News & Updates

Medi-Cal ambulance rides are going to cost taxpayers a lot more

By AUSTILL STUART

September 17, 2022

https://www.ocregister.com/2022/09/17/medi-cal-ambulance-rides-are-going-to-cost-taxpayers-a-lot-more/

A little-noticed amendment recently approved by the Centers for Medicaid Services for California’s Medicaid plan, Medi-Cal, could cost the state’s taxpayers and patients dramatically. The amendment, 22-0015, raises the reimbursement rate that Medi-Cal will pay for ambulance rides by over $800 per trip. A Medi-Cal patient’s ambulance ride will now cost state taxpayers over $1,000 per trip, up from about $120 per trip.

The increased reimbursement rates in the amendment could result in a revenue windfall for local fire departments that are increasingly looking to provide emergency medical services (EMS)—not so they can better serve patients, but so they can use EMS as a revenue generator. Notably, despite handling over 70% of ambulance rides in California, private ambulance companies aren’t going to receive this higher reimbursement rate because it is only available to public EMS providers.

EMS agencies exist to serve all patients with life-saving services as quickly and effectively as possible, not to charge taxpayers high costs and siphon off the most profitable patients to generate money that can be shifted to other projects.

While Medi-Cal patients may have previously provided less reimbursement than rates paid by some insured patients for their ambulance trips, justifying a ninefold increase in per-trip rate needs clear justification. Yet, proponents and state officials have not provided any data justifying the ambulance ride cost increase.

California’s county-based emergency medical services system has existed since 1981. The state Emergency Medical Services Authority (EMSA) was created after the proliferation of city- and county-based EMS agencies led to jurisdictional conflicts, and a more unified approach to EMS transport was needed. Since then, the county-based EMS system has served Californians well for over four decades, with EMSA providing oversight and many local governments partnering with private ambulance companies.

But, today, fire departments view emergency medical services as a way to get more funding. Earlier this year, Senate Bill 443, which died in the state legislature, would have allowed local fire departments to effectively create their own EMS agencies. But fire departments don’t want oversight from the state’s Emergency Medical Services Authority. And they don’t want to conduct competitive bidding for ambulance subcontracts, where private providers would likely provide better services at lower costs.

Recent experience shows how this unaccountable fire department takeover of EMS happens. For example, in 2019-20, Chula Vista entered an EMS contract with the same company that had provided its ambulance services since the late-1970s. Chula Vista raised rates considerably to nearly $3,900 per ambulance trip. But, the ambulance company providing those services only received $1,720 per trip while the fire district siphoned off over $2,000 per trip. Then, after jacking up ambulance prices, the fire department told city leaders that, rather than hold another competitive bidding process to see what private companies would charge per trip, the fire department should provide all emergency services and keep all of the funding.

If municipal fire agencies want to take control of emergency medical services away from cities, counties, and private providers, they should competitively bid for the opportunity to do so alongside other EMS providers. They should also be subject to the same standards and oversight, which they aren’t currently.

Unfortunately, this Medi-Cal amendment raising reimbursement rates to public providers and the previously proposed state legislation, which may return next session, make it look as though fire departments believe they can bully their way into becoming unregulated EMS agencies that charge astronomical prices to taxpayers.

Ambulance services are obviously often a matter of life and death. If lawmakers and regulators believe the state’s system needs improvement, they should publicly and transparently propose EMS changes and judge providers on a level playing field. If fire departments want to displace existing county EMS providers and private ambulance companies, they should be offering taxpayers higher quality services at lower costs. Right now, it appears they’re offering neither.

Austill Stuart is the director of privatization research at Reason Foundation.

An idea whose time has come? EMS and local communities should investigate transformative models to reduce psych holds in local EDs – something hospitals and EMS agencies often say contribute to EMS offload delays.

-------------------------

Mental Health Crisis Leads Hospitals to Create a New Type of ER

Recliners and games in “Empath units” are helping move patients with psychiatric ailments out of emergency rooms.

