HCFA is still silent on revamping ambulance payments

Baltimore, MD-Hospital emergency departments (EDs) are still waiting for new regulations regarding Medicare ambulance payments. After nearly a year of government criticism of the payment system and charges of fraud on the part of certain providers, the updated rules appear to be nowhere near ready for release.

In a Federal Register filing last June, the Health Care Financing Administration (HCFA) threatened to act to bring more clarity and consistency to the Medicare ground ambulance payment regulations. A law passed by Congress last summer also directed HCFA to develop a fee-based payment schedule for ambulance reimbursements.

After nearly nine months, the agency has remained virtually silent on the issue.

A tight-lipped HCFA official refused to provide details as to when the new modified rules would be forthcoming. However, the official, who asked not to be quoted in accordance with HCFA policy, did say that hospitals and EDs are not likely to be affected in any way by the modifications.

"If they're doing things right, they shouldn't have to worry about this," the official told The Managed Care Emergency Department.

However, hospitals should be mindful that HCFA is expected to take a narrower stance on approving payments for ground ambulance service in the future in the following ways:

By focusing more closely on standards of medical necessity. Medical necessity determinations are likely to be made based more closely than ever on the patient's ICD-9-CM codes reported by the provider on the claims form, according to information previously supplied by HCFA.

Last June, the Medicare agency released a list of those diagnosis codes in its proposed rulemaking. If a condition isn't reflected by one of the ICD-9-CM codes listed by HCFA in its new regulations, the ambulance service will likely not be viewed as medically necessary and therefore not payable.

Forbidding providers and suppliers from billing patients directly. Under the new regulations, providers will not be able to bill patients if the service was deemed by the Medicare carrier to be medically unnecessary. The only way around this prohibition, according to the HCFA proposal, is for a provider to inform the patient in a written statement prior to rendering the service that the service will not be covered by a carrier.

Clarifying distinctions between basic life support (BLS) and advanced life support (ALS) transportation. Medicare officials are said to be concerned that ALS services are being routinely billed by certain providers when they weren't needed by patients.

In fact, a report issued in November by the Office of the Inspector General of the U.S. Department of Health and Human Services called the oversight of ambulance payments so inconsistent it encouraged widespread fraud and abuse.