Trailblazer/CMS Notices: Certification of Coverage for Ambulance Transportation – September 2, 2010

Trailblazer has published this notice in September, 2010:

This article is primarily intended for physicians who certify Medicare coverage for ambulance transportation, though the underlying message is applicable to all physicians who order and certify other services for Medicare payment. Understanding Medicare requirements for payment and certification of ambulance transportation is the responsibility of providers who supply ambulance services as well as physicians who certify ambulance services for Medicare payment.

TrailBlazer has encountered a persistent and extremely high number of claims for non-emergency ambulance transportation for patients routinely traveling to and from dialysis. Dialysis patients in some metropolitan Texas areas regularly travel by ambulance at a rate many times higher than patients in other communities. We have found that most of the claims we review for these ambulance transports to and from dialysis (and to a lesser extent, for ambulance transportation in other circumstances) are inappropriate in that the patients do not qualify for Medicare payment of their ambulance transportation. The loss to the Medicare program by inappropriately reported claims such as these is remarkable, not just in administrative resources, but more importantly, in terms of Medicare benefit dollars.

Payment for ambulance services of the kind represented by this problem requires a physician to certify the patients as having met Medicare’s requirement for ambulance transportation benefits. Experience demonstrates that most physicians have little knowledge of the coverage and payment requirements for services they certify, thus do not understand the financial impact of their actions. That seems to be the case with ambulance services.

The Medicare ambulance benefit is very narrow. Payment is properly made for transportation of patients in medical emergencies as well as selected non-emergency transportation. Medicare does not allow for payment of ambulance services for patients who are able to travel by other means of transportation and whose medical condition is not compromised by doing so. In an effort to educate certifying providers, TrailBlazer published a job aid titled “Physician Guidelines for Certifying Ambulance Transfers”PDF in June 2010 regarding physician certification of Medicare payment for routine non-emergency ambulance transportation. “Documenting ‘Why’ for Non-Emergent Ambulance Services,” a notice regarding several important ambulance payment requirements, primarily the patient’s necessary medical condition at the time of the covered transport, followed in August 2010. The two documents include basic requirements for Medicare ambulance payment.

TrailBlazer’s medical directors strongly encourage physicians who certify ambulance services to immediately review and apply the information contained in the articles mentioned above as well as in TrailBlazer’s Local Coverage Determination (LCD) regarding ground ambulance services (see hyperlinks below). With Medicare resources stretched as thin as they are, lack of physician knowledge must not continue enabling unwarranted losses of financial resources intended for and otherwise available as payment for medically reasonable and necessary health care.

(Reference: From the Desk of the Medical Director)

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