ByJohn Tozzi

September 26, 2022

https://www.bloomberg.com/news/articles/2022-09-26/hospitals-empath-units-replace-the-er-for-mental-health-patients

With mental health treatment in short supply, Americans experiencing a psychiatric crisis frequently land in a hospital emergency room—brought in by the police or loved ones—and usually stay there until they can be safely discharged or transferred. That means patients can spend hours or even days stuck on a gurney until a spot opens in a psych ward, the only other setting deemed appropriate.

The approach rarely offers any real treatment for mental health conditions, and it ties up scarce ER beds. That’s spurred some hospitals to try a new idea: mental health crisis units designed to treat people quickly in a more serene setting, so they can stabilize patients and send them home. “There’s no other emergency in the ER where the default treatment is to find them a bed,” says Scott Zeller, assistant clinical professor of psychiatry at the University of California in Riverside. Zeller developed the model, called Empath (emergency psychiatric assessment, treatment, and healing), to improve care while avoiding unnecessary time in the emergency department.

The idea is an open room with recliners, soft lighting, TVs, and card tables. At the two dozen or so Empath centers in the US today—with dozens more on the way—patients who are medically stable are seen by a psychiatric specialist within an hour and quickly start any needed medication. By speeding up treatment and observing the response, doctors can send more patients home with recommendations for follow-up care, rather than automatically placing them in a psychiatric hospital.

Since the 1950s, most US psychiatric beds have vanished under the policy of “deinstitutionalization” that followed budget cuts and exposés of inhumane conditions in mental hospitals. The number of public psychiatric beds per 100,000 people dropped from 340 in 1955 to 12 in 2016, according to the nonprofit Treatment Advocacy Center. After the institutions emptied out, hospitals and jails became the de facto replacements.

Covid-19, which strained hospital capacity while exacerbating Americans’ mental distress, amplified the problem. A study of one pediatric facility found the average length of psychiatric boarding more than doubled, to 4.6 days, during the first year of the pandemic. A survey by the Massachusetts College of Emergency Physicians showed that at the average hospital, almost 30% of ER beds are occupied by people experiencing a behavioral health emergency, with some patients remaining there for weeks.

Zeller developed what became the Empath model when he was medical director of a psychiatric emergency center in Alameda County, Calif., which served as a regional destination for psychiatric transfers from local emergency departments. Most patients were brought in involuntarily by the police, and the county aimed to move those who were medically stable to the center as quickly as possible. The approach, Zeller found in a 2014 study, meant patients spent less than two hours in the ER waiting for treatment, and only 1 in 4 needed to be admitted for inpatient psychiatric care.

Part of the solution was getting people out of a setting that can aggravate mental distress. “That environment itself, within the ED, can be very frightening,” Zeller says. “It’s claustrophobic, there are lights and noises and scary equipment and uniformed personnel running all around, and they’re not allowed to move.”

The setting for the Alameda study was essentially a big waiting room. The hospital bought recliners to make patients more comfortable, organized group activities such as board games, and added stations where patients could get water, snacks, and linens so they wouldn’t have to ask a nurse for basics. “That allows the treatment to work a little better, if people aren’t feeling adversarial, but rather engaged,” Zeller says.

As the Alameda study got more attention, other hospitals sought to replicate the approach. Zeller and his colleagues started talking about redesigning the concept. “If we were going to be able to build something from scratch, what would we do?” he asked. Hospitals envisioning new facilities could make them feel less clinical and more inviting than the waiting room, with more space, higher ceilings, natural light, and fresh air.

M Health Fairview Southdale Hospital in suburban Minneapolis opened an Empath unit in March 2021. Lewis Zeidner, director of clinical triage and transition services, says it’s more like a living room than an ER, though it’s adjacent to the emergency department. The unit has 15 recliners and a staff of psychiatrists, psychiatric nurses, and therapists—one clinician for every two patients—around the clock. Hospital admissions for mental health crises have fallen to 14% from 40%, and there’s been a dramatic drop in repeat visits.

