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HomeMy WebLinkAbout2000 06 12 Regular E City's Emergency Medical Patient Transport Service COMMISSION AGENDA ITEM E CONSENT INFORMATIONAL PUBLIC HEARING REGULAR X Meeting MGR IDEPT ~~ Authorization 12 June 2000 REQUEST: Fire Department requesting the City Commission review the recommended fee charges for the City's emergency medical patient transport service. PURPOSE: To request that the City Commission review information presented on a fee structure that is set for Medicare reimbursement for medical transport and to provide further direction as the City Commission deems appropriate. CONSIDERATIONS: A. December 11, 1995 - Regular Meeting City Commission The City Commission approved the Second Reading and Public Hearing by motion Ordinance No. 608 authorizing the provision of Emergency Medical Services Patient Transport by the Winter Springs Fire Department. The fee charge for transport service for each person is hereby established as $184.63 per transport. B. August 11, 1997 - Regular Meeting City Commission The City Commission approved the Second Reading and Public Hearing by motion Ordinance No. 673 (Attachment 1) establishing the fees relating to the City's operation of the emergency medical patient transport system as follows: 1. Transport rate for a City resident of $185.00 2. Transport rate for a non-resident of $280.00 3. A mileage rate established of$6.00 per loaded mile transporting patients to facilities located outside of Seminole and Orange Counties. 4. Regarding emergency medical patient transport, when a resident of Winter Springs is transported from within the city limits by another June 12,2000 Regular Agenda Item "E" Page 2 entity, the resident will pay only the established fee for a city resident. The balance of the bill will be forwarded to the City of Winter Springs for payment from the Medical Transport Services Fund. C. February 14, 2000 - United States Department of Health & Human Services, Health Care Financing Administration (HCF A) HCF A reached an agreement outlining a national fee schedule for Medicare payments for ambulance services (Attachment 2). The new fee structure, to be implemented over four years starting in January 2001, will eliminate the widely varying service rates across the United States under the current system, which relies on historical charges to set the amount an ambulance provider can recover from a regional Medicare "carrier" or intermediary. In its place, every request for payment to Medicare for an ambulance transport will be the same amount for a base transportation rate and payment for each mile a Medicare patient is transported. It is also anticipated that most insurance carriers will rely upon this established fee structure for reimbursement for ambulance services as the insurance industry currently uses established Medicare reimbursement rates as their basis of payment. D. April 25, 2000 - Seminole County Board of County Commissioners Seminole County adopted a Resolution to allow the Fire Rescue Division to charge for emergency and non-emergency transport services the maximum allowable charge as determined by Medicare effective May 1,2000 (Attachment 3). The current maximum allowable by Medicare is $304.51 for transport and $4.81 per loaded mile for mileage charges. Seminole County's rate prior to May 1,2000 was a flat fee of$280.00. Other cities and providers are currently studying or implementing similar fee schedules as Seminole County has done. E. Considerations Since the City of Winter Springs Fire Department began emergency medical patient transport services, the Medical Transport Budget has absorbed an increasing amount of the direct costs of providing Emergency Medical Services from the Fire Department General Fund Budget. The 1996 Department proposal to the City was that the Medical Transport fee would provide relief to the General Fund Budget for the incremental cost of personnel time, supplies associated with the transport, and 50% ofthe replacement cost of the vehicle. The Medical Transport fund has provided the incremental cost of personnel time for transport, but all medical supplies, equipment, and 100% of the vehicle replacement fee has been budgeted in the past couple of years to come out of the Medical Transport fund and not the General Fund. The two (2) transport vehicles that have been purchased over the last two (2) budget years would have been split 50/50 between the General Fund and the Medical Transport Fund and would have been $135,000.00 each. However, the Medical Transport fund has purchased both vehicles at a total of $270,000.00. June 