Continuation of telehealth reimbursement models available through the current CMS waivers will be beneficial to EMS because they help facilitate protocols that include a telehealth consult as part of an EMS Treatment in Place (TIP) protocol by allowing providers to be reimbursed for telehealth services originating at the patient’s residence, and without an established patient:provider relationship.

And because the current waivers allow telehealth providers to reimburse ambulance agencies for the facilitation of provider requested telehealth services.

Salient waiver language, with links, included at the end of the article.

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Carper, Scott introduce legislation to extend hospital-at-home for 5 years

BY JOSEPH CHOI - 05/15/24

https://thehill.com/policy/healthcare/4664765-tom-carper-tim-scott-acute-hospital-care-at-home-program-extension/

Sens. Tom Carper (D-Del.) and Tim Scott (R-S.C.) will introduce legislation Wednesday that would extend the Acute Hospital Care at Home (AHCAH) waiver program past its 2024 expiration date.

In response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) introduced several waivers and flexibilities in 2020, allowing for various inpatient-level hospital services to be conducted in patients’ homes.

The AHCAH program was initially set to expire with the end of the COVID-19 public health emergency but was extended to December 31, 2024, by the Consolidated Appropriations Act passed last year.

Carper and Scott’s bill would further extend the flexibilities provided by AHCAH for another five years.

“Since Hospital at Home was implemented just a few years ago, we have seen this program deliver positive patient outcomes and reduce costs nationwide,” Carper said in a statement.

“I recently had the opportunity to celebrate Delaware’s own ChristianaCare as they admitted their 1,000th patient through the program,” he continued. “Today, I’m glad to join Senator Scott in introducing legislation to extend the Hospital at Home program for five years, and ensure hospitals across the country can continue to meet seniors right where they are.”

Carper joined Sen. Marco Rubio (R-Fla.) earlier this year in introducing another bill that would similarly build on the AHCAH program to include observation status patients, those who physicians are still determining whether they need to be admitted to inpatient care or can be discharged.

An aide for Carper told Politico recently that the senator plans to introduce legislation making hospital-at-home waivers permanent.

A CMS study from November that observed patients admitted under the AHCAH waiver from November 2021 to March 2023 found that they experienced a “low mortality rate consistent with the hospital-at-home literature and minimal complications related to escalations back to the brick-and-mortar hospital.”

Waiver Language:

 EXPANSION OF TELEHEALTH WITH 1135 WAIVER: Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs. Prior to this waiver Medicare could only pay for telehealth on a limited basis: when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service.

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

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 [CMS-1744-IFC]

RIN 0938-AU31

Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Interim final rule with comment period.

“….. We note that in specifying that direct supervision includes virtual presence through audio/video real-time communications technology during the PHE for the COVID-19 pandemic, this can include instances where the physician enters into a contractual arrangement for auxiliary personnel as defined in § 410.26(a)(1), to leverage additional staff and technology necessary to provide care that would ordinarily be provided incident to a physicians’ service (including  services that are allowed to be performed via telehealth). For example, physicians may enter into contractual arrangements with a home health agency (defined under section 1861(o) of the Act), a qualified infusion therapy supplier (defined under section 1861(iii)(3)(D) of the Act), or entities that furnish ambulance services in order to utilize their nurses or other clinical staff as auxiliary personnel under leased employment (§ 410.26(a)(5)). In such instances, the provider/supplier would seek payment for any services they provided from the billing practitioner and would not submit claims to Medicare for such services. For telehealth services that need to be personally provided by a physician, such as an E/M visit, the physician would need to personally perform the E/M visit and report that service as a Medicare telehealth service.”

https://www.cms.gov/files/document/covid-final-ifc.pdf

Latest state law designed to help assure patients are not in the middle of billing disputes between providers and insurers.

A downloadable copy of the bill is at the link in the news report.

