The Centers for Medicare and Medicaid Services (CMS) issued a notice to expand prior authorization in January 2016 for repetitive nonemergency medical transport in five additional states. Phase 1 of this plan is already in operation in South Carolina, New Jersey, and Pennsylvania. Last spring, the Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which expands the “Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport Model” to Maryland, Delaware, North Carolina, West Virginia, Virginia and the District of Columbia. The notice was issued in the Federal Register on October 23, 2015.

What is the purpose of the prior authorization program for nonemergency medical transport?

CMS is looking for ways to reduce spending in the Medicare program and has initiated several new payment and service delivery models. Through its “Innovation Center,” it is testing a three year pilot program in South Carolina, New Jersey, and Pennsylvania to see if its costs can be reduced for scheduled, repetitive nonemergency transports. The CMS is looking for ways to combat any fraudulent billing for these medical transports.

An ambulance must first obtain prior authorization from their Medicare Administrative Contractor (MAC) for these medical transports. Medicare beneficiaries now know beforehand whether the program will cover their non-emergency transports to treatments. Unfortunately many sick and fragile elderly may be left with few options to get to their scheduled appointments if Medicare denies payment for an ambulance to take them to cancer or dialysis treatments. Ambulance companies have found in the first year of the pilot program in South Carolina, that the Medicare contractor (Palmetto GBA) has made inconsistent decisions about payment for repetitive non-emergency transports to treatments.

The pilot program fails to address the very real problem for those patients who do not qualify for reimbursement for transports, but have no family or friends who can take them to 3 to 4 hour dialysis sessions. These patients are too weak to drive themselves and cannot afford the cost of medical transport without the help of the Medicare program.

Will the program be expanded nationally?

If cost savings are shown, fraudulent payments eliminated, and access to care for patients is not reduced, the CMS plans to expand this program nationally in January, 2017. The October 23, 2015 Federal Register notice did not indicate whether CMS will expand the prior authorization program nationally. CMS plans to have an evaluation contractor look at Phase I and Phase II to see if these criteria are met before making a determination to expand the program nationwide.

Medtrust Medical Transport provides emergent and non-emergent ambulance services. We support patients and their families in Charleston, Myrtle Beach and Georgetown, South Carolina with a fleet of fully-equipped ambulances. Our goal is to provide compassionate and timely patient care.