12, 2000 Regular Agenda Item "E" Page 3 This extra expense to the Medical Transport Fund has caused a projected budget deficit of approximately $20,000 in revenues for the upcoming budget year. If approved to charge the maximum allowable Medicare rate it is anticipated that this deficit will be eliminated and a reserve in the fund will be carried over. Discussion on the fact that current City residents receive a smaller transport bill than do non-residents has prompted us to provide the following information. Payer Cate~ory Percellta~e of Trallsports Percellt Collected Insurance 51% 71% Medicaid 4% 23% Medicare 25% 82% Veterans .025% 33% Workers Compensation .075% 62% Self Pay 20% 14% As indicated above most of the medical transports are for patients with insurance and Medicare. As previously stated most insurance companies reimburse to the Medicare established rate, so to have a lower rate for residents versus non-residents helps subsidize the insurance industry and does nothing to lower the rates for the citizens of Winter Springs. If the recommended Medicare fee structure is adopted, the economic impact will generate additional revenue for the Medical Transport Fund and help to offset increasing operational costs and well as reduce the need for additional tax revenues to fund these costs. FUNDING: No additional funding is required. Fees collected for this service will be deposited in the Medical Transport Services Fund and will be expended as approved by the City Commission in the budget process. RECOMMENDATION: The Fire Department recommends that the City Commission adopt a resolution, that the fees and charges for ambulance transport and loaded mileage shall not exceed the maximum allowable charge, as determined by Medicare, and henceforth charges for these services shall automatically be adjusted to coincide with the Medicare approved rate(s). June 12, 2000 Regular Agenda Item "E" Page 4 IMPLEMENTATION: Upon adoption of a Resolution as set forth by the City Commission. ATTACHMENTS: 1. Copy of Ordinance No. 673. 2. Copy of HCFA proposed rule. 3. Copy of Seminole County Resolution. COMMISSION ACTION: ATTACHMENT 1 ORDINANCE NO. ~ AN ORDINANCE OF TIlE CITY OF WINTER SPRINGS, FLORIDA, PROVIDING FEE CHARGES FOR THE CITY OPERATED EMERGENCY MEDICAL PATIENT TRANSPORT SYSTEM; PROVIDING FOR CONFLICTS; SEVERABILITY AND PROVIDING FOR AN EFFECTIVE DATE. WHEREAS, the City Commission of the City of Winter Springs, Florida, has upon available information and data deemed it to be in the best interest of the citizens of the City that it operate a emergency medical patient transport system; and WHEREAS, the City Commission of the City of Winter Springs, Florida, has deemed it important to the citizens of the City that the City's operation of the emergency medical patient transport system be at a cost that is equal to and/or less than that of private industry, so that no public monies are used to subsidize said system; and WHEREAS, the City Commission of the City of Winter Springs, Florida, has the authority to establish fees for services; NOW, THEREFORE, BE IT ORDAINED BY THE CITY C011NIISSION OF THE CITY OF WINTER SPRINGS, FLORIDA, AS FOLLO\VS: SECTION I: That the following schedule of fees relating to the City's operation of the emergency medical patient transport system is hereby established; 1. Transport rate for a City resident of$185.00 2. Transport rate for a non-resident of $280.00 3. A mileage rate established of $6.00 per loaded mile transporting patients to facilities located outside of Seminole and Orange Counties. 4. Regarding emergency medical patient transport, when a resident of Winter Springs is transported from within the city limits by another entity, the resident will pay only the established fee for a city resident. The balance of the bill will be forwarded to the City of Winter Springs for payment from the Medical Transport Services Fund. SECTION II: That in the event it is determined by the City Commission that a change to the fee schedule is warranted, the change shaU be accomplished by Resolution approved by the Winter Springs City Commission. SECTION III: That IS any section or portion of a section or subsection of this Ordinance proves to be invalid, unlawful, or unconstitutional it shaU not be held to invalidate or impair the validity, force or effect of any other section or portion of a section or subsection or part of this Ordinance. SECTION IV: That aU ordinances or parts of ordinances in conflict herewith are hereby repealed to the extent of said conflict. SECTION V: This ordinance shaH take effect upon passage and adoption. PASSED AND ADOPTED