CMS expanding ambulance program integrity payment model nationally

The Centers for Medicare and Medicaid Services announced Tuesday that it will expand the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide. The model has saved Medicare about $650 million over four years while preserving quality of care and access to essential services, the agency said.

Citing an approach geared to protect taxpayer dollars and target the most significant program integrity risks facing healthcare programs, CMS said it is working to prevent, rather than chase, fraud, waste and abuse through proactive measures. Ambulance services have long been associated with inappropriate overuse and high improper payments, meaning many payments don't meet program requirements – intentionally or otherwise – and contribute to what the agency called the "inappropriate spending" of Americans' tax dollars. 

The CMS Comprehensive Error Rate Testing program, which measures improper payments in the Medicare fee-for-service program, has consistently found ambulance services, specifically non-emergent ambulance transports, to be in the top 20 Part B services with improper payments. The estimated improper payment rates for non-emergent ambulance transports in 2017 and 2018 were 22.6% and 18.6%, respectively.  

WHAT'S THE IMPACT?

The RSNAT Prior Authorization Model tests whether prior authorization – or advanced approval of a service before the service is furnished, and before a claim is submitted for payment – helps save Medicare money while maintaining or improving the quality of care for repetitive, scheduled nonemergency ambulance transportation.

These services are covered under Medicare Part B for Medicare beneficiaries who need to ride in ambulances to certain medical appointments, most often for dialysis treatment. With the expansion of the model, CMS said it's ensuring that the right payments are made at the right time for the right beneficiary for covered, appropriate and reasonable services.

Based on the model's First Interim Evaluation Report in 2018, the Chief Actuary of CMS certified that nationwide expansion of the RSNAT Prior Authorization Model would reduce net Medicare spending. The Second Interim Evaluation Report, released Tuesday, supports previous findings. 

It found that the model reduced RSNAT service use by 63% and RSNAT expenditures by 72% among beneficiaries with end stage renal disease and/or severe pressure ulcers during the first four years of the model. This decrease in RSNAT service expenditures, in turn, caused a total decrease of Medicare fee-for-service expenditures of 2% (about $650 million over four years). The report did not find evidence that the model adversely affected quality of care.

The RSNAT Prior Authorization Model began in New Jersey, Pennsylvania and South Carolina in 2014 and in 2016. North Carolina, Virginia, West Virginia, Maryland, Delaware and the District of Columbia were added in accordance with section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015. The model is expanding nationwide under the authority of section 1834(l) (16) of the Social Security Act, as added by section 515(b) of MACRA.

The model's program integrity, patient safety and cost-saving elements will continue without interruption in the current states beyond December 1, 2020, when the model was originally scheduled to end in these states. 

CMS will release more information on the national expansion and implementation dates for additional states as it becomes available. The national model will follow the same design as the current model. CMS is continuing to monitor the COVID-19 Public Health Emergency and will take that into account when determining the time frame for expansion into additional states.

The OACT certification memo can be found here. The Phase 1 and 2 evaluation reports are here. 

ON THE RECORD

"CMS program integrity functions allow us to hold the entire healthcare system accountable, protect beneficiaries from harm and safeguard taxpayer dollars." said CMS Administrator Seema Verma. "When deployed appropriately, prior authorization can help ensure Medicare requirements are met before a service is provided and the claim is paid, without creating any new documentation requirements for providers. The RSNAT model has proven a resounding success, and beneficiaries across the country deserve to benefit from it."
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com