The unit sees 250 patients a month with depression, anxiety, PTSD, and substance use problems. “They’re everyday people who get to a place in their life where things feel more out of control,” Zeidner says. The setting opens a window to evaluate patients and determine whether they should be admitted for inpatient treatment. Before the Empath option, that was usually the only destination if a clinician was worried about a patient’s security. “We want to keep people safe,” he says. “You can’t reverse suicide.”

After University of Iowa Health Care opened an Empath unit in its main hospital building in Iowa City, the number of suicidal patients admitted and the length of time they waited in the ER dropped dramatically, researchers found. “Once we had it, we were like, ‘Oh my gosh, how did we do this without it?’” says Heidi Robinson, director of behavioral health services for the hospital’s nursing department.

A separate Iowa study looked at the economics of the approach and found that revenue in the emergency department increased as fewer patients left before being treated. But the boost wasn’t enough to cover the cost of the Empath unit—$1.4 million to open and $2.6 million in annual operating expenses. Zeidner says hospitals tend to lose money on inpatient mental health beds anyway, and the advantages to patients of avoiding those admissions are clear. With the success of its suburban Southdale Empath unit, M Health Fairview is considering another at its downtown Minneapolis location, with room to treat adolescents as well as adults. “There’s a growing understanding,” Zeidner says, “that this crisis is not going away.”

The latest legal challenge. 

Perhaps one of the reasons that the Congressionally mandated Committee on Ground Ambulance Balance Billing has not been seeded yet is that the feds are waiting for the various legal challenges to play out to help guide the recommendations from that committee?

----------------------

Texas Medical Association files another surprise billing lawsuit

MAYA GOLDMAN

September 22, 2022

https://www.modernhealthcare.com/legal/surprise-billing-lawsuit-texas-doctors

The Texas Medical Association filed its second lawsuit against the federal government’s surprise billing arbitration process Thursday.

An August rule on the independent dispute resolution for surprise medical bills still unlawfully favors insurers over providers, the medical association alleges in its complaint to the U.S. District Court for the Eastern District of Texas.

“We are, once again, asking for the law to be followed as Congress intended, and for the challenged provisions to be invalidated. There should be a level playing field for physicians and healthcare providers in payment disputes after they’ve cared for patients,” Texas Medical Association President Dr. Gary Floyd said in a news release.

The lawsuit comes just after the American Medical Association and American Hospital Association dropped their legal challenges to the policy. The AMA and AHA support the Texas lawsuit. “We intend to make our voice heard in this case by filing an amicus brief that explains how the final rule departs from congressional intent just as the September 2021 interim final rule did,” the organizations said in a joint statement Thursday.

The Texas Medical Association first sued regulators over the arbitration policy last year. The interim regulation required arbiters to pick the offer for surprise bill payment that came closest to the insurer's median contracted in-network rate. Judge Jeremy Kernodle of the U.S. District Court for the Eastern District of Texas ruled in favor of the Texas physicians in February.

The federal government appealed the decision in April, but subsequently finalized a rule requiring arbiters to consider both an insurer’s median contracted in-network rate and additional information when deciding the payment for a surprise bill.

The Texas Medical Association contends the final rule does not go far enough to protect provider payments. The methodology for calculating insurers’ median in-network rates is “deflated” compared to insurers’ actual average contracted rates, the group argued in the news release.

“These provisions of the final rule are manifestly unlawful and will unfairly skew [independent dispute resolution] results in insurers’ favor, granting them a windfall they were unable to obtain in the legislative process. At the same time, they will undermine healthcare providers’ ability to obtain adequate reimbursement for their services, to the detriment of both providers and the patients they serve,” the complaint says.

Very, very well-done article in the Des Moines Register.

Special thanks to West Des Moines EMS Deputy Chief and NAEMT Board Member David Edgar for coordinating this important series.

The on-line article is behind a subscription wall, but we’ve placed a PDF version of the 2 part series, and the accompanying editorial here.