this J I ~ day of ~ 1997, In Chambers at Winter Springs, Seminole County, Florida. CI ORillA ./'" PAUL P. PART ATTEST: -m~ ~ S;-€-l'f-V-f:-L-ER*- MARTHA JENKINS, DEPUTY CITY CLERK ~ 2<6 I Iq97 FIRST READING SECOND READING AND PUBLIC HEARING ~ (I I \ C] 9/ Cf4 L g I I qgl / POSTED ATTACHMENT 2 HCFA Beneficiaries Plans & Providers States Researchers Students Medlcare MedIcaId CHIP Customer Service FAQs Search Negotiated Rulemaking Committee on Medicare Ambulance Fee Schedule Committee Statement February 14,2000 The Negotiated Rulemaking Committee on Medicare Ambulance Fee Schedule has concurred in the following recommendations, considered as a whole, on the content of a proposed rule (and its preamble) pursuant to section 1834(1) of the Social Security Act. In its negotiations, the Committee took into account the factors listed in the Act. Some of these factors are explicitly mentioned in the Committee Statement. Others are implicitly reflected in the recommended provisions. The Committee accepted the advisory report from the Medical Workgroup. Section 1834(1) of the Social Security Act requires that, in developing the Medicare ambulance service fee schedule, the Committee consider the following issues regarding: a Definitions that link payment to the type of s~rvices furnished. a Appropriate regional and operational variations. a Methodology to phase-in the revised payment in an efficient and fair manner. a Mechanisms to control increase in expenditures for ambulance services. a Adjustments to account for inflation and other factors. I. Ambulance Service Level A. Definitions The Committee defined seven levels of ambulance service: 1. Basic Life Support (BLS): Where medically necessary, the provision of basic life support (BLS) services as defined in the National EMS Education and Practice Blueprint for the EMT -Basic including the establishment of a peripheral intravenous (IV) line. 2. Advanced Life Support. Levell (ALS 1 ): Where medically necessary, the provision of an assessment by an advanced life support (ALS) provider and/or the provision of one or more ALS interventions. An ALS provider is defined as a provider trained to the level of the EMT-Intermediate or Paramedic as defined in the National EMS Education and Practice Blueprint. An ALS intervention is defined as a procedure beyond the scope of an EMT -Basic as defined in the National EMS Education and Practice Blueprint. 3. Advanced Life Support. Level 2 (ALS2): Where medically necessary, the administration of at least three different medications and/or the provision of one or more of the following ALS procedures: a Manual defibrillation/cardioversion. a Endotracheal intubation. a Central venous line. a Cardiac pacing. o Chest decompression. o Surgical airway. o Intraosseous line. 4. Specialty Care Transport (SCT): Where medically necessary, in a critically injured or ill patient, a level of inter-facility service provided beyond the scope of the Paramedic as defined in the National EMS Education and Practice Blueprint. This is necessary when a patient's condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area (nursing, medicine, respiratory care, cardiovascular care, or a paramedic with additional training). 5. Paramedic Intercept (PI): These services are defined in 42 CFR 410.40. They are ALS services provided by an entity that does not provide the ambulance transport. Under limited circumstances, these services can receive Medicare payment. 6. Fixed Wing Air Ambulance (FW): Fixed wing air ambulance is provided when the patient's medical condition is such that transportation by either basic or advanced life support ground ambulance is not appropriate. In addition, fixed wing air ambulance may be necessary because the point of pick-up is inaccessible by land vehicle, or great distances or other obstacles (for example, heavy traffic) are involved in getting the patient to the nearest hospital with appropriate facilities. 