementation of new helicopter ambulance safety standards– Impacts certain operating rules–New compliance date is April 22, 2015– Does not impact new requirements for terrain

awareness and warning systems or flight data monitoring systems• April 22, 2017/2018 implementation dates

RECENT TRENDS

IN FRAUD & ABUSE

ENFORCEMENT

The Scope of the Problem

• CMS estimated that Medicare lost more than $24 billion on fraud and abuse in FY 2009– Roughly 7.5% of total payments• Other experts place the

number at as high as $70 billion per year!!

• ACA allocated an additional $250 million to fund additional audits

• New provisions that allow Medicare contractors to use recoupments to fund further anti-fraud activities– Allow process to become self-

sustaining!!

Funding for Anti-Fraud Measures

• Away:–Random post-payment audits–So-called “Pay and Chase”

• Towards: –Use of data analysis to identify

systemic issues–Use of prepayment reviews

Shift in Focus

1. ALS emergency transports

2. Hospital Discharges3. Dialysis

EMS Areas of Focus

• Investigation into overutilization of ALS emergency– $2.5 million settlement– Debate as to whether overbilling was fault

of City or its billing agent

•12 neighboring cities paid $1.2 million to settle similar charges– Same billing agent

The City of Dallas

•September 2008, a whistleblower suit is filed alleging town was overbilling ALS emergency–95% of transports billed ALS emergency

•Town settles for $4.5 million–Based on advice of lawyers, who indicated potential liability could reach $100+ million

•Town sues lawyers for malpractice–They allege actual overpayment was only $108,000

Clinton, Iowa

• July 30, 2014 letter to provide community• Purportedly to educate on common errors

• Issues:1. PCS Form – “simply checking

boxes or listing medical conditions/diagnosis is inappropriate”

2. SCT – “Critical illness/injury is defined as….a patient who is experiencing an acute life-threatening episode”

NORIDIAN HEALTHCARE SOLUTIONS

•Targeted prepayment reviews throughout its service areas•California•Utah•Northern Marianas Islands

NORIDIAN HEALTHCARE SOLUTIONS

OIG REPORT ON UTILIZATION

• Between 2002 – 2011: – 269% increase in dialysis transports• 85% increase in number of ESRD patients

transported by ambulance

WISCONSIN DIALYSIS Description 2013

Paid $2012

Paid $%

Change

A0425 Ground Mileage $174,867 $154,524 13.17%

A0428 BLS Non-Emergency

$827,609 $644,086 28.49%

Totals $1,265,209 $1,047,456

20.79%

“In 2007, Medicare paid $38 million per year to Texas ambulance suppliers related to excess services per beneficiary, compared to services per beneficiary in the remainder of the U.S. Audit findings…show that much of the excess is not justifiable based on the patients’ conditions.”

Case Study: Texas Dialysis

TEXAS DIALYSIS

150,000

350,000

550,000

2007 2008 2009 2010 2011

Allowed #

Allowed #

Texas DIALYSIS

0

50,000,000

100,000,000

2007 2008 2009 2010 2011

Medicare Paid $

Medicare Paid $

TEXAS DIALYSIS

0.00%

10.00%

20.00%

30.00%

40.00%

2007 2008 2009 2010 2011

% of Claims DeniedNational Average

TEXAS DIALYSIS

Case Study: Puerto Rico

“FCSO quickly identified an extreme data anomaly related to non-emergency ambulance services provided in Puerto Rico and the U.S. Virgin Islands. More specifically, our analysis of paid claims data for procedure code A0428 – ambulance service, basic life support, non-emergency transport (BLS), revealed that utilization in Puerto Rico for this procedure code was over 1,000 percent higher than the rest of the United States.”

Case Study: Puerto Rico

“Data analysis also revealed that 95 percent of non-emergency ambulance utilization in Puerto Rico involved repetitive transportation of dialysis patients to/from their dialysis facilities as compared to less than 5 percent in Florida. Although dialysis patients may have multiple health issues, the vast majority can safely and routinely travel by means other than an ambulance.”

• 2008 Medicare Payment Data:– Puerto Rico• ~620,000 Medicare beneficiaries• 407,000 dialysis transports

– CA, FL and NY combined• ~11 million Medicare beneficiaries• 356,000 dialysis transports

Putting That In Perspective…

Puerto Rico – Dialysis

0

20,000,000

40,000,000

60,000,000

20092010

Medicare Paid $

Medicare Paid $

•Medicare Strike Team has been actively investigating ambulance services― Focus on dialysis― Numerous indictments

― Sept. 27, 2013 – Philly couple charged with $4.4 million fraud involving medically unnecessary services and payment of kickbacks

― April 23, 2013 – 7 individual charged with conspiracy to commit $3.6 million health care fraud

The City of Brotherly Love

• Texas – owners of a Rio Valley ambulance service and a billing agency indicted for submitting approximately 1,500 false claims for dialysis patients• Texas – owner of a Houston-based ambulance service convicted of $2.4 million fraud involving false claims for dialysis• Los Angeles – owners of LA ambulance service plead guilty to $13 million fraud involving dialysis patients• Indiana – general manager of a ambulance service pleads guilty to complex fraud involving falsified trip reports for dialysis transports

Recent Fraud Convictions

•Rep. Kevin Brady (R – TX 8th) has called for hearings on Medicare ambulance fraud in Houston– Fallout from Houston Chronicle

articles

•2009 Medicare Payment Data– $62 million spent on ambulance in

Houston– $7 million spent on ambulance in NYC

Harris County, Texas

•Sen. Orrin Hatch (R – UT)•Sen. Charles Grassley (R – IA)•February 2, 2012 letter to HHS Secretary Sebelius– Asking for steps CMS is taking to curb

ambulance abuses in Houston– Focus on dialysis– Asking specifically why CMS has not

imposed a temporary moratorium on new enrollments

Harris County, Texas

TEMPORARY MORATORIUM ON NEW ENROLLMENTS

• On July 26, 2012, CMS announced a temporary moratorium on enrollment of new ground ambulance suppliers in Houston and surrounding counties

• Response to wide-spread fraud and abuse• Key findings:

– 26 counties in US with more than 200,000 Medicare beneficiaries• On average, there is less than 1 ambulance supplier for every

10,000 Medicare beneficiaries in these counties• 9.5 ambulance supplier per 10,000 Medicare beneficiaries in

Harris County, Texas (Houston)• 275 active ambulance suppliers in Harris County

– Two-thirds have not been billing continuously since 2008

TEMPORARY MORATORIUM ON NEW ENROLLMENTS

• On February 4, 2014, CMS announced that it was extending the moratorium on new ambulance enrollments in Houston metropolitan area for another 6 months– Through June 30, 2014

• New temporary moratorium on enrollment of new ambulance suppliers for Philadelphia metropolitan area

• Further extended through December 31, 2014

PRIOR AUTHORIZATIONDEMONSTRATION PROJECT

• On May 22, 2014, CMS announced that it was implementing a prior authorization process for dialysis transports in 3 states– New Jersey– Pennsylvania– South Carolina

• Prior authorization required for claims to be paid– Alternative is 100% prepayment review

PROTECTING INTEGRITY IN MEDICARE ACT OF 2014

• Proposes to expand dialysis prior authorization project nationwide–2015 • MAC Jurisdiction L (DC, DE, MD)• MAC Jurisdiction 11 (NC, VA, WV)

–2017• Rest of the nation

Brian Werfel, Esq.A.A.A. Medicare

Consultant631-265-5650

bwerfel@aol.com