De Moines EMS Series.pdf

Notable quotes:

“Many people regard EMS as an essential service, but the system in Iowa and across the U.S. struggles to remain financially viable and to fulfill its mission of quickly delivering care to the sick or injured, local and national emergency officials say.”

“According to U.S. Bureau of Labor Statistics' data from 2021, the median pay for a full-time emergency medical technician was $17.76 an hour, even though the job requires training that, for a full-fledged paramedic, typically costs $10,000 to $20,000.”

"The fix isn’t just money, but the fixes require money,"

This is good news for some systems using the PHE waivers for their EMS delivery…  Some will expire when the PHE ends, some carry on until the end of the calendar year in which the PHE ends.  There is a link and list of these waivers at the end of this note.  

Many of the telehealth waivers will expire 151 days after the PHE ends, unless Congress moves to make them permanent.

-----------------------------

HHS expected to renew COVID-19 PHE for 11th time

Molly Gamble

Sept. 14, 2022

https://www.beckershospitalreview.com/finance/hhs-expected-to-renew-covid-19-phe-for-11th-time.html

HHS is set to extend the COVID-19 public health emergency by its standing deadline of Oct. 13.

HHS last renewed the PHE July 15 for another increment of 90 days with a pledge to provide states with 60 days' notice if it decided to terminate the declaration or allow it to expire. Aug. 14, the date in which states would have 60 days' notice, came and went without updates or notifications from the agency, suggesting the declaration will extend.

If renewed on the deadline of Oct. 13, the next deadline would be Jan. 11, 2023.

This would make for the 11th renewal of the PHE since its declaration in January 2020 by former and current HHS secretaries Alex Azar and Xavier Becerra, respectively. The renewal would occur as HHS plans to shift costs of COVID-19 vaccines and treatments to the commercial market, a process beginning this fall that is expected to take months. 

Hospitals have advocated for the PHE's extension. In July, the Federation of American Hospitals, which represents investor-owned or managed hospitals, urged HHS "in the strongest terms possible" to renew PHE through 2023.

"While we all long for the day when we can declare the emergency over, that day is not yet in sight for America's hospitals," FAH CEO Chip Kahn wrote in his July 27 letter to Mr. Becerra. Mr. Kahn urged HHS to not only renew the PHE for another 90 days by its current deadline of Oct. 13, but to "send a clear signal that an additional 90-day extension may be necessary."

For an overview of the flexibilities tied to the PHE and what occurs when the declaration ends, check out a comprehensive brief from Kaiser Family Foundation here.

--------------------

https://www.cms.gov/files/document/ambulances-cms-flexibilities-fight-covid-19.pdf

Payment for Vaccine Administration:

“CMS will continue to pay approximately $40 per dose for administering COVID-19 vaccines in outpatient settings for Medicare beneficiaries through the end of the calendar year that the COVID-19 PHE ends.”

Add-On Payment for Vaccines in the Home:

“We’ll continue to pay a total payment of approximately $75 per dose to administer COVID-19 vaccines in the home for certain Medicare patients through the end of the calendar year that the COVID-19 PHE ends.”

Ambulance Treat in Place:

“This waiver will end with the end of the PHE.”

CMS Hospital Without Walls (Transport to Alternate Destinations):

During the Public Health Emergency (PHE) for the COVID-19 pandemic, we have temporarily expanded the list of allowable destinations. {Editor’s Note: Although not expressly stated in the waiver, this waiver will likely end with the PHE.}

Another example of how existing services models are not sustainable with skyrocketing costs of service delivery and historically low reimbursement rates, regardless of who the provider is, public, private, hospital-based, etc.

Community leaders need to be educated on the true cost of EMS service delivery, the cost differences based on service levels and provider types (public, private, 3^rd service governmental, hospital-based, etc.), decide what service level the community really wants based on the levels of investment needed for each level, and begin to fund EMS delivery the way other essential public services are funded.

Click here to view a recent webinar hosted by the Academy of International Mobile Healthcare Integration discussing costs and funding models based on service delivery levels.

