Author: Aaron Director

Quick Takes: Cost of Readiness

There is a widespread recognition in the industry that reimbursement doesn’t fully take into account the costs of service readiness. But until 2020, we haven’t had data to support that understanding. The new cost data collection requirements give us that opportunity IF we are able to gather and report readiness data effectively and accurately. As part of our Quick Takes series, we talk about these issues and give some things to think about in your service right away.

Quick Takes: The Role Of Service Mix

The data collection that launches in less than 10 months will include a wide variety of elements. Service area and service mix may seem like minor pieces of the collection, but they play a big role in analysis of utilization. As part of our Quick Takes series, we identify some questions you should be able to answer about YOUR service in order to be ready.

Quick Takes: NPIs

As part of our new Quick Takes series, here’s a brief discussion about the issues around having single or multiple NPIs under the new data collection requirements. Interested in taking a deeper dive into this topic? Learn from our panel of experts during the webinar Single vs. Multiple NPIs: Challenges and Opportunities on Tuesday, December 11th.

CMS Launches Outreach Effort to Ambulance Providers & Suppliers

As part of the Bipartisan Budget Act of 2018 (BBA 2018), the Congress instructed CMS to develop a cost collection system to collect cost and revenue data related to the provision of ambulance services. Ambulance services are defined by federal law to include all levels of emergency and non-emergency services. 

CMS is in the first phase of this process. The Congress instructed the Agency to engage with stakeholders before specifying through notice and comment rulemaking the data collection system. By law, CMS is required to specify the final system by December 31, 2019. CMS must also identify the first group of providers and suppliers selected for the first representative sample by that date as well. It appears that the goal is to have the contractor develop a proposal before the 2019 rulemaking cycle which will begin next summer.

To engage with the stakeholders, CMS, through its contractor the RAND Corporation, is reaching out providers and suppliers to learn more about the costs and revenues associated with providing ambulance services.

During the American Ambulance Association’s annual meeting earlier this month, CMS through the RAND Corporation, convened a focus group where they selected several AAA members who were able to talk directly with the contractor. The discussion centered around characteristics of ambulance services that matter for determining costs. The group also talked about how data is currently captured at the state and local levels, as well as how data is tracked within ambulance services. There was also a lot of discussion about the importance of standardizing data elements and not relying upon different state or local definitions, which could confound the data and make it impossible to compare costs across states.

As we have reported previously, it is critically important that the data collected through this process is standardized and reflects the actual cost of providing ambulance services. It is important to make sure that the data is useable not only for supporting the ambulance add-ons after they next expire in 2023, but also to help implement broader reforms and innovative payment models.

CMS is now reaching out to others in the industry. If you receive an email or a phone call from RAND Corporation, please respond. 

If you have questions about, or would like assistance with regard to, this project, please contact Tristan North at tnorth@ambulance.org.

Chart of Accounts Review Started

Earlier this week, the American Ambulance Association kicked off the new season of the data collection webinar series with a free session – an overview of a draft chart of accounts for ambulance services. This chart is intended to help services meet the upcoming reporting requirements, while standardizing definitions across the industry to aid in consistent reporting.

With nearly five hundred registrants, the webinar was a tremendous success, and as a follow-up, the draft chart of accounts was sent to each registered person. Moving forward, the next step is to collect feedback from the wide variety of providers who were on the call (and those who watched the recording later). We’ll be collecting that feedback over the coming days, and hope to have a revised and refined product available later this year.

A huge THANK YOU to all those who participated on the webinar, and to the many of you who have already provided feedback. Sharing your help and expertise only improves this tool for the entire community, and we very much appreciate it!

California, Here We Come!

Coming up on September 25-28, the California Ambulance Association will be holding their 2018 Annual Convention – and we’ll be there!

Come hear from our Cost Data Collection experts on the current regulatory situation, and what you need to do to start preparing your service NOW. You’ll come away with a short series of to-do items to determine your readiness and move things ahead.

We’ll see you there!

AAA PreCon Workshop on Mandatory Cost Data Collection

AAA is excited to announce that this year we will be holding a full day pre-conference workshop at the AAA Annual Conference & Trade Show! Join industry experts Rebecca Williamson, Angie McLain, Asbel Montes, Kathy Lester, Scott Moore, and Brian Werfel to learn what the new cost data collection mandates will require and how you and your service can get ahead of the game and prepare for these changes.

