EMS providers working on claim denial situation
by For the MBJ
Published: November 22,1999
Even though emergency medical service providers in Mississippi are concerned that only half of all Medicare claims have been paid lately, medical leaders are not resting on their laurels.
“We have taken steps to reverse the denial rate trend, but nothing has changed,” said Steve Delahousey, director of operations for the Gulf Coast region of American Medical Response, the nation’s largest emergency medical service provider, with 17,000 vehicles in 38 states. Delahousey, a registered nurse and registered paramedic, is the longest-serving member on the governor-appointed Emergency Medical Services Advisory Council, and is on the reimbursement committee for Mississippians for Emergency Medical Services (MEMS). “The carrier has the flexibility and the authority to reopen cases in appeals and admit they made a mistake in denying the claims. But instead, the situation has gotten increasingly worse.”
On March 3, in a statement prepared by Nancy-Ann Min Deparle, administrator for the Health Care Financing Administration (HCFA), before the bipartisan congressional health care task force, emergency services were defined from a “prudent layperson” perspective.
The statement read, “Medicare … organizations are required to pay for emergency services without regard to prior authorization or whether the provider has a contractual relationship with the plan.”
Excerpts from the Balanced Budget Act of 1997 referred to the prudent layperson standard definition of an emergency medical condition as follows: “the term ‘emergency medical condition’ means a medical condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.”
“We were, at first, encouraged by the BBA from a national perspective because we recognized the need for changes in health care reform,” Delahousey said. “We reviewed the BBA carefully prior to its implementation and thought the ambulance industry was going to fare OK even though we knew we were going to have to modify the way we did some things.”
Even though the state department of health doesn’t regulate Medicare, Delahousey presented the issue to the state health board last December and urged members to get involved.
“The state health department is concerned with public health in Mississippi,” he said. “The fact that at least 18 counties have seen a reduction in services – and that 80% of all ambulance transports in Mississippi have indicated problems with emergency claims denied by Medicare – makes it an issue for them to consider.”
In a letter dated May 5, Dr. Ed Thompson, Mississippi’s state health officer, wrote United Health Care’s director, John Cook, about the impact of Medicare ambulance claim denials.
“The Mississippi State Board of Health recently voted unanimously to file an intent to adopt into existing emergency medical services regulations the ‘prudent layperson’ definition developed by HCFA,” he wrote. “I encourage you to consider this action in future reviews of claims filed by ambulance providers on behalf of all Medicare patients.”
In a May 13 meeting in Washington, D.C. arranged by Ilene Gordon, Senate Majority Leader Trent Lott’s (R-Miss) staff representative in Jackson, between HCFA officials, including Nancy Edwards, deputy administrator of HCFA, and MEMS members, Beverly Courtney, MEMS president-elect and representative of AAA Ambulance, told HCFA attendees that the reimbursement situation in Mississippi had reached a critical point.
“In the past two years, there has been a significant increase in the number of Medicare Part B ambulance claims being denied by the carrier, United Health Care,” she said. “Many of these denials are for emergency calls. Pre-hospital EMS is being adversely affected because many ambulance services have had to reduce services or shut down completely in some counties. The providers have followed the appropriate channels in an attempt to resolve this issue with the carrier and the HCFA Regional IV office in Atlanta. The results have been unsatisfactory.”
Since 1995, AMR in Mississippi, the state’s largest ambulance provider, has seen a 1,466% increase in the number of ambulance claims denied by Medicare. In 1999, 86% of all emergency claims were overturned at the administrative law judge (ALJ) level, he said.
In a follow-up letter dated May 20, MEMS representatives asked HCFA officials for clarification of 12 items, which included the question of whether or not the carrier must look at appeals results to review their policies and procedures, Delahousey said.
“In September, HCFA wrote back and said absolutely, the carrier has to use that data to formulate future policies and practices,” he said. “Interestingly enough, on the same date of that letter but before we knew about the letter’s existence, we met with the carrier in Jackson to resolve our problems and we asked them the same question – do they look at the administrative law judge rulings to formulate future policies? They answered no, they do not. Obviously, there was miscommunication. To the best of our knowledge, the carrier still does not look at that and offers no explanation for their decisions.”
U.S. Congressmen Ronnie Shows, Gene Taylor and Bennie Thompson have provided assistance in opening communication lines to HCFA and Congress, Delahousey said.
“Because of the BBA, hospitals and home health agencies are shutting down or reducing services,” he said. “It doesn’t mean we have fewer sick people in Mississippi. If anything, we have more. They turn to ambulance services to get them where they need to go. They can’t rely on home care, because those services are being diminished. Many rural hospitals are being shut down, so ambulances are being asked to drive further distances to get to hospitals that are able to stay afloat. Now the ambulance services aren’t getting paid for a lot of those transports.”
Calls to John Cook of United Health Care in Jackson were not returned for this story.
Contact MBJ contributing writer Lynne Wilbanks Jeter at email@example.com or firstname.lastname@example.org.
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