7. Rotary Wing Air Ambulance (RW): Rotary wing air ambulance is provided when the patient's medical condition is such that transportation by either basic or advanced life support ground ambulance is not appropriate. In addition, rotary wing air ambulance may be necessary because the point of pick-up is inaccessible by land vehicle, or great distances or other obstacles (for example, heavy traffic) are involved in getting the patient to the nearest hospital with appropriate facilities. B. Emergency Response Modifier F or the BLS and ALS 1 levels of service, an ambulance service that qualifies as an emergency response will be assigned a higher relative value to recognize the additional costs incurred in responding immediately to an emergency medical condition. An immediate response is one in which the ambulance provider begins as quickly as possible to take the steps necessary to respond to the call. There is no emergency modifier for PI, ALS2, or SCT. II. Regional and Operational Variations A. Operational No operational differences will be recognized. All types of providers will be paid under the same fee schedule. Thus, the same payment will be made for a comparable service provided by a private, volunteer, municipal, or hospital ambulance. B. Regional Variations .1. Cost of Living Differences An adjustment will be made to recognize the cost of maintaining an ambulance supplier in various geographic areas. While not specifically directed at the expenses of ambulance suppliers, the Committee agrees that the most appropriate available index to use for this purpose is the practice expense (PE) component ofthe geographic practice cost index (GPCI) as used in the Medicare physician fee schedule. The Committee agrees that the index is applied to 70 percent of the ground and water ambulance base rate amount and 50 percent of the air base rate amount. This modifier is applied based on the location from which the beneficiary is transported. 2. Rural Services The Committee agrees that an adjustment needs to be made to the rates paid for ambulance services provided in rural areas with low population density to recognize the higher costs per transport incurred by those suppliers. However, the Committee was informed that none ofthe options for recognizing geographic disparities other than MSA/non-MSA could be easily adopted and implemented by HeF A. In order to compensate for these costs, while recognizing the inadequacy of the methodology to properly address this problem, the Committee agrees that an additional adjustment will be made to the mileage rate if the location from which the beneficiary is transported is located in a rural area. The definition of a rural area is an area outside a Metropolitan Statistical Area (MSA) or a New England County Metropolitan Area (NECMA) or an area within an MSA identified as rural, using the Goldsmith modification. The calculation of this modifier is discussed below as part of the Fee Schedule. The Committee recognizes that this rural adjustment is a temporary proxy to recognize the higher costs of low-volume suppliers. It believes that, as soon as possible, a methodology needs to be developed that more appropriately addresses payment to low-volume rural ambulance suppliers. III. Medicare Ambulance Fee Schedule The ambulance fee schedule payment equals a base rate payment plus a payment for mileage. Ground and water ambulance services are paid using the same fee schedule. The Committee agrees that HCF A will set the amount of the base year (CY 1998) expenditures to be used for determining the payment levels for air ambulance services between $134,827,792 and $158,000,000. A. Base Rate The relative value unit (RVU) scale for the ambulance fee schedule is as follows: Ground or Water Service Level BLS BLS-Emergency ALSI ALS I-Emergency ALS2 SCT PI RVU 1.00 1.60 ALSI 1.90 2.75 3.25 1.75* Air Service Level FW and RW HCFA sets the RVUs based on the amount of base year expenditures. Loaded Mileage Ground or water Air (FW) Air (R W) $5.00 per statute mile $6.00 per statute mile $16.00 per statute mile * The base rate RVU for PI services is equal to the difference between the RVUs for ALS2 and BLS. B. Geographic Modifier Ground or Water: The practice expense (PE) portion of the physician GPCI applied to 70 percent of the base rate. Air: The PE portion of the GPCI applied to 50 percent of the base rate. C. Rural Modifier Ground or Water: A 50 percent add-on to the mileage rate (that is, a rate of$7.50 per mile) for each of the first 17 miles. The regular mileage allowance will apply for every mile over 17 miles. Air: The modifier is applied to the total payment for the services (that is, the sum of the base rate adjusted by the geographic modifier and the mileage). The value of the modifier is dependent on the air base year expenditures as follows: Base Year Expenditures Less than $145 million $145 million to less than $150 million $150 million or greater Modifier Percentage 25 35 50 IV. Implementation Methodology The ambulance fee schedule will be phased in over a 4-year period. The payment during the transition period will be based on a combination of the fee schedule payment and the amount the carrier would have paid absent the fee schedule. Payment in the first year of the transition will be the sum of20 percent of the fee