Ambulance Transportation Services Audits. Bureau of Medicaid Program Integrity Agency for Health Care Administration March 2014

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1 Ambulance Transportation Services Audits Bureau of Medicaid Program Integrity Agency for Health Care Administration March 2014

2 Training Objectives This training is designed for Fire Rescue Chiefs, to: Provide an overview of the Florida Medicaid Ambulance Transportation Services Coverage and Limitations Handbook. Provide information on procedure codes, fees, and modifiers for Medicaid reimbursable ambulance transportation services. Provide information regarding lessons learned from previous Medicaid Program Integrity audits of ambulance transportation service providers. Improve compliance with Florida Medicaid policy. 2

3 Types of Florida Medicaid Handbooks Ambulance providers must use the Medicaid Ambulance Transportation Services Coverage and Limitations Handbook in conjunction with: Florida Medicaid Provider General Handbook, which contains general information about the Medicaid program. Florida Medicaid Provider Reimbursement Handbook, CMS-1500, which contains procedures for submitting claims. 3

4 Types of Florida Medicaid Handbooks, cont d The Florida Medicaid Provider General Handbook provides information for providers regarding: The Florida Medicaid program, Recipient eligibility, Provider enrollment, Fraud and abuse policy, and Resources. 4

5 DEFINITIONS 5

6 Advanced Life Support (ALS) The provision of medically necessary supplies and services during ground ambulance transportation, including the provision of at least one ALS intervention. The ALS intervention must be medically necessary and in accordance with state and local laws, required to be conducted by an emergency medical technicianintermediate (EMT-Intermediate) or EMT- Paramedic. 6

7 Basic Life Support (BLS) The provision of medically necessary supplies and services during ground ambulance transportation. The ambulance must be staffed by an individual who is qualified in accordance with state and local laws as an emergency medical technician-basic (EMT-Basic). 7

8 CHAPTER 2 Describes: Medicaid ambulance transportation services, limitations, exclusions, and prior authorization process. 8

9 Service Requirements Medicaid may only reimburse for medically necessary ambulance services provided to eligible Medicaid recipients. The recipient must be eligible for Medicaid on the date the service is rendered. 9

10 Medical Conditions List The Medical Conditions List is compiled and maintained by the Centers for Medicare and Medicaid Services (CMS). The Medical Conditions List contains ambulance codes for both emergency and non-emergency conditions. The condition code is based on the recipient s condition at the time of transport as observed and documented by the ambulance crew. 10

11 Medical Conditions List, cont d Use of the condition codes will not guarantee payment of the claim or payment for a certain level of service. Ambulance providers and suppliers must retain adequate documentation of the patient s condition, other on-scene information, and details of the transport (e.g., medications administered, changes in the patient s condition, and miles traveled), all of which may be subject to medical review by Medicaid or Medicaid s authorized representative. 11

12 Medical Conditions List, cont d Medicaid will rely on medical record documentation to justify coverage, not simply the condition codes by themselves. 12

13 Medical Conditions List, cont d If the recipient s medical condition is not included on the Medical Conditions List, but appears to the ambulance provider to meet Medicaid s definition of medical necessity, the ambulance provider must obtain authorization from the Medicaid area office to be reimbursed for the trip. 13

14 How to Obtain a Copy? To obtain a copy of the most updated Medical Conditions List codes, please view the Current Medicare Claims Processing Manual, Chapter 15, for Ambulance on the Centers for Medicare & Medicaid Services Web site, 14

15 Levels of Life Support Services Reimbursement for Ground Ambulances Medicaid will reimburse for ground ambulance services when the recipient s condition falls within one or more of the condition codes listed on the Medical Conditions List, pending Medicaid eligibility on the date of service. 15

16 Reimbursement Based Upon Levels of Life Support Services for Ground Ambulances Medicaid will not pay ALS rates when the recipient s condition, as listed on the Medical Conditions List, requires only BLS services, even if the vehicle is licensed and equipped for ALS services. 16

17 BLS Examples Abdominal pain without other signs or symptoms Allergic reaction with slow onset Non-traumatic eye symptoms Alcohol intoxication or drug overdose without airway compromise Sick person - Fever 17

18 ALS Examples Abnormal, potentially life-threatening, cardiac rhythm Altered level of consciousness Convulsions/Seizures Pregnancy complication/childbirth/labor Major Trauma Sexual assault with major injuries 18

19 19

20 Scenario #1 EMS was contacted regarding a 14 year old with sore throat for 2 days. 20

21 Scenario #1 21

22 Scenario #1 22

23 Scenario #1 ALS or BLS? Provider submitted procedure code 462 (acute pharyngitis) Provider billed ALS Claim adjusted to BLS 23

24 Scenario #2 EMS was contacted regarding a 45 year old with chief complaint feeling suicidal. 24

25 Scenario #2 25

26 Scenario #2 26

27 Scenario #2, cont d ALS or BLS? Provider submitted procedure code (Unspecified psychosis) Provider billed ALS Claim adjusted to BLS 27

28 Scenario #3 EMS was contacted regarding a 61 year old female with chief complaint shortness of breath and pain all over for 2 days. 28

29 Scenario #3 29

30 Scenario #3 30

31 Scenario #3 ALS or BLS? Provider submitted procedure code (Respiratory abnormality, other) Provider billed ALS Claim adjusted to BLS 31

32 Scenario #4 EMS was contacted regarding a 51 year old with a chief complaint overdose. 32

33 Scenario #4 33

34 Scenario #4 34

35 Scenario #4 ALS or BLS? Provider submitted procedure code (Antidepressant type drug abuse) Provider billed ALS Claim adjusted to BLS 35

36 Analysis of Scenarios Medicaid reimbursement for ALS or BLS is based on the recipient s medical condition at the time of transport as listed on the Medicare Ambulance Medical Condition List. 36

37 Analysis of Scenarios, cont d Medicaid will not pay ALS rates when the recipient s condition, as listed on the Medicare Ambulance Medical Condition List, requires only BLS services, even if the vehicle is licensed and equipped for ALS services. Medicaid relies on medical record documentation to justify coverage, not simply the condition codes by themselves. 37

38 Audit Process

39 Audit Process Demand Letter Preliminary Review Physician Consultant Review Preliminary Audit Report Subsequent Review by Physician Consultant Final Audit Report 39

40 What Do We Look For? Medicaid abuse means provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary, coded incorrectly on the claim, or that fail to meet professionally recognized standards for health care. 40

41 Overpayments Overpayment includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claims, unacceptable practices, fraud, abuse, or mistake. 41

42 Tips to Minimize Non-Compliance Understand Medicaid policy stated on the Florida Medicaid Ambulance Transportation Services Coverage and Limitations Handbook and bill for Medicaid reimbursement according to policy. Void improper claims when reasonably practical. Conduct self audits on a routine basis. If you are under investigation DO NOT take action to void claims or submit a self audit. 42

43 Tips to Minimize Non-Compliance Audit of the provider s claims to Medicaid for a specified period of time performed by the provider. Audit should be a detailed evaluation of the provider s claims to Medicaid. It may be focused on particular issues or comprehensive. 43

44 Resource Video training on Medicaid Provider Compliance Program & Provider Self Audits: Present a high level overview of a Compliance Program. Increase understanding of the value of self-audits. Provide details on how to perform a self-audit and submit it to Medicaid Program Integrity. Please see the video at the Florida AHCA YouTube channel at: na-jm 44

45 How Do I Ask Questions? For Audit/Compliance questions, please with Medicaid Program Integrity. For Policy questions, please with the Bureau of Medicaid Services. 45

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