Medicare Ambulance Open Door Forum – April 2011

The following is a “less than live” blog post regarding the CMS Medicare Ambulance Open Door Forum held April 6, 2011.  This is by no means a transcript of the presentation (far from it!) and I am not going to address many of the Q&A questions.

The Use of Mapquest to determine mileage:

Apparently, some one has received some sort of denial for using Mapquest for mileage determinations to comply with the fractional mileage requirements.  CMS personnel stated that this is adequate as long as it was also documented why the use of Mapquest was necessary.

Crossover payment:

This deals with secondary payors paying the patient rather than the supplier.  CMS personnel indicated that this problem was fixed, at least for the original complaint.

ABN (Advanced Beneficiary Notice) use by Ambulance Services:

Basically, there are three requirements for an ambulance service to have a mandatory use of an ABN:

  • the service provided is a medicare covered benefit;
  • the provider believes that payment for the services may not be made because the service is not reasonable and necessary at the time of service; and
  • the ambulance service provided is non-emergency in nature.

If these three conditions are met, then the provider must issue an ABN to the beneficiary if the provider eventually wants to bill the beneficiary.  The provider may, even if one of these conditions is not met, choose to issue an ABN to the beneficiary, but there is no mandatory requirement if the service is not a medicare covered benefit.  A couple of examples were offered to clarify:

  1. Beneficiary goes from a SNF to a dialysis, but not the nearest dialysis facility to the SNF.  The provider is not required to issue an  ABN to the beneficiary because the mileage for the transport to the farther dialysis facility is not a covered benefit.  Only the transport and mileage to the nearest facility is covered.  The provider may, however, issue an ABN to the beneficiary;
  2. Beneficiary treated at Hospital A, now requires transport to tertiary-care Hospital B.  Family insists on air transport when the physician indicates only ground transport is required.  Air Ambulance provider must issue an ABN in this case as the service is a covered benefit for transport to higher level of care, the provider knows they will not be paid for the upgraded transport and it is non-emergency transport (defined as scene to hospital – this is a hospital to hospital scenerio).  ABN must be issued to beneficiary to make beneficiary aware that Medicare will not cover this service and the provider will bill the patient as the responsible party.

In short, the provider may issue an ABN, but is not required to do so in a situation where the provider believes they will not be paid by Medicare unless the situation meets all three conditions noted above.

Medicare Advantage plans and Fractional Mileage:

Apparently some Medicare Advantage (MA) plans are not dealing with fractional mileage well – sometimes even denying the mileage part of the claim.   The general rule for the MA plans is they have the flexibility to change some of the rules and contract with providers for less than Medicare rates, but they do need to pay at least Medicare rates for all non-contracted providers.

If the MA plan does not pay appropriately, CMS advised to appeal to the contractor for the first step, then there is an independent contractor which hears the second step of the claims.

During the Q&A, there was a question regarding return of payments that are generally considered not medically necessary under regular Medicare.  The question was unresolved, but the gist of the answer is that the MA plans have some flexibility and they may pay for these services, but it is at the discretion of the MA plan and the questioner needed to resolve this with the MA plan directly.

Other questions:

Provider enrollment – Remember, under new rules, there is an increased enrollment fee and site visit requirement for Medicare providers.  This generated a complaint from a municipal fire service provider;

Specialty care transports – This is a function of beneficiary condition, not what the paramedic does in the ambulance.  There is a definition in the rules (sounds like a later blog post for me!);

Disallowed MA claims past the timely filing deadline – remember, if the government or a contractor cause you to not be able to meet the timely filing deadline, then a provider can still bill Medicare.  But the fault must lie with the government or a contractor, not a mistake of fact or law by the billing party.


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