Mandatory Cost Data Collection: When Is It Happening & How to Prepare

September 5, 2018 | 9:00 AM – 4:00 PM | MGM Grand, Las Vegas
$75 for Annual Conference attendees | $250 workshop-only

2018 federal legislation expanded Medicare cost reporting to ambulance services, although with some important differences from other Medicare reporters. Failure to meet these new reporting requirements could lead to significant sanctions including loss of Medicare revenue. In this session, we will review how we got to where we are, what the new mandates will require based on current regulations, and how best to prepare yourself and your service for the phase-in.

Ambulance Cost Data Collection is Coming

Although the most prominent ambulance provision passed in the Bipartisan Budget Act of 2018 (H.R. 1892) was the five-year extension of the Medicare add-ons, the Act also included important language directing the Centers for Medicare and Medicaid Services (CMS) to collect cost and other financial data from ambulance service suppliers and providers.

This week, an editorial from AAA Senior Vice President of Government Affairs Tristan North was featured in the June issue of JEMS‘s “EMS Insider”. Read the full article►

Overview of The Moran Company Recommendations on Ambulance Cost Collection System

Overview of The Moran Company Recommendations on Ambulance Cost Collection System

 From 2012 – 2014, The Moran Company developed, through a three-phase project, recommendations about how the Medicare program could collect costs associated with providing ambulance services. Consistent as well with the findings of the Congressionally mandated report on ambulance cost reporting/cost collection, The Moran Company determined that Medicare cost reporting would not be appropriate, result in the submission of accurate data, or solve the historic problem of under-reporting by the industry. Instead, The Moran Company recommended a “hybrid” model that relies on the data elements and accounting methods used in Medicare cost reporting and collects this information in a two-step process to ensure that the unique and varied business structures and their cost differences are appropriately captured.

Step 1:  Collect information to categorize ambulance services to allow for a statistically representative grouping and for appropriate comparison of cost data.

The first step would involve all ambulance operations completing a very short (8-10 question) survey for each of their NPIs. The information collected in this step could include:

  • Organizational designation (e.g., a government authority, independent company, public safety or fire-based, hospital-based, other) [this information ensures that an appropriate number of each type of organization is represented in the cost collection step]
  • Percentage of volunteer EMT labor [this information ensures that an appropriate number of all volunteer, partial volunteer, and no volunteer services are represented in the cost collection step]
  • Volume of ambulance services delivered per year [this information ensures that costs from small, medium, and large services are represented in the cost collect step]
  • Percentage of Medicare emergency and non-emergency services provided per year [this information ensures that the costs of both emergency and non-emergency services are appropriately captured in the cost collection step]
  • Average duration of transports [this information ensures that the costs associated with various lengths of transport are captured in the cost collection step]
  • Whether the service has a sole source contract and, if so, the percent of the activity provided under that contract [this information ensures that the cost differences associated with sole source contracts are captured in the cost collection step]
  • If required to pay fees to the local jurisdiction [this information ensures that the costs associated with local jurisdiction fees are captured in the cost collection step]
  • Other services that are a requirement of doing business [this information allows for the costs that may not be ambulance-related but mandated by local contracts to be accounted for in the cost collection step]
  • Percentage of transports that are urban, rural, or super rural [this information is important to ensure that the costs associated with each designation are appropriately represented in the cost collection step]

Step 2:  Collect cost and revenue information from a statistically appropriate group of ambulance suppliers and providers.

The second step would involve providing information about specific cost and revenue data elements.  These would be consistent with the existing Medicare cost reporting elements for other providers, but in certain instances tailored to ensure that all allowable costs of ambulance services are collected.  For example, vehicle maintenance and fuel would be part of ambulance cost data and included, even if these data elements are not included on nursing home costs reports.

CMS would determine a statistically appropriate sample size for each organization type and ensure an appropriate mix of rural, urban, super-rural, as well as volunteer, sole source, and emergency/non-emergency services.  Over time all ambulance providers and suppliers would be required to report the data, but no individual service (defined by the NPI number) would be required to report every year.

Public Reporting.  Once CMS has collected the data, it will make a de-identified file of the information available to allow policy-makers and stakeholders to evaluate the information collected.  The AAA’s goal is to use this information to allow for meaningful reform that for the first time would link the payment rates to the cost of providing services.  The AAA also seeks to modernize the use of ambulance services in the health care system through policies such as alternative destination, treatment at the scene with referral and no transport, and community paramedicine.

Copyright © 2018 American Ambulance Association, All rights reserved.