This may be the latest, but it WILL NOT be the last!

---------------------------------- 

AMR to discontinue service in Youngstown

by: Jennifer Rodriguez, Megan Lee

Sep 14, 2022

https://www.wkbn.com/news/local-news/amr-to-discontinue-service-in-youngstown/

YOUNGSTOWN, Ohio (WKBN) – American Medical Response (AMR) sent a letter to the City of Youngstown Wednesday notifying the city that it will be discontinuing service in Youngstown.

According to the letter sent to the city, AMR will not renew its agreement with the city, and the current agreement will end on December 31, at 11:59 p.m.

The letter states AMR has been serving the city for over 30 years without any cost to the city or taxpayers. It also states that the company is not being reimbursed for medical calls.

“We have discussed throughout the last three years, the subsidy is needed to overcome inadequate Medicaid reimbursement which makes up a significant portion of our services and which is below our costs,” it stated.

It goes on to state, “The current Ohio Medicaid base rate for a basic life support emergency transport is $120 and has not been re-based by the state in years. When we treat and transport Medicaid patients, we are reimbursed far below the cost of providing service — approximately 42% of our cost. More than half our transports, or 54%, are Medicaid recipients.”

In April, Youngstown City Council voted down a $625,000 subsidy to “ensure continued EMS and ambulance services” for the city. All council members voted no except Third Ward Councilwoman Samantha Turner.

At that time, Fourth Ward Councilman Mike Ray said the door was not completely shut, but there were some details that needed to be worked out first.

We don’t know if that’s still the amount to keep AMR in place. When asked if the city should reconsider the vote, Turner said, “We should. If they’ll take it.”

Today, we asked several council members their thoughts on the notice and AMR stating they need more money.

“We asked admin months and months ago to go out for an RFP to see who else may be interested with that much money on the line, it’s only responsible of us to do that but the admin hasn’t done it, surprise, surprise,” said Fifth Ward Councilwoman Lauren McNally. “They are the largest EMS service in the country and I feel they are bullying us into a money grab since we have ARP money right now.”

“They are the largest ambulance company in the country, I feel like they are extorting us because we have some extra money now. I’m not sure what’s going to happen. My ultimate feeling is, have their services improved, what are they willing to give in return? Are they adding trucks, are we going to get better response terms, are the citizens of Youngstown going to be served any better because of the extra money? If not, what’s the point of payment? We can’t get or continue to get mediocre or bad service,” Oliver said.

“What we see in front of us doesn’t make sense to pass at this point, so we definitely wanna continue the conversation,” Ray said.

In January, AMR Regional Director Ed Powers used a computer presentation to explain the problems, saying while an average ambulance run costs about $300, Medicaid only reimburses the company $130 – a gap of 48%.

“Medicaid currently covers about 48% of our expense. We need another 52% just to break even,” Powers said.

“During that three years, we’ve explored all kinds of different models, trying to create a sustainable model. I mean, we knew five years ago that the model wasn’t sustainable,” he said.

Youngstown Law Director Jeff Limbian said the letter from AMR was not unexpected.

“The City of Youngstown, under Mayor Brown’s direction, has been to negotiate with AMR for many months now. Some members of City Council would like a more expansive analysis to see if there are other ambulance companies available to come into the city,” he said. “There is currently a request for proposals to determine if there are other interested ambulance entities. If that process does not produce an additional option, we anticipate that discussions will continue with AMR.”

According to Powers, AMR gave the city a 115-day notice to find new services. And if services aren’t found…

“Oh, it would mean a holy disaster to be perfectly blunt. We don’t anticipate that’ll happen. Mayor Brown is going to move heaven and earth to make sure that the citizens are protected. There will be ambulance service one way or another,” Limbian said.

Powers says the company hopes that the administration in Youngstown sits down with AMR to discuss any future plans or negotiations because he says AMR has invested a lot in the City of Youngstown.

