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Ride's Over: Medicare Report May Drastically Reduce Nonemergent Transports

The NEMT Industry could be poised to see a significant increase in dialysis patient transports. Is your organization prepared? See the article below:

The long-awaited RSNAT report has been released. Officially that’s the First Interim Evaluation Report of the Medicare Prior Authorization Model for Repetitive Scheduled Nonemergent Ambulance Transport. The pilot program for this prior-authorization project, which began in three states in 2014 and then expanded to five more and Washington, D.C., in 2016, has since been stalled awaiting the results of this study. Now that the study is out and its findings do not seem to prevent expansion of the project to the remaining 42 states, what’s next?

Before we look at what impact this project may have on the future of nonemergent ambulance service, we first need to consider what the project is about and what the study actually found. The prior-authorization program requires that patients transported on a regular basis (the main example being dialysis patients) have their medical conditions prescreened to determine whether they require an ambulance or not. The Medicare administrative contractors review medical records and physician certification statements for these patients to determine if they meet coverage criteria. If the patient is approved, they can transport by ambulance for the next 60 days; if they are not approved, they must find another way to get to their medical appointments.

The focus of the RSNAT report was to determine whether the prior-approval process resulted in a cost savings for the Medicare program and impacted the patient’s access to care. On the cost savings issue, the report found the process reduced up to 80% of repetitive nonemergent ambulance transports, which resulted in a savings to Medicare of $171 million annually. The report also noted a 15% reduction in the number of ambulance companies in the pilot states, suggesting this program is actually closing the doors of many small ambulance companies that have provided primarily repetitive nonemergent transports.

As for the impact on patients, the report found there was “little or no impact on quality and adverse outcomes for ESRD (end-stage renal disease) beneficiaries or access to care.” However, the report went on to note there was a 15% increase in emergency dialysis use, “suggesting the possibility that the prior authorization may have resulted in some delay in ESRD treatment.”

What It Means

So with these two hurdles jumped, where does that leave the ambulance industry and, more important, these ESRD patients?

It seems clear that the prior-authorization process will soon expand to all states and thus dramatically reduce the number of repetitive nonemergency trips by ambulance—and, to a lesser extent, the number of ambulance companies in general. This will leave tens of thousands of patients looking for a new way to their appointments. Ride-share services are already getting into the healthcare game, with the Uber Health dashboard allowing facilities to schedule their patients’ visits and Lyft Concierge working the same way through its application interface. Wheelchair and stretcher van companies are also alternatives, and they have been around for much longer than ride-share services, but the report noted many commenters believed that “improper utilization of repetitive scheduled nonemergent ambulance transports before prior authorization reflected a lack of availability of reliable, affordable, and condition-appropriate transportation options.”

This prompts several questions: Are ride-share services, or even wheelchair or stretcher van companies, prepared for the types of patients who may be going to dialysis treatment? What about the return trips after dialysis, when the patient is at higher risk for hypotensive crisis? What does a “condition-appropriate” vehicle look like? What kind of training does the person behind the wheel have? What type of liability does accepting these patients assume?

These are all questions we must answer in the near future, as this prior-authorization program expands and patients begin seeking these alternative transport services.

G. Christopher Kelly is an attorney who focuses on federal laws and regulations as they relate to healthcare providers and specifically to the ambulance industry. He lectures and advises EMS service clients across the U.S. This article is not intended to be legal advice; for more information or specific questions, reach Chris at chriskelly@ems-ambulance.law.

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