Uncovering Medicaid—The Other Entitlement

Not Just Medicare
For as long as we’ve been around the ambulance billing scene, everyone has hung on every word that comes from the Centers for Medicare and Medicaid Services (CMS) pertaining to Medicare. But note the name of the agency . . . it not only contains the word “Medicare” but also the word “Medicaid.”

The Health Insurance Association of America defines Medicaid this way:

“A government insurance program for persons of all ages whose income and resources are insufficient to pay for health care. Medicaid is state-administered and financed by both the states and the federal government.”

The Federal government infuses cash to the individual States who then add funding and administer the program each in its own manner. This is why Medicaid rules vary so widely across the United States as the program is splintered by State government oversight and administration.

Medical Necessity Blinders
The ambulance industry, and by extension the ambulance billing industry, is so focused on the global definitions of medical necessity as defined by the behemoth, Medicare, that there is a tendency to miss the differences in the medical necessity rules for the various State Medicaid programs.

While the insurance industry tends to follow Medicare guidelines very closely, not all States’ Medicaid programs follow suit. This is where things become blurred.

We cannot just assume that because the Medicare Administrative Contractor in a certain jurisdiction will pay certain claims for ambulance service that the Medicaid program in a particular State will pay the same claim.

We must remove the blinders and look closely into those State rules to ensure compliance with them. The rules may be similar, but in most cases are different.

An Example
Pennsylvania is a good example of how the Medicaid medical necessity definition is very different from the Medicare definition. Since it’s near and dear to our hearts given our geographical location, we think it’s helpful to share with you one State’s rules.

The Pennsylvania Code Section §1245.52 outlines these guidelines.

“Payment for ambulance transportation will be made subject to the following conditions:

(1) For ambulance transportation to be considered medically necessary, one or more of the following conditions shall be documented in the remarks section of the Medical Services/Supplies Invoice:

(i) The patient is incapacitated as the result of injury or illness and transportation by van, taxicab, public transportation or private vehicle is either physically impossible or would endanger the health of the patient.

(ii) There is reason to suspect serious internal or head injury.

(iii) The patient requires physical restraints.

(iv) The patient requires oxygen or other life support treatment en route.

Notice how broad and non-specific the definition is, and also notice that while there are certain parallels to Medicare’s definition, there is a definite variation from the more detailed Medicare rules.

Take note, in many States the rules haven’t changed for a long time, and PA is a good example of that fact. The above guidelines for medical necessity have basically been in place in the instruction manuals for well over a decade.

These guidelines were issued long before many modern treatments and procedures were in place. The rules don’t adequately reflect present-day EMS practices.

Too Much Left for Interpretation
You may recall that we have mentioned in previous blogs that the Federal Government has, for the first time, extended funding for the Recovery Audit Contractor (RAC) program to Medicaid in addition to Medicare.

RAC auditing has been successful for the government and has resulted in millions of recovered dollars that the Feds say should have never been spent on ambulance transportation in the first place. 

These outdated medical necessity definitions are being used to determine the appropriateness of Medicaid payments. Given the gap between the rules and current EMS practice, there’s a lot being left for an auditor to interpret.

Your billing office could, conceivably, be following all guidelines very closely and still an auditor may render an interpretation of the rules that results in your needing to defend your billing of certain claims. 

The best you can do is to constantly monitor the connection between the provider side of the equation and the office side and do all that you can to constantly review your own QA/QI processes.

Document, Document, Document
We recommend you take these steps to remain in compliance with the rules.

First, be sure that you know your State’s published Medicaid guidelines. Find them, print them, save them, and have them available to review often.

Second, educate your staff, especially your billing office staff. Provide guidance, especially denoting the differences between the fairly well-known Medicare guidelines and the not-so-familiar State guidelines. If you outsource your billing, be sure to use a contractor that stays on top of the many important guidelines and monitors all bulletins and updates.

Finally, be sure the street providers who man the ambulance understand how to properly document their runs in order to alert the billing office regarding patient assessments and conditions which may not be billable to the Medicaid program at all.

We say this time and time again . . . Document, Document, Document!

Scratching the Surface
To adequately cover this subject would be to write a term-paper-like dissertation. We have neither the time nor the space allotment to do so, nor do you probably have the time to read it all.

So we’ll end by admitting that we’ve only scratched the surface on this important subject.

Our purpose in posting this information is to make you aware. So now it’s your turn to ask questions within your own organization.

Enhanced is here to help if you feel you have gaps. We’re “fanatical” about compliance! Our Certified Ambulance Coder trained staff are continually educated in the many rules and regulations that drive your State’s Medicaid along with monitoring other payer sources, as well.

Call us today at (800) 369-7544 or e-mail Chuck Humphrey at chumphrey@enhancedms.com for more information about the services we offer at Enhanced Management Services.

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