“We actually hire residents off the street that are non-medical providers. We train them to be a medical provider and then give them jobs to work on our ambulances, and then they’re paying taxes to the City of Youngstown. So they’re… everybody here is invested in the City of Youngstown and nobody wants to leave,” Powers said.

Limbian hopes AMR will want to go back to the drawing board if the administration is unsuccessful in finding an alternative company.

“You know, it was a hard lesson for us to learn, to come to that realization, but now that we do understand that there just isn’t the money for them to make in the town the size of Youngstown with the volume that we have. So their requests are reasonable,” Limbian said.

The Youngstown Fire Department recently stopped using its fire trucks for emergency medical calls after it was determined what they were doing was illegal. The fire department needs what is known as “standing orders” from a hospital and is working to get them.

The Youngstown Professional Fire Fighters IAFF Local 312 responded to AMR’s announcement calling on city leaders to talk about the future of pre-hospital care for the city:

“Now is the time to address the inequalities that have plagued Youngstown for years. We are witnessing firsthand the ramifications of putting profits over patients. The citizens of Youngstown deserve access to basic infrastructure like public safety, which includes a sustainable, professional EMS system. The Youngstown Professional Fire Fighters urge the city leaders to finally recognize our abilities to help our citizens and negotiate the implementation of a first-class pre-hospital system.”

This action, while not unique as many providers have left certain communities, this is an interesting decision in a high-profile community to cease a certain service within the community. 

The wage pressures due to regulatory issues in California (fast food worker wages up to $22/hr.), the overall worker shortage, and the desire to seek generally higher reimbursement for emergency services, may all be factors that led to this action. 

This might be a bellwether for other providers dropping select services in some communities.  For example, like many physicians have, ambulance providers could elect to not provide non-emergency transfer services to Medicaid patients, while continuing to provide services for other commercially insured patients.

Imaging what would happen to a region’s healthcare system if all ambulance providers simply took the stand on low Medicaid reimbursement and said ‘no’ to any Medicaid, non-emergency transfer?  Or told the hospitals if they want the Medicaid patient transported, the hospital will have to pay, perhaps in advance, for the transfer?

If no provider was willing to provide non-emergency services for say Medicaid patients, does then the 911 safety net provider become the ONLY option?  Meaning, publicly funded agencies may then HAVE to provide the service if there is no one else?  What would that do to the availability of the 911 safety net system?

That might align incentives in states with ridiculously low ambulance Medicaid rates that have not changed in decades, to increase the ambulance rates.  Imaging the hospital association joining the state’s ambulance association to advocate for higher ambulance reimbursement rates.

Perhaps this same action could be taken for patients insured by commercial insurers who have a pattern on choosing to make surprise payments (payment less than perhaps a state required % of UCR, or % of Medicare), placing their members at risk for a high balance due to the surprise payment?  “I’m sorry, but ‘XXXX’ insurer is on our blacklist for surprise underpayments, and we do not want to put the patient at risk for a large out of pocket expense, so we are NOT going to provide the scheduled transfer”.  That, too, might send a very strong message to ‘XXXX’ insurance?

To some, it may seem harsh to deny non-emergency medical services to patients based on their who their payer is but hasn’t the U.S. healthcare system been doing that forever!?

AMR Letter Exiting NEM LA.jpg

Despite the intimation in the headline, the news report provides commentary on a federal report that reveals a small number of providers are likely responsible for the majority of potentially fraudulent telehealth billing, not unlike other aspects of the healthcare delivery system.

Reports like these will be crucial as MedPAC, HHS, Congress and states consider making payment flexibilities enacted as part of the PHE, permanent. The availability of telehealth has helped EMS provide enhanced services to prevent avoidable ER visits.

------------

'Guardrails' needed? Telehealth fraud cost Medicare $128M in first year of COVID pandemic, feds say

Ken Alltucker

USA TODAY

September 11, 2022

https://www.usatoday.com/story/news/health/2022/09/11/covid-telehealth-fraud-medicare-hhs/8013711001/

Key Points:

• During the first year of the COVID pandemic, 1,714 doctors and health providers billed Medicare nearly $128 million in “high risk” claims, according to a new report from federal investigators.
• Telehealth industry officials caution against creating “inappropriate barriers” to care, saying the report shows only a small number of providers engage in potential fraud or wasteful billing.
• More than 28 million seniors and disabled residents on Medicare accessed telehealth in the first year of the pandemic, an 88-fold increase from the previous year.