Moran Company Report

In 2012, the AAA engaged The Moran Company, a DC-based health care analytics firm, to determine the most appropriate way for the Centers for Medicare and Medicaid Services (CMS) to collect cost data from ambulance service suppliers and providers. Due to the high percentage of small ambulance service suppliers and the different types of ambulance service providers and suppliers, The Moran Company determined sending a tailored cost survey to a representative sampling of the industry was the best way for CMS to obtain the cost data. The Moran Company issued its findings in a report in April 2014.

In February 2018, Congress passed language directing CMS to collect ambulance cost data along with the 5-year extension of the Medicare ambulance add-ons as part of the Bipartisan Budget Act of 2018 (H.R. 1892). The language is based on a modified version of a provision included in the Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2017 (S. 967). The language in H.R. 1892 sets the foundation for data collection based on a system similar to the one proposed by The Moran Company.

For more information about the findings of The Moran Company report, please access the below documents.

If you have questions about The Moran Company report or the development of an ambulance cost data collection system by CMS, please contact AAA Senior Vice President of Government Affairs Tristan North at tnorth@ambulance.org.

Collecting Data for the Future

Collecting Data for the Future:  Understanding the New Statutory Cost Collection Requirement

By Kathy Lester, JD, MPH, Lester Health Law PLLC

On February 9, the President signed into law the Bipartisan Budget Act of 2018 which thankfully included a five-year extension of the ambulance add-ons.  Along with the add-ons extension, the Congress included language requiring the Centers for Medicare and Medicaid Services (CMS) to develop and implement a new cost data collection system for ambulance service providers and suppliers.  While cost collection may sound difficult, the process outlined in the new authority strikes the appropriate balance and will minimize the burden on ambulance service providers and suppliers, while allowing the federal government to collect meaningful data that can be used to address the inadequate reimbursement rates and modernize Medicare ambulance payment policies.

Knowing some time ago that the industry would need to provide CMS with cost information, the AAA for the past six years has been working with The Moran Company, a well-respected health care analytical firm in DC, on the best way to collect ambulance cost data.  Most recently, the AAA Payment Reform Committee has been working with the cost collection experts at The Moran Company to identify the data elements that CMS would need to collect to establish accurate information about the cost of providing ground ambulance services.  We have also developed educational materials that we will share with Members to help ensure a smooth transition into this system.

General

The core components of the new cost collection system for providers and suppliers of ground ambulance services are:

  • A requirement that the Secretary of Health and Human Services, through notice-and-comment rulemaking, must develop a data collection system to collect:           (1) cost; (2) revenue; (3) utilization; and (4) other information determined appropriate by the Secretary;
  • This system may use a cost survey; and
  • The data collect should include information: (1) needed to evaluate the extent to which costs are related to payment rates; (2) on the utilization of capital equipment and ambulance capacity; and (3) on different types of ground ambulance services furnished in different geographic locations and low population density areas.

Representative Sample

Under the statute, the Secretary must select a representative sample of providers and suppliers from whom to collect data.  The sample will be determined based on the type of providers and suppliers (such as those that are part of a governmental organization, fire, hospital-based, etc) and the geographic locations (such as urban, rural, and low-population density areas).  An individual provider or supplier (defined most likely by National Provider Identifier) may not be requested to submit data in two consecutive years, to the extent practicable.

Reporting Requirements

A provider or supplier selected to report data must do so in the form and manner and at the time specified by the Secretary.  If a provider or supplier that has been selected to report does not do so, then the provider or supplier may be subject to a 10 percent payment reduction, unless the hardship exemption applies.  Providers or suppliers that are penalized may seek a review of the application of the penalty.  The Secretary does have the authority to take into consideration certain hardships as to why a provider or supplier was unable to submit their data and waive the penalty.

Modification Over Time

The Secretary may revise the system over time.

Public Availability of the Data

The Secretary will provide the information collected available through the CMS Website, similar to the process used for other data CMS collects.

MedPAC Report

In addition, the language includes a study/studies from the Medicare Payment Advisory Commission (MedPAC).  MedPAC is required to issue at least one report, and potential subsequent reports, on the following:

  • An analysis of the information submitted by providers and suppliers through the data collection system;
  • An analysis of any burden on providers and suppliers associated with the data collection system;
  • A recommendation as to whether information should continue to be submitted through such data collection system or if it should be revised;
  • The adequacy of payments for ground ambulance services;
  • Geographic variations in the cost of furnishing ground ambulance services; and
  • Other information determined appropriate by the Commission.

