American Academy of Home Care Physicians
Promoting the art, science and practice of medicine in the home.

1999 Vol. 11 No. 4
Issn# 1049-0028

Government Update
By: C. Gresham Bayne, MD

Negotiated Rulemaking Process for Ambulance Payment Affects Our Patients
A complex process is underway whereby the HCFA, using federal mediators, has engaged the relevant parties in discussion of a major new payment methodology for ambulance services. A clear consensus exists for emergency transports for our patients and the federal definition of an emergency will apply (the Prudent Layperson's Rule). However, there appears to be little discussion of non-emergent transports from the home, and the only physician on the Committee represents the American College of Emergency Physicians.
If the interpretation of the proposed rule published in Jan 22, 1999 Federal Register is maintained, it may preclude non-emergency transportation of homebound patients for appropriate testing in a doctor's office, outpatient surgicenter, or locations other than hospitals (acute, skilled nursing and rehabilitation). Although such transportation is clearly indicated for bed bound, spastic patients and other categories of patients needing consultative services such as endoscopy and imaging tests, the only outlet may be through a complex, paper-based process analogous to the Certificate of Medical Necessity for durable medical equipment.

In my locale of San Diego, we are having terrific problems in accessing certain tests for our patients since home health nurses have become reluctant under IPS restrictions to perform even incidental blood draws; the last mobile ultrasound service stopped business in April, 1999; and ambulance companies refuse to transport to non-hospital facilities unless it is an emergency or the patient guarantees payment up front. Thus, to get an INR, diagnostic ultrasound in a patient with DVT, or CT scan in a patient with acute delirium, or any specialty consult, we now have to arrange for transport to the hospital emergency room.

Below is a short history compiled from downloads of federal documents describing where we are in the process. You may gain access to updated data at the HCFA web site at http://www.hcfa.gov/medicare/ambmain.htm.

From the September 17, 1999 Federal Register:
"SUMMARY: In accordance with section 10(a) of the Federal Advisory Committee Act, this notice announces the dates and locations for the sixth and seventh meetings of the Negotiated Rulemaking Committee on the Ambulance Fee Schedule. This meeting is open to the public. The purpose of this committee is to develop a proposed rule that would establish a fee schedule for the payment of ambulance services under the Medicare program through negotiated rulemaking, as mandated by section 4531(b) of the Balanced Budget Act (BBA '97) of 1997.

DATES: The sixth meeting is scheduled for October 4, 1999 from 9:00 a.m. until 5 p.m. and October 5, 1999 from 8:30 a.m. until 4 p.m. E.S.T. The seventh meeting is scheduled for December 6, 1999 from 9 a.m. until 5 p.m., December 7, 1999 from 9 a.m. until 5 p.m., and December 8, 1999 from 8:30 a.m. until 4 p.m.

ADDRESSES: The 2-day October meeting will be held at Turf Valley Hotel, 2700 Turf Road, Ellicott City, Maryland 21042; (410) 465-1500.

The 3-day December meeting will be held at Doyle's Hotel, 1500 New Hampshire Avenue, N.W., Washington, D.C. 20036; (202) 483-6000.

FOR FURTHER INFORMATION CONTACT:
Inquiries regarding these meetings should be addressed to Bob Niemann ((410) 786-4569) or Margot Blige ((410) 786-4642) for general issues related to ambulance services or to Lynn Sylvester, ((202) 606-9140) or Elayne Tempel, ((207) 780-3408) facilitators."

Current payment policy as published in the federal register (updated in Jan 17, 1997 proposed rule for ambulances): "[42 CFR 410.40(c)] (c) Limits on origins and destinations. Medicare Part B pays for ambulance transportation of a beneficiary- [42 CFR 410.40(c)(1)]

To a hospital or CAH or SNF, from any point of origin; [42 CFR 410.40(c)(2)]
To his or her home, from a hospital or CAH or SNF; or [42 CFR 410.40(c)(3)]
Round trip from a hospital or CAH or a participating SNF to an outside supplier to obtain medically necessary diagnostic or therapeutic services not available at the hospital or CAH or SNF where the beneficiary is an inpatient." Note that this policy does NOT allow for payment from the home to other than a hospital setting.
Current payment policy updated in the federal register Jan 22, 1999 (64 Fed Reg 3637): "Sections 410.40(c) and (e) do not permit routine coverage of, or payment for, transportation to non-hospital-based or independent diagnostic and treatment facilities. Currently, we pay for transportation to these types of facilities only if the beneficiary is an inpatient at a hospital, RPCH, or SNF and the treatment needed is not available at that inpatient facility. We do not cover round trip transportation to non-hospital-based facilities from the beneficiary's home." Apparently, the local San Diego ambulance carriers are experiencing an enforcement of this statute due to the publicity of the current rulemaking process. Note the specific inclusion of a nonpayment policy from the patient's home to destinations other than the hospital.

The minutes of the Rulemaking Committee do not include any reference to a change in the above most recent exclusionary statement about payment for transportation by ambulance from the patient's home to a non-hospital, non-emergency setting. If you would like to view the minutes of the HCFA actions, please consult their web site at http://hcfa.gov/medicare/ambmain.htm. It is too late to submit formal comments but you may wish to contact HCFA directly by calling their representative on the committee Nancy Edwards at 410-786-5674 or go to the next public meeting at Doyle's Hotel in Washington D.C. on Dec 6-8.

Stark II Update
Several of you have asked about the current status of the Stark II . The answer is that no changes have yet been made. HCFA still has not written final regulations implementing the law after having issues proposed regulations in January 1998 calling for numerous exceptions to the compensation ban. The AAHCP had commented recommending clarity with regard to the impact on home care agency medical directors and referring physicians. As a result of the lack of change, all of the old requirements--$25,000 cap and the rest--are still in place.
Reported in August was a bill sponsored by Representative William Thomas of California which would dilute the 6-year old physician self-referral law by eliminating the ban on compensation arrangements between doctors and healthcare organizations. It would not change the self-referral provision. Many of the large healthcare organizations are supporting this bill. However, Rep. Fortney "Pete" Stark, author of the law, reportedly criticized the Thomas bill and introduced his own, more modest attempt to clarify the law. His bill would replace all exceptions to the compensation ban with a "fair market value" standard. We will keep you posted if new developments occur.