The federal government eased telehealth requirements at the beginning of the COVID-19 pandemic so more Americans could get remote care with fewer obstacles.

A report by government investigators last week found that more-permissive remote care has come at a price. During the first year of the pandemic, 1,714 doctors and health providers billed Medicare nearly $128 million in “high risk” claims, according to the Department of Health and Human Services Office of Inspector General.

Investigators said less than 1% of the 742,000 Medicare-certified doctors and other providers of telehealth services submitted roughly a half million problematic claims. Yet the billings are concerning enough that government investigators urged the Biden administration to tighten oversight to ensure millions of Americans can access remote care while safeguarding taxpayer dollars.

“We're really looking at practices that indicate a high probability of fraud, waste or abuse,” said Andrew VanLandingham, the HHS inspector general’s senior counselor for policy. 

The report comes less than two months after the inspector general's office alerted medical professionals about rising telemedicine fraud by companies that often pay kickbacks to doctors, labs and others to generate orders paid by Medicare and other federal health programs. Also in July, the Justice Department announced 36 people were charged for over $1 billion in health fraud involving telemedicine providers. Some were part of a telemarketing network that lured thousands of elderly or disabled patients to get unnecessary genetic testing or orders for medical equipment.

Medicare fraud, telehealth access and 'inappropriate barriers'

The latest inspector general report doesn’t address whether doctors or other providers intended to commit fraud, VanLandingham said, but the analysis suggests a high likelihood of billing abuses.

The report informs the Centers for Medicare and Medicaid Services, Congress and other stakeholders of potential ways a small percentage of providers are exploiting Medicare and suggests strategies to tighten oversight during the third year of the pandemic. 

The report also comes as Congress must decide whether to permanently extend pandemic-era telehealth rules that accelerated the use of remote care.

Telehealth industry officials say the report shows only a small number of health providers engage in potential fraud or wasteful billing. The officials also say decision-makers must evaluate the importance of convenient access for millions of Americans who get appropriate care.

“We want to make sure that in addressing concerns about fraud – as minute as that fraud might be – you're not erecting really harsh and inappropriate barriers,” said Kyle Zebley, the American Telemedicine Association’s senior vice president of public policy.

Before 2020, Medicare largely restricted telehealth to people who accessed medical care via video and audio connections set up in rural clinics. Amid the pandemic, Medicare allowed recipients in cities and suburbs to get care remotely, often from their home, via a phone call or a video chat. Medicare also more than doubled the types of services eligible for reimbursement

Medicare wanted to make it easier for people to get care without the risk of COVID-19 exposure during a visit to a clinic or hospital.

During the first year of the pandemic, more than 28 million seniors and disabled residents on Medicare accessed telehealth, an 88-fold increase from the previous year. Another inspector general report, also released last week, showed the expanded telehealth services reached more people in underserved populations and lower-income families eligible for Medicare and Medicaid.

The report did not identify doctors or hospitals that submitted claims investigators considered likely fraud, waste or abuse. However, examples included unnamed doctors who charged extra fees, billed the highest and most expensive level of care every time and submitted bills every day of the year.

Under Medicare’s fee-for-service billing, doctors are paid for the number of tests, procedures or other services they perform. And when patients require a higher level of care, reimbursement is more lucrative.

The report broadly recommended Medicare review the more than 1,700 doctors and providers suspected of abusive billing practices. Medicare also should crack down on a billing practice that allows lower-level providers such as physician assistants or nurse practitioners to bill Medicare using the name of a supervising physician. Billing using a supervisor's name existed before the pandemic, but VanLandingham said investigators are concerned such practices in telehealth could result in more subpar care.