Timeline

The Secretary must implement the data collection system according to the following timeline:

The AAA will continue to keep you informed as the development and implementation of the ambulance cost data collection system moves forward.

12/31/2019
  • Specify the data collection system
  • Identify providers and suppliers that would be required to submit information for the representative sample

2020 – 2024

 

  • Collect data each year from a representative sample of providers and suppliers
 2022  

  • First year a provider or supplier that has been asked to submit data and has not sufficiently submitted the data may be subject to a 10 percent payment reduction.
 2023  

  • MedPAC report due
 2025+  

  • Collect data as the Secretary determines appropriate but no less often than once every 3 years

The AAA will continue to work with The Moran Company and other experts to make sure data collection system works for all ambulance service providers and suppliers and leads to information that the industry needs to move toward making the add-ons permanent and modernizing the benefit to include new payment models, including transports to alternative destinations, treatment with referral and no transport, and mobile integrated health.

Overview of The Moran Company Recommendations on Ambulance Cost Collection System

Overview of The Moran Company Recommendations on Ambulance Cost Collection System

 From 2012 – 2014, The Moran Company developed, through a three-phase project, recommendations about how the Medicare program could collect costs associated with providing ambulance services. Consistent as well with the findings of the Congressionally mandated report on ambulance cost reporting/cost collection, The Moran Company determined that Medicare cost reporting would not be appropriate, result in the submission of accurate data, or solve the historic problem of under-reporting by the industry. Instead, The Moran Company recommended a “hybrid” model that relies on the data elements and accounting methods used in Medicare cost reporting and collects this information in a two-step process to ensure that the unique and varied business structures and their cost differences are appropriately captured.

Step 1:  Collect information to categorize ambulance services to allow for a statistically representative grouping and for appropriate comparison of cost data.

The first step would involve all ambulance operations completing a very short (8-10 question) survey for each of their NPIs. The information collected in this step could include:

  • Organizational designation (e.g., a government authority, independent company, public safety or fire-based, hospital-based, other) [this information ensures that an appropriate number of each type of organization is represented in the cost collection step]
  • Percentage of volunteer EMT labor [this information ensures that an appropriate number of all volunteer, partial volunteer, and no volunteer services are represented in the cost collection step]
  • Volume of ambulance services delivered per year [this information ensures that costs from small, medium, and large services are represented in the cost collect step]
  • Percentage of Medicare emergency and non-emergency services provided per year [this information ensures that the costs of both emergency and non-emergency services are appropriately captured in the cost collection step]
  • Average duration of transports [this information ensures that the costs associated with various lengths of transport are captured in the cost collection step]
  • Whether the service has a sole source contract and, if so, the percent of the activity provided under that contract [this information ensures that the cost differences associated with sole source contracts are captured in the cost collection step]
  • If required to pay fees to the local jurisdiction [this information ensures that the costs associated with local jurisdiction fees are captured in the cost collection step]
  • Other services that are a requirement of doing business [this information allows for the costs that may not be ambulance-related but mandated by local contracts to be accounted for in the cost collection step]
  • Percentage of transports that are urban, rural, or super rural [this information is important to ensure that the costs associated with each designation are appropriately represented in the cost collection step]

Step 2:  Collect cost and revenue information from a statistically appropriate group of ambulance suppliers and providers.

The second step would involve providing information about specific cost and revenue data elements.  These would be consistent with the existing Medicare cost reporting elements for other providers, but in certain instances tailored to ensure that all allowable costs of ambulance services are collected.  For example, vehicle maintenance and fuel would be part of ambulance cost data and included, even if these data elements are not included on nursing home costs reports.

CMS would determine a statistically appropriate sample size for each organization type and ensure an appropriate mix of rural, urban, super-rural, as well as volunteer, sole source, and emergency/non-emergency services.  Over time all ambulance providers and suppliers would be required to report the data, but no individual service (defined by the NPI number) would be required to report every year.

Public Reporting.  Once CMS has collected the data, it will make a de-identified file of the information available to allow policy-makers and stakeholders to evaluate the information collected.  The AAA’s goal is to use this information to allow for meaningful reform that for the first time would link the payment rates to the cost of providing services.  The AAA also seeks to modernize the use of ambulance services in the health care system through policies such as alternative destination, treatment at the scene with referral and no transport, and community paramedicine.

2013 Final Report by The Moran Company

Copyright © 2018 American Ambulance Association, All rights reserved.

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