schedule and 80 percent of the former payment methodology. The fee schedule percentage will increase by 30 percentage points for each of the second and third years, with the former payment percentage decreasing by the same percentage points during that time. The fee schedule becomes fully implemented at 100 percent in the fourth year. Implementing payment under the fee schedule at only 20 percent in the first year is intended to give ambulance providers a period oftime to adjust to the new payment amounts, which for some providers may be substantially lower than current payments. Thus, the transition is as follows: Fee Schedule Percentage Former Payment Percentage Year One 20 50 80 100 80 50 20 o Year Two Year Three Year Four V. Mechanisms to Control Increases in Expenditures for Ambulance Services Unlike other Medicare services that have become subject to a fee schedule, the ambulance industry cannot arbitrarily increase the number of services it furnishes in order to circumvent lower payments per service. Therefore, the Committee has not suggested mechanisms to control expenditures. VI. Adjustments to Account for Inflation and Other Factors The Committee acknowledges that the statutory provisions regarding annual updates, as stated in section 1834(l)(3)(B) of the Social Security Act, will be the adjustments to account for inflation. That section provides for an annual update based on the percentage increase in the consumer price index for all urban consumers (CPI-U; U.S. city average) for the 12-month period ending with June of the year previous to its application to the fee schedule. For 2001 and 2002, the increase in the CPI-U is reduced by 1.0 percentage points for each year. Other than the Geographic and Rural adjustments, the Committee agrees not to make any other adjustments to the fee schedule. E) Return to the previous page Last Updated February 17, 2000 HCFA Beneficiaries Plans & Providers States Researchers Students Medicare Medicaid CHIP Customer Service FAQs Search ..- . .-.......-. ... Ito8lth CaN! FlllilllClng Mnllnlstrll60n !k~~~ Deportment oJ Health i~~71l:l:t,' & Human Ser....icell J;oi:}'.;'"ft~, HCFA Beneficiaries Plans & Providers States Researchers Students Medicare Medicaid CHIP Custom,er Service FAQs Search Convening Report for Negotiated Rulemaking for an Ambulance Fee Schedule FEASIBILITY OF REACHING CONSENSUS ON AN AMBULANCE FEE SCHEDULE In our telephone interviews with potential participants, we explained the regulatory negotiation process and the role of the FMCS as facilitator/mediator. In addition to a telephone interview, the American Ambulance Association submitted written comments, a copy is attached. A few of the parties were familiar with the negotiated rulemaking process or had participated in other "reg-negs". Almost all of the parties expressed a strong desire to participate in the negotiations and believed that a consensus on an ambulance fee schedule was possible. While all participants believed consensus was possible many challenges were also identified. Many parties identified the short time frame for the "reg-neg" committee (hereafter "the committee") to complete its work as a challenge, despite the proposed schedule of up to eight meetings by June 1, 1999. One party suggested that HCFA consider approaching Congress to allow it to exceed the January 1,2000, deadline for a promulgation of a final rule to allow the negotiated rulemaking process adequate time. They believed this was not unreasonable in view of a possible delay in implementing the fee schedule because of Y2K concerns. The facilitators share this concern also, and recommend that the time frame and a possible extension be a topic of discussion at one of the early meetings. The fixed pool of money available for ambulance fees was also identified as a challenge for the committee. To the extent a reallocation of fees under a new fee schedule creates winners and losers consensus may be more difficult. Many believe that the problem of a limited pool of money would be further acerbated by the entry of municipal governments and volunteer organizations into the Part B ambulance fee pool. Many, but not all, viewed this as making a limited pie even smaller. On a positive note, many parties expressed the view that if the slices of the pie were divided fairly, consensus is possible. Obviously, the difficulty will be reaching a consensus on what is "fair". RECOMMENDED PARTICIPANTS As previously mentioned, all the parties (with one or two exceptions, discussed below) we interviewed were enthusiastic about participating in the negotiated rulemaking. A few expressed the desire to