While it is not often that we get excited about an OIG opinion, this one is significant because the CMS OIG referenced the clinical and fiscal benefits associated with TIP!
From the Opinion:
“Nevertheless, for the following reasons, we believe the risk of fraud and abuse presented by the Proposed Arrangement is sufficiently low under the Federal anti-kickback statute for OIG to issue a favorable advisory opinion, and, for the following reasons and in an exercise of our discretion, we would not impose sanctions under the Beneficiary Inducements CMP.
Third, even when a Federal health care program pays for the TIP services furnished under the Proposed Arrangement, the Proposed Arrangement appears unlikely to increase costs to Federal health care programs and may ensure an appropriate level of care for patients to whom Requestor furnishes EMS services in response to a 911 call. More specifically, TIP services may be a viable option, in certain circumstances, to improve quality of care and avoid unnecessary transports to hospital emergency departments. Consequently, TIP services have the potential to lower costs for Federal health care programs while also delivering timely, appropriate, and medically necessary care to patients on-site who do not also require transportation to a hospital.”
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The Office of Inspector General (OIG) just issued a favorable Advisory Opinion to a municipal EMS Agency regarding its proposal to bill patients’ insurance plans—and waive any patient cost-sharing amounts—for treatment-in-place (TIP) services provided to patients who are not transported.
While the OIG has already issued favorable opinions and a regulatory safe harbor (42 CFR § 1001.952(k)(4)) concerning cost-sharing waivers for emergency ambulance transports, this is the first time the OIG has addressed cost-sharing waivers related to non-transport services.
Key Takeaways
Medicare Part B does not currently cover TIP services. However, Advisory Opinion 24-09 indicates that the OIG is favorable to cost-sharing waivers related to TIP services that are covered by state Medicaid programs and Medicare Advantage plans. Moreover, the OIG seems to indicate that if Medicare Part B covered TIP services in the future, cost-sharing waivers would be permitted under the conditions outlined in the Opinion.
The OIG emphasizes the advantages of TIP services, stating:
“[T]o the extent the Proposed Arrangement avoids an ambulance transport or subsequent hospital care, [it] could reduce costs to Federal health care programs overall, thereby mitigating the risk of inappropriately increased costs to Federal health care programs. Further, the TIP services furnished by Requestor under the Proposed Arrangement may result in patients receiving care more quickly and efficiently and at a more appropriate level of care . . . More specifically, TIP services may be a viable option, in certain circumstances, to improve quality of care and avoid unnecessary transports to hospital emergency departments. Consequently, TIP services have the potential to lower costs for Federal health care programs while also delivering timely, appropriate, and medically necessary care to patients on-site who do not also require transportation to a hospital.”
Note: Agencies must separately consider any implications of cost-sharing waivers for TIP services concerning non-Federal healthcare payers. There may be limitations under state law or a contract with a private healthcare payer. Finally, while indicative of the OIG’s stance on this practice, like all OIG advisory opinions, Advisory Opinion 24-09 cannot be relied upon by any other agency, and agencies are encouraged to obtain expert advice concerning their specific situation when considering cost-sharing waivers.
More About the Opinions and Circumstances
The county-based ambulance service proposed implementing a charge for TIP services furnished in connection with 911 responses - limited to emergency responses only (i.e., only responses that meet the definition of “emergency response” at 42 CFR § 414.605). Their charge for TIP services would be based on the level of care furnished to the patient and would not exceed amounts currently submitted for payment for the same level of care furnished in connection with an ambulance transport. The charge would be imposed regardless of the patient’s health insurance (e.g., regardless of whether the patient is enrolled in commercial insurance or a Federal healthcare program), whenever it provides an emergency response and furnishes care to a patient at the scene but does not transport the patient by ambulance. The ambulance service proposed accepting any health insurance payment (including Federal healthcare programs) for TIP services as payment in full and not billing patients for any cost-sharing amounts (e.g., copayments) associated with covered TIP services. This waiver would apply to both County residents and nonresidents and be applied uniformly to all patients who receive TIP services.
The OIG cited the following reasons why it believes the risk of fraud and abuse is “sufficiently low” under the Federal anti-kickback statute (AKS) and why the OIG would be favorable to the Proposed Arrangement:
- Uniformity of Waiver. The ambulance service would uniformly apply its cost-sharing waiver policy for all individuals who receive TIP services in connection with an emergency response regardless of payor.
- Minimal Implication to Federal Payers. The OIG noted that neither Medicare Part B nor the State Medicaid program in the ambulance service’s state currently covers TIP services. Only a handful of Medicare Advantage plans and certain Medicaid programs in states adjacent to the service’s home state currently cover TIP services. Thus, in most circumstances, the Proposed Arrangement would result in no costs to Federal healthcare programs.
- No Increased Costs. Citing TIP's benefits, the OIG stated that the Proposed Arrangement was unlikely to increase costs to Federal health care programs and may ensure an appropriate level of patient care.