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Here’s a new law to help Hoosiers with surprise ambulance bills

by: Jana Garrett

May 17, 2024

https://www.tristatehomepage.com/news/indiana-news/heres-a-new-law-to-help-hoosiers-with-surprise-ambulance-bills/

HENDERSON, Ky. (WEHT) – According to the Indiana House Republicans, State Representative Tim O’Brien supported a new law that would will require health insurance companies to reimburse for ambulance services that are not part of a person’s coverage plan.

According to a report by Health Affairs, about 28% of emergency trips in a ground ambulance result in a potential surprise bill. Officials say these bills can place a “significant” financial burden on patients, often leaving them with “overwhelming” expenses they may struggle to pay.

Rep. O’Brien says going forward, those who use an out-of-network ambulance service will be protected from having to pay more for that service than their in-network rate plus either their deductible or copay. Out-of-network ambulance providers must now accept either the patient’s in-network rate plus their deductible or copay, or the 400% of the Medicare rate for those services.

Rep. O’Brien says currently, there is no set time frame in which an ambulance service must receive payment from health plan providers. Under this new law, service providers must receive payment within 30 days of the claim being filed.

Officials say House Enrolled Act 1385 goes into effect July 1.

Here’s a new law to help Hoosiers with surprise ambulance bills

Excellent research project published in the peer-reviewed journal Pre-Hospital Emergency Care.

It’s no surprise to many of us that the study found only 6% of 1.7 million EMS responses reviewed involved a time-critical EMS intervention.

The results from this study could help EMS systems and communities grapple with appropriate resource deployment, when using an evidence-based Emergency Medical Dispatch (EMD) system.

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Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes

Matthew J. Levy, Remle P. Crowe, Heidi Abraham, Anna Bailey, Matt Blue, Reinhard Ekl, Eric Garfinkel, Joshua B. Holloman, Jeff Hutchens, Ryan Jacobsen, Colin Johnson, Asa Margolis, Ruben Troncoso, Jefferson G. Williams & J. Brent Myers

Published online: 29 Apr 2024

https://doi.org/10.1080/10903127.2024.2342015

https://www.tandfonline.com/doi/full/10.1080/10903127.2024.2342015

Abstract

Objectives

Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue.

Methods

This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome).

Results

Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue.

Conclusions

In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Another example of the economic crisis in EMS, regardless of provider type, even in communities where Public Provider GEMT revenue per Medicaid service runs >$1,000.

It will be interesting to see if the PP-GEMT programs change, based on the on-going CMS audits of cost reports that are the basis for the PP-GEMT reimbursements.

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With profits slow to materialize, San Diego considers another overhaul of its ambulance service

The mayor’s proposed budget would take $6 million in projected surplus from the city’s ambulance fund. But projections have been off so far — and the independent budget analyst just cautioned against such a move.

By David Garrick

May 9, 2024

https://www.sandiegouniontribune.com/news/politics/story/2024-05-09/with-profits-slow-to-materialize-san-diego-considers-another-overhaul-of-its-ambulance-service

SAN DIEGO —  Ambulance service in San Diego may soon undergo significant changes despite the recent success of a new model where private ambulances transport patients and the city oversees deployment, staffing and billing.

The new set-up, called the alliance model, has improved emergency response times since it began in October, and fire officials say it’s on track to generate millions in revenue the city could use to enhance services.

But Chief Colin Stowell says he will soon launch a comprehensive analysis to determine whether to stick with the alliance model, bring ambulance service completely in-house or go with some sort of hybrid approach.

Bringing the service in-house means ambulance workers would become city employees and no longer work for private ambulance companies. Los Angeles, San Francisco and Chula Vista have in-house ambulance service.

“The alliance model has stabilized our system, but where do we take that?” Stowell told the City Council’s Budget Review Committee last week. “We’re in for a very exploratory next year on the EMS front.”

Stowell estimated that fire officials, with help from a consultant, will come forward this winter with recommendations for what the city’s ambulance system should look like moving into the future.

The analysis will evaluate the three options — alliance, in-house or hybrid — on emergency response times, financial risks, financial benefits and other factors, he said.

“Those are all going to be options on the table, and we’ll evaluate the risks and benefits of those,” Stowell said.

