CMS to expand prior authorization for ambulance transport

CMS will expand its prior authorization model for non-emergency ambulance transport nationwide, the agency said Tuesday.

The model, which allowed Medicare to pay ambulances for taking patients to scheduled non-emergency healthcare visits, saved the federal government about $650 million over four years, CMS said in a statement. The experiment didn’t appear to cause serious adverse outcomes, analysts said in the agency’s second interim evaluation report of the model. CMS said it’s monitoring the COVID-19 pandemic to determine when it makes sense to roll out the model to new states.

“Ambulance services have long been associated with inappropriate overuse and high improper payments, meaning many payments don’t meet program requirements — intentional or otherwise — and contribute to inappropriate spending of Americans’ tax dollars,” the agency said in a statement.

The estimated improper payment rate for non-emergency ambulance transports was 22.6% in 2017 and 18.6% in 2018.

Overall, CMS said the model reduced the scheduled transports by 63% and related expenses by 72% for Medicare beneficiaries with end-stage renal disease or severe pressure ulcers.

All the model’s current participants will continue to participate in the model past the pilot’s original end date of December 1. They include Delaware, Maryland, New Jersey, Pennsylvania, North Carolina, South Carolina, Virginia, West Virginia and Washington, D.C.

According to the report, analysts found the model led to a small decrease in dialysis use and a slight increase in emergency dialysis use among ESRD beneficiaries. Researchers also saw a reduction in emergency department use and unplanned hospitalization with no impact on mortality.

“Ambulance suppliers that depended heavily on (repetitive, scheduled, non-emergent ambulance transport) exited the market when the model started, particularly in year one states,” the report said.


Tags: covid-19, pandemic

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