enlist the support of their Congressional representatives in securing a seat at the negotiation table, they were referred to deal directly with the agency. Below is our recommendation for committee membership. One of the concerns of the facilitators is that the committee be balanced in membership to represent all of the interests affected by the rule while not creating a committee that is too big. In making our recommendations regarding membership we are guided by whether the organization has an interest that is affected by the proposed rule and whether the named party can adequately represent the interest of that group. In this regard, we interviewed four individuals who expressed an interest in participating and who were quite knowledgeable, but did not represent an interest group, per se. Our recommendation is to not include those individuals (discussed in greater detail below). This was a difficult call for the convenors given the fact that these individuals by virtue of their positions would be capable of representing some aspects of the rural interests. There are a number of options for HCF A to consider. To the extent they are affiliated with one of the other recommended participants, they may participate through those organizations. HCF A could invite these individuals to form a coalition to represent the interests of rural providers. The National Association of Counties was suggested as another potential participant, they should be contacted to see if they are interested in or capable of representing the interests of rural counties. Based on our interviews of the parties below we have identified the following interest groups. They fall in to the following categories: ambulance service providers; health care providers; first-end responders; emergency room personnel; emergency medical system authorities; labor unions; and an "other" category. Within these broad categories of potential parties, several interests have been identified. They are the needs of rural versus urban providers of ambulance services; the unique needs of air service providers; state and local needs. AMBULANCE SERVICE PROVIDERS AIR EV AC SERVICES, INe. Air Evac Services is a for profit provider of air patient transport services (helicopter and fixed wing) and conducts approximately 8,000 transports per year. It previously was hospital based and made the transition to its present form in December 1997. Air Evac Services believes that as funding for hospital ambulance service moves from Part A to Part B, more hospitals will shift to independent providers of air ambulance service as a cost saving measure. The interest represented by Air Evac Services is that of the for profit non- hospital based air transportation industry. We recommend the inclusion of this group. AMERICAN AMBULANCE ASSOCIATION AAA is an association representing over 750 ambulance companies throughout the country; its members include a broad spectrum of ambulance service providers. The majority of AAA members are privately owned ambulance companies. We recommend the inclusion of this group. ASSOCIATION OF AIR MEDICAL SERVICES AAMS is an association which represents air ambulance service and critical ground providers. They would represent the unique needs of air transportation which may be required due to the different types of mission profiles which exist across the country. AAMS has stated that if coverage is an issue for the "reg-neg", it would like an opportunity to submit a written statement of "coverage" issues. We recommend the inclusion of this group. HEAL TH CARE PROVIDERS AMERICAN HEALTH CARE ASSOCIATION AHCA represents skilled nursing facilities, which provide services under both Part A and B. In January, 2000, skilled nursing facilities will begin to bill Medicare for ambulance services as if they were providers of ambulance services under Part B. In essence, they will become the provider and biller of such services, where they previously did not have to worry about ambulance fees or costs. We recommend the inclusion of this group. AMERICAN HOSPITAL ASSOCIATION Currently a significant number of hospitals provide hospital based ambulance service. Like the AHCA, hospitals will begin billing for ambulance services under Part B where they previously did not do so. This will represent a major change in billing for hospitals. With respect to the issue of coverage, AHA has indicated that it has previously submitted to RCF A a letter dated on about August 17, 1997, listing the coverage issues it belives still need to be resolved. We recommend the inclusion of this group. GERALD FIKES Mr. Fikes is the Director of Emergency