Officials had been expecting millions in profits from the switch to the alliance model — but that has been slow to materialize because of delayed payments for ambulance transports and what city officials characterize as flawed projections.

Before the switch, private ambulance company Falck USA handled staffing, deployment and billing for the city. Under the alliance model, the city took over those roles — and the financial risks and potential benefits that come with them.

The shift was prompted by frustration with poor response times and a new state law that boosts reimbursement rates on ambulance transports for government agencies. A consultant had estimated the city would generate $15 million in surplus cash during the alliance model’s first three years.

The consultant projected $6.5 million during the ongoing fiscal year that ends in June, another $3 million in fiscal year 2025 and $5.5 million in fiscal 2026.

But Stowell said the city is certainly going to lose money this year. Fire officials have projected a $6.1 million surplus in fiscal 2025, but Stowell and the city’s independent budget analyst said that’s also in doubt.

Stowell said the main problem has been the long lag times between when an ambulance transport takes place and when the city gets paid by Medicare, MediCal, private insurers and the state reimbursement program.

“There is a significant lag time, and we have to remember that the money will eventually come in and we will eventually be whole,” Stowell said. “We’re still on track.”

But Stowell also conceded that some of the projections from last year have turned out to be off the mark.

He said projections for collection rates and the percentage of patients who are covered privately seem to be accurate, but that estimates of call volumes and state reimbursement money have been off.

“We’re working completely on projections that were done,” he said. “We are seeing things that maybe weren’t as accurate on those projections.”

The boosted reimbursements come under the state’s public provider ground emergency transportation inter-governmental transfer program.

But Stowell stressed that the lag time was the main problem, explaining that the city was more than $8 million in the red during the first month of the alliance model last October.

The city pays roughly $9 million a month total to primary ambulance provider Falck USA and secondary provider American Medical Response for ambulance services on a per-hour basis.

Because of lag time, the city received only $135,000 in payments last October. That’s why it was well over $8 million in the red for that month.

While payments and reimbursements have been rising, city officials don’t expect to be in the black during the ongoing fiscal year and have expressed doubts about fiscal 2025.

Councilmember Marni von Wilpert, who leads the council’s Public Safety Committee, said last week she was disappointed that the city is not meeting the earlier projections.

Stowell said last year he hoped to have enough excess revenue to add new programs like nurse triage, telemedicine and street-based interventions.

Signaling a major shift in priorities, he said last week that the goal is to have enough excess revenue to have adequate “seed money” to possibly bring ambulance service in-house.

But Mayor Todd Gloria’s proposed budget for fiscal 2025, which relies significantly on one-time revenue sources to close a large deficit, anticipates taking $6 million in projected surplus from the city’s ambulance fund.

The city’s independent budget analyst cautioned last week that such a move could be problematic because of the alliance model’s disappointing results so far.

The IBA says revenue will exceed expenses under the alliance model in fiscal 2025, but probably not by enough to generate the $6 million Gloria wants to take away to balance the city budget.

The IBA says Gloria should consider reducing that amount when he releases a revised version of his budget proposal next week.

Stowell recommended waiting until this fall to revisit the situation. He said the doubts fire officials expressed to the IBA were partly based on being uncomfortable making projections 14 months into the future.

Our neighbors to the north have typically been a bit more transformative in EMS delivery than we in the states!

We know this because a couple of the AIMHI member agencies are high performance / high value members of AIMHI.

This model makes a lot of clinical, operational, and financial sense, and allows skilled EMS clinicians to not only respond to the low-acuity 911 calls, but also allows EMS crews in the field to triage patients who do not meet clinical criteria for a transport to the ED, to be treated in place, with a CP follow-up visit.

Very innovative, and patient-centric approach to system redesign!

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P.E.I.'s new paramedic units aimed at reducing demands on ambulances, ERs

Units could help free up ambulances in rural parts like Souris, West Prince

Stu Neatby · Journalist

5/8/24

https://www.saltwire.com/atlantic-canada/news/peis-new-paramedic-units-aimed-at-reducing-demands-on-ambulances-ers-100963025/

Health decision-makers say a new non-ambulatory unit could help keep more ambulances in rural areas like West Prince and Eastern Kings.

