Wachler & Associates Health Law BlogCMS Expands Prior Authorization Ambulance Payment Model
The Centers for Medicare & Medicaid Services (CMS) announced on September 22, 2020 that the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) will be expanded nationwide. Under this system, Medicare pays ambulances for the transport of patients to their scheduled, non-emergency healthcare appointments.
The prior authorization model was launched in 2014 by CMS in select states that displayed a higher utilization of RSNAT services. RSNAT services are essential medical services that have been previously scheduled and require non-emergency ambulance transportation for at least three round trips within ten days, or a minimum of once a week for at least three weeks. These types of ambulance services are covered under Medicare Part B, provided that the services are deemed medically necessary. Under the payment model, the ambulance transportation company must submit a prior authorization request to their Medicare administrative contractor (MAC) on behalf of the beneficiary and include a physician certification statement noting the medical necessity of the service. Once the physician certification statement has been reviewed, the MAC will issue a determination as to whether the beneficiary qualifies for RSNAT.
The purpose of the prior authorization model is to decrease Medicare spending through the reduction of ambulance transportation services that are not covered by Medicare and do not meet coverage standards, without negatively impacting access to care for beneficiaries. The prior authorization model began in 2014 with New Jersey, Pennsylvania, and South Carolina participating, and in 2016 expanded to Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia. The model will now be expanded nationwide as a result of the success in those nine states.
Over the course of four years, evaluations of and reports on the modal indicated that the prior authorization model reduced Medicare spending without compromising access to and quality of care for beneficiaries. Ambulance services are often associated with overuse and erroneous payments that are too high or fail to meet program requirements. The model serves as a national program that attempts to prevent fraud and waste proactively. According to the Second Interim Evaluation Report, RSNAT services were utilized 63% less and RSNAT expenditures among beneficiaries were reduced by 72% as a result of the model. This reduction in RSNAT service costs decreased overall Medicare fee-for-service spending by 2%, or $650 million. Based on the reports, there were no findings that the model negatively impacted quality of care. Current states in the program will continue to participate after December 1, 2020, the original ending period for the model. More information will be released by CMS regarding the national expansion, which will follow the same program design as the present model.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new CMS developments in Medicare and other rules and regulations that may have an impact on health insurance coverage. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.