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CMS launches ambulance precertification program

Measure intends to cut abuse, but critics worry about sickly patients left in the lurch

The Centers for Medicare & Medicaid Services has imposed preauthorization requirements on non-emergency ambulance trips in three states to control skyrocketing utilization and improper Medicare payments linked to this benefit.

The program started Monday and will run for three years in New Jersey, Pennsylvania and South Carolina, according to the international law firm Reed Smith LLP. The program may be expanded if it saves money, Kaiser Health News reported.

CMS defines repetitive ambulance service as medically necessary ambulance travel furnished in three round trips or more during a 10-day period, or trips provided at least weekly for at least three weeks, the firm noted. Patients who need these services often require dialysis, wound care or cancer treatment.

The number of people with end-stage renal disease who need dialysis has grown dramatically since 1980, KHN reported. A 2013 report by the Office of Inspector General found that Medicare claims for ambulance trips to dialysis centers rose by 1,436 percent in Pennsylvania, 1,129 percent in New Jersey and 9,659 percent in South Carolina between 2002 and 2011.

These figures compare to a national growth rate of 269 percent for this benefit, KHN noted. Moreover, CMS extended its moratoria on new, ground ambulance provider applications in fraud zones in response to program integrity threats.

The model preauthorization program has met with mixed reactions. On the upside, beneficiaries will know in advance if their ambulance trips qualify for payment.

But the downside is that some people will be left without transportation to appointments that might mean the difference between life and death, patient advocares say. Some patients don't qualify for reimbursed transportation and lack friends or family to take them to facilities. They can't return from appointments alone, since treatments may leave them too weak to drive. Many patients can't afford any form of transportation, KHN noted.

"If they don't get to appointments, they'll end up in the hospital at even greater costs to Medicare," healthcare consultant Marsha Simon told KHN.  

For more:
- read the KHN article
- here's the Reed Smith article

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