On May 7, Health Minister Mark McLane announced the province’s ambulatory provider, Island EMS, has officially launched new community paramedic response units (CPRU) – paramedic units intended to help 911 calls for patients with lower acuity needs.

McLane said as many as 35 per cent of 911 calls are from patients who don’t need to go to hospitals. He said the new CPRU units will be staffed by advanced care paramedics who can provide in-home treatments or referrals.

"This could save the patient a ride to the emergency department if they don't need to go there. Paramedics will connect the patient with appropriate care within the community," McLane said at a news conference the Island EMS office in Charlottetown.

The new units have been operating in an unofficial capacity since the fall, but Tuesday’s announcement signalled that the appropriate policy protocols for these CPRU teams are in place.

In lieu of ambulances, the CPRU paramedics will be transported via a Chevy Traverse or Subaru Outback stamped with the word "paramedic" on the hood.

Wait times

The province’s ambulance response times have grown longer across the board in both urban and rural community over the last year.

The wait times are longest in Souris, O’Leary and Alberton, which have median response times longer than 20 minutes. This compares to just over 15 minutes in Charlottetown, 12 minutes in Summerside and just over 12 and a half minutes in Stratford.

James Orchard, general manager of P.E.I. operations for Island EMS, said the new units will help free up ambulances, particularly those based in areas around Souris, Montague, O’Leary and Alberton, to get to emergencies faster.

Orchard said around half of 911 calls are based in Charlottetown.

"A lot of times the rural ambulances are being drawn into the centres because that's where the call volumes are. But, of course, all it takes is one call out in a very rural area and now we're behind the eight-ball to get to that call,” Orchard said.

"These units can handle that volume so that our rural ambulances are not pulled into it.”

Across P.E.I., the median ambulance response time was 14 minutes and 41 seconds for the period between Jan. 1 and March 31 of 2024. That’s 3 minutes and 24 seconds longer than the same time period in 2023.

Two of the community paramedic response units will be based in Charlottetown while one will be located in Summerside.

Helping patients

Orchard said patients often do not know how to navigate the health system. He said paramedics are well situated to be “advocates and navigators” for patients.

“People don't know what resources are really, in some cases, just down the street for them. In a lot of those cases, those resources are available, we just don't know about them," he said.

Dr. Scott Cameron, the provincial medical director for emergency health services, said these units could also help alleviate some of the stresses in emergency rooms.

“When 911 is called and paramedics arrive on the scene, patients will be triaged. Patients must meet the clinical indicators to be transported to the emergency department,” Cameron said at the May 7 news conference.

“If they do not meet clinical indicators for transport, Island EMS paramedics will leverage the CPRU team as necessary."

Tyler Graves, the president of the Paramedic Association of P.E.I. and a member of the new units, says the new units will allow more advanced care paramedics like himself to work to their full scope of practice.

"It's a huge opportunity for paramedics to just kind of prove that we can practise at a higher level,” Graves said. "But then also for the communities, it helps get people out of the hospital and keeps them out of the hospital if there's things that we can be doing at home."

Source Article

This action is helpful, since many EMS systems are using telehealth for service delivery, as well as participating in Hospital at Home programs.

Further, the extension of the Ambulance Access Act of 2024 is crucial to EMS system sustainability.

The House Ways and Means Committee has been staunch advocate of advancing the EMS profession! Their actions today are a further demonstration of their commitment to help patient’s access care, and EMS systems.

Recall that Dr. Ed Racht and I were invited to provide testimony at the Ways and Means Committee Field Hearing at GMR’s North Texas Headquarters. Committee members expressed support for EMS systems, and payment reform to include reimbursement for Treatment in Place (TIP).

To view the EMS specific parts of that hearing, click this link.

Following that hearing, Ways and Means Committee Chair, Jason Smith, met with several of us during NAEMT’s EMS on the Hill Day in April!