"For oversight purposes, it's really critical for us to understand who was seeing that patient and where the physician was because that's how we can really ensure that that beneficiary is getting good quality care," VanLandingham said.

A 'facility fee,' double billing and other prolific charges

The report found hundreds of doctors inappropriately charged a "facility fee" while also billing for a telehealth visit.

Medicare allows a hospital or clinic to charge a facility fee when they host a patient who gets care from a remote provider – for example, a rural hospital that lacks a roster of specialists might connect a patient with a remote specialist located in a big city. However, a doctor who provides remote care isn't allowed to also collect a facility fee. Nearly two dozen doctors were prolific double billers, collecting a facility fee and a telehealth visit more than 1,000 times over the year, the report said.

Fiscal watchdog groups said the inspector general report points out potential problems Congress and Medicare must fix before extending the pandemic telehealth policies beyond the end of the public health emergency, now set to expire in mid-October, though it will likely be extended to mid-January. Congress passed a bill to stretch the relaxed telehealth policies five months beyond the public health emergency. Legislation pending in the Senate would continue the policies through 2024.

Josh Gordon is director of Health Policy for the Committee for a Responsible Federal Budget, a nonpartisan research group. His group released a report in April calling for safeguards to avoid unnecessary use, incentives, fraud and abuse. 

"If you set things up with the right incentives and the right guardrails from the beginning, it's a lot easier to get a handle on these programs over the long term," Gordon said. "If you wait, have it become very popular, very expensive, then it becomes much harder to go back and install guardrails or change the incentives."

AIMHI benchmarking reports perform a fundamental service to EMS leaders and local policy makers by demonstrating the clinical, operational, and economic outcomes of High Performance/High Value EMS (HPHVEMS), systems. These reports also demonstrate the innovation and system design changes that occur in these systems to meet the current challenges in EMS delivery and sustainability.

AIMHI’s goal in releasing this information is to ensure the progress and growth of the HPHVEMS model and expand the reputation and efficiency of EMS nationally and internationally.

AIMHI will be releasing quarterly reports on the member EMS systems that will highlight the demographic, clinical, operational, and financial outcome statistics of the nation’s highest performing EMS systems.  The data contained in these reports will demonstrates excellent clinical outcomes and proficiency, outstanding operational effectiveness, and exceptional financial efficiency.

This is the report you want to read if you want to know how your urban or suburban EMS system compares to these systems on key measures such as response times, cardiac arrest survival, cost per unit hour, cost and revenue per transport, and reliance on local tax subsidy.

Data contained in this quarter’s report includes:

• System delivery changes that have occurred in member service areas
• Medical First Responder (MFR) utilization
• Light and siren use by member agencies
• Accreditations by agency
• Service area information (population, size, response and transport volume)
• Response time goals and performance

Additional benchmarking reports will be released quarterly, to keep the information current, relevant and digestible.

Click here to download the Quarter 1 Benchmark Report

This is important information for all ambulance providers participating in GEMT programs.

Very specific communication by CMS and the CMCS reminding states that GEMT providers should only include costs directly related to GROUND EMERGENCY MEDICAL TRANSPORT services in their cost reports (i.e.: ‘Medicaid covered services’), and NOT costs that unrelated to covered services (E.g.: costs related to medical first response).

Here's the CMS Memo:

CMS Memo on Cost Allocation for GEMT - 8-17-22.pdf

This is stated in this part of the attached memo:

“Costs such as fire and rescue personnel and equipment are generally not directly or indirectly related to Medicaid covered services. As such, cost identification methodologies that inappropriately allocate costs associated with fire and rescue personnel and equipment to the Medicaid program potentially would be unallowable under the federal cost allocation requirements. For example, if state or local law requires that both a fire truck and an ambulance be dispatched to emergency scenes to transport a potential patient, even though the ambulance will be the only vehicle that participates in the transport of the Medicaid beneficiaries to a facility for treatment, only costs incurred in the provision of a Medicaid-covered service may be allocated to Medicaid.”