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House committee advances bill to extend telehealth rules

MICHAEL MCAULIFF

May 08, 2024

https://www.modernhealthcare.com/politics-policy/telehealth-rules-waiver-extension-congress

Congress took the first step Wednesday to extend expiring telehealth rules, hospital at home services and other programs aimed at rural hospitals.

The House Ways and Means Committee passed the Preserving Telehealth, Hospital, and Ambulance Access Act of 2024 by a vote of 31-0, setting it up for passage by the full House later this year.

The bill would extend for two years telehealth rules adopted during the pandemic that are due to expire at the end of the year, as well as extend similar rules for Medicare's hospital at home program for five years.

The measure also expands the practitioners eligible to bill Medicare for telehealth services to physical therapists, occupational therapists, audiologists and speech language pathologists. And it allows federally qualified health centers and rural health clinics bill Medicare for telehealth services, and delays in-person visit requirements for remote mental healthcare.

"One of our top priorities on this committee is helping every American access healthcare in the community where they live, work and raise a family. In rural America, in small towns, families often struggle to get healthcare," Ways and Means Committee Chair Jason Smith (R-Mo.) said. "Without this bill, beneficiaries will no longer be able to talk to their doctors or receive acute hospital care from the comfort of their home, starting at the end of this year."

While the bill received broad bipartisan support, many of the Democrats on the committee complained that Republicans failed to include significant fraud prevention measures.

"it's difficult to view this bill as progress with regard to fraud since it gives [the Centers for Medicare and Medicaid Services] no new authority, and no new enforcement tools," said Rep. Lloyd Doggett (D-Texas).

"There's much more to do here to protect consumers," said the ranking Democrat on the committee, Rep. Richard Neal (Mass.)

Republicans agreed that more should be done to target fraud, but suggested it should be addressed in a different, broader bill.

One potentially controversial provision in the bill requires pharmacy benefit managers that work with Medicare Part D plans to de-link the compensation they pay themselves from the rebates they secure based on drugs' high list prices. Rep. Brad Schneider (D-Ill.) said the provision will save the government about $500 million, although official estimates were not yet available. The provision does not apply to the broader commercial market, though Schneider and Rep. Nicole Malliotakis (R-N.Y.) both called for expansion of the provision to the commercial market. Large PBMs oppose such provisions.

Other extensions in the bill cover Medicare’s Low Volume Adjustment and the Medicare-Dependent Hospital Program, which give rural hospitals bonus payments, and are due to expire at the end of 2024. The payments would be extended until September 2025. The bill includes a nine-month extension for Medicare add-on payments for ambulance services in areas with poor access. Republicans opposed amendments to add more time to the extensions, saying they were not paid for.

The committee is still considering several other bills designed to ease stresses on rural hospitals. Among them:

• The Preserving Emergency Access in Key Sites Act of 2024, which would boost ambulance payments for hospitals in locations that are hard to reach.
• The Rural Hospital Stabilization Act of 2024 to boost grants to rural hospitals.
• The Rural Physician Workforce Preservation Act of 2024 to require that 10% of 1,200 recently approved Medicare graduate medical education training slots go to rural hospitals.
• The Second Chances for Rural Hospitals Act of 2024, which would allow rural hospitals that closed as long ago as 2017 to reopen as Rural Emergency Hospitals, which receive $276,000 monthly payments from Medicare to support 24-hour emergency services.

Democrats suggested that because of objections they raised, the bills would not pass in the Democratic-controlled Senate. Republicans argued that the House should not worry what the Senate might do.

Whether the Senate ever takes up the specific bills, passing them through the committee and likely through the full House makes them available for negotiations that are likely to begin once the November elections are over and Congress grapples with unfinished business.

"Many of these bills won't become law," Neal said. "There's much more we could have done and likely we will do, post-election time."

Kudos to the team at Atrium Health on this amazing accreditation!

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Atrium Health Earns First Accreditation in Mobile Healthcare, Paramedicine

'The accreditation serves as a symbol of excellence'

By SARAH ROSE • News Writer

May 7, 2024

https://www.ainonline.com/aviation-news/general-aviation/2024-05-07/atrium-health-earns-first-accreditation-mobile-healthcare

The Commission on Accreditation of Medical Transport Services (CAMTS) announced that Atrium Health’s Mobile Integrated Health, Mobile Medicine from Charlotte, North Carolina, is the first entity that has earned full accreditation under CAMTS Mobile Integrated Healthcare (MIH) Accreditation Standards.

“For Atrium Health’s Mobile Integrated Health team, this accreditation signifies our organization's commitment to providing safe, high-quality medical care by meeting specific criteria related to safety, equipment, quality, training, and operational procedures to patients in our communities. This accreditation serves as a symbol of excellence within the industry, and we are proud to have it.” said Atrium MIH director Amanda Williams.

For accreditation, the program completes a self-assessment using a standards compliance tool. Once submitted, the standards compliance tool is reviewed for compliance and completeness before site surveyors visit the program to interview the staff.

“We knew it would be a while after we published the standards for programs to apply and complete the process," said CAMTS executive director Eileen Frazer. "Most programs need as much as a year to prepare documents, policies and procedures, education records, meeting minutes, safety documents, etcetera to meet the standards. We ask for a lot of documentation and interview a lot of people in the program as part of the process.”

Another example of a growing number of state legislature’s stepping up to make EMS reimbursement reform a priority. 

This bill not only provides a mechanism for reimbursement for Treatment in Place and Transport to Alternate Destinations, but also removes patients from balance billing disputes by requiring state regulated health plans to reimburse EMS at billed charges, or at least 325% of the Medicare allowable fee.

It was announced yesterday that Governor Tate Reeves signed this bill into law!

Link to the legislation below.

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Bill to increase third-party reimbursements for EMS headed to governor

By Anthony Warren

Apr. 24, 2024

https://www.wlbt.com/2024/04/24/bill-increase-third-party-reimbursements-ems-headed-governor/

JACKSON, Miss. (WLBT) - A bill that will increase compensation for ambulance service providers is on its way to the governor’s desk.

On Wednesday, the state House of Representatives adopted the committee report for H.B. 1489, the “Mississippi Triage, Treat and Transport to Alternative Destination Act,” a bill that would, in part, increase how much insurance companies must pay ambulance firms for services provided.

The House approved the committee report on a 119-0 vote, with three representatives absent or not voting.

The Senate approved the report last week on a 50-0 vote, with one senator absent or not voting, and another senator voting present.

Julia Clarke, president of the Mississippi Ambulance Alliance, was sitting in the House gallery when the measure was approved.

“With this legislation, Mississippi would join our neighbors [in] Louisiana, Texas, Arkansas, and other states in recognizing this is a first-responder cost-of-readiness issue for ambulance providers large and small,” she said. “I’m so pleased they [passed] it.”

Under the act, third-party payors would be required to pay for treatment in place when a patient is not transported to a hospital.

That amount would be the local fees set by the city or county contract or 325 percent of Medicare, whichever is greater. In the absence of a local rate, the ambulance provider would be paid their billed charges or 325 percent of Medicare, whichever is greater, Clarke explained.

Figures provided by the Ambulance Alliance show EMS providers in the state charge between $988 and $1,224.82 for a basic life support emergency response in urban areas. Medicare reimburses those companies just $398.56.

Basic Life Support ambulances are staffed with two EMTs, rather than an EMT and a paramedic. EMTs are trained to provide emergency first aid, assess a person’s condition and determine the treatment needed, and administer some medications, such as epinephrine, according to WebMD.

State Health Officer Dr. Daniel Edney backed the measure, saying the funding will be a major boost for EMS providers, who are currently not paid when a patient refuses transport, or if they’re transported to a facility other than a hospital.

“If an ambulance goes to a home and there’s a diabetic whose blood sugar has dropped, they correct it and stabilize the patient, and the patient [who needs] to go to the ER chooses not to go, then they’re not reimbursed for the services they just provided, which makes no sense,” he said.

“They need to be reimbursed for the care that [they’re] rendering and the cost of that care, which includes running an ambulance and doing all the things it takes to have an ambulance ready to go.”

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Governor Tate Reeves signed into law HB1489

https://billstatus.ls.state.ms.us/documents/2024/pdf/HB/1400-1499/HB1489SG.pdf

From their legislative team:

As a summary, the 1489 bill mandates for Health Benefit Plan Private Insurance to:

• To pay for Treatment in Place (TIP) (lines 61- 96)

• Pay for trips that are Transported to Alternate Destinations (TAD) (lines 39 -54)

• The reimbursement rate for an ambulance service provider whose operators assess, triage, treat or transport an enrollee to an alternative destination shall be not less than the minimum allowable reimbursement for advanced life support rate with mileage to the scene. (line 87-91)

• Out of Network Ambulance to reimbursed for all covered services, which will now include TIP and TAD, at the greater of:
• • Contracted rates between ambulance service and county, municipality, special district or by ordinance (lines 95-103)
  • 325 % of Medicare for respective services originating in the respective geographical area (lines 107-109)
  • The ambulance providers billed charges in the absence of contracted rates between ambulance service and county, municipality, special district or by ordinance (line 104-111)

The importance of receiving the Net Savings to Medicare information from CMS cannot be understated! 

It serves as a basis for the economic valuation that Congress, as well as state and local governments can use to demonstrate the financial savings of changing the EMS economic model from a reimbursement for TRANSPORT, to reimbursement for on scene Treatment in Place (TIP).

Release of this data helps facilitate a Congressional request to the Congressional Budget Office (CBO) to provide a CBO for current the legislation in the House and Senate to reimburse ambulance agencies for TIP services.

Links to the full report in the release below.

Snapshot:

FOR IMMEDIATE RELEASE ET3 Savings Data Supports EMS Treatment in Place Legislation Clinton, Miss. — The National Association of Emergency Medical Technicians (NAEMT) received the data in response to a Freedom of Information Act (FOIA) (5 U.S.C. § 552) request seeking documents from the recently ended Emergency Triage, Treatment and Transport (ET3) pilot program. The report shows that the average Net Savings to Medicare (NSM) per Medicare beneficiary was $537.53 when a patient was treated-in-place instead of taking an ambulance ride to the hospital emergency room, which is one of the most expensive places to receive health care.  EXECUTIVE SUMMARY: Newly available federal data from the Centers for Medicare & Medicaid Services (CMS) demonstrates more than $500 in Net Savings to Medicare per patient encounter under the recently ended ET3 pilot program. The results validate the need for passage of NAEMT-supported federal legislation to enable payment for EMS Treatment in Place (TIP). The ET3 program’s per patient savings to the Medicare program was documented in a March 2023 external fiscal analysis presented to CMS as part of the Development of Performance-Based Payment (PBP) Eligibility and Methodology. This data validates the economic value of EMS Treatment in Place (TIP) payment models and the need for Congressional action to enable payment for TIP. “This data from CMS’ external evaluator proves the significant savings to the Medicare program. We also have patient experience data from patients enrolled in the ET3 program demonstrating that patients who are not transported to the ER have higher patient satisfaction with the EMS response,” said Matt Zavadsky, Chair of NAEMT’s EMS Economics Committee and a member of the CMS ET3 Model Quality Workgroup. “This proves the economic and patient experience benefit of changing the EMS payment model from payment for transport, to payment for the care we provide.” NAEMT has long advocated for providing ambulance agencies the flexibility to navigate patients to the right care in the right setting through federal and state reimbursement of TIP. Medicare currently does not cover TIP as a benefit; therefore, EMS is not reimbursed for care unless a patient is brought to the hospital. The current EMS economic model incentivizes transportation to a hospital emergency department, even when a less expensive level of care is appropriate.   Reimbursing EMS agencies for TIP will save Medicare billions of dollars on unnecessary emergency department visits, enhance patient experience, shorten task times for EMS agencies struggling with workforce shortages, help decompress overcrowded hospitals and emergency departments, and meet patients’ needs without long waits at the hospital. To view the ET3 economic evaluation, click here. To view the current legislation in Congress authorizing CMS to pay for TIP, click here and here. About NAEMT

Without commenting on the continued frustration of the media referring to ambulance ‘rides’, negating the fact that personnel provide medical care, what this report hints at, but does not specifically state, is that most new state legislation requires insurers to pay essentially billed charges, hence limiting out of pocket expense to the patient’s deductible or coinsurance.

You can see recently passed state legislation at the National Conference of State Legislatures’ EMS Bill Tracker here: https://www.ncsl.org/health/emergency-medical-services-legislation-database

Or view other example EMS legislation at NAEMT’s database here: https://naemt.org/advocacy/sample-state-ems-legislation

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More states are adding protections against big ambulance bills

March 27, 2024

Maya Goldman & Tina Reed

https://www.axios.com/2024/03/27/surprise-medical-bills-ambulance-health-costs

More states are jumping in to shield patients from large, unexpected bills for ambulance rides in the absence of federal protections.

Why it matters: Ground ambulances are a major source of surprise bills, and it's unlikely Congress will pursue nationwide protections anytime soon after excluding them from the landmark No Surprises Act in 2020.

The big picture: Patients in an emergency can hardly shop around for an ambulance covered by insurance. More than half of ambulance rides are out of network, putting patients on the hook for surprise bills that typically cost hundreds of dollars.

• Congress carved out ground ambulances from its surprise billing legislation that prevents patients from paying more than the in-network cost for care unwittingly received out of network.
• At the time, it was seen as too challenging to figure out regulation for this unique corner of the health care system, and lawmakers ordered further study.

Driving the news: Washington state last week became the 16th state to pass consumer protections for ambulance bills, and Indiana's governor signed a similar bill earlier this month.

• Just two states had some protections for ambulance bills in the 1990s, but momentum has grown since passage of the No Surprises Act.
• Four states passed ambulance billing laws in 2023, and more are looking to take up legislation.

How it works: State laws cap patient costs for out-of-network ambulance rides at what the patient would pay if it was covered by insurance, and health plans are on the hook for the rest.

• Some state laws, like the new one in Washington that takes effect next year, peg health plan charges to local or Medicare rates.
• Other states, like Delaware and Maine, settle payments through an arbitration system, similar to the federal surprise billing law.
• Colorado only bans surprise bills at privately run ambulances, which accounted for about 30% of emergency rides nationwide in 2020, per KFF. Meanwhile, Maryland only covers those provided by fire departments and other public agencies.

The ambulance industry has largely been on board with how states are approaching these laws, Tristan North, a lobbyist for the American Ambulance Association, told Axios.

• But insurers have raised concerns that some states are setting benchmark rates far above what Medicare pays, said a spokesperson for insurance trade group AHIP.

Yes, but: The state laws are ultimately limited, because most employer-sponsored health plans — a huge chunk of the private market — fall under federal regulation.

• "It's good to know that Washington has this new law now, but we're hoping to see it go one step further to the federal level," said Christy Shum, who received a bill for about $7,000 when her infant son was transferred from one hospital to another last year.
• Shum's employer-sponsored insurance initially covered only about $1,000 for the out-of-network ride, but the charges were eventually wiped without much explanation, Shum said.

What's next: A commission created by the No Surprises Act to study ground ambulances will soon formally submit recommendations to lawmakers, which will include a $100 cap on patient costs and linking insurer payments to locally regulated rates when possible.

• President Biden recently called for extending surprise billing protections to ground ambulances, but there's little expectation that lawmakers will take up legislation this year.
• This Congress has struggled to pass modest bipartisan payment changes, and some of the biggest champions of the No Surprises Act are no longer in office.

The bottom line: "We really need to build the groundswell of support — more than we already have, apparently — to see Congress address it," said Patricia Kelmar, a director at Public Interest Research Group and member of the federal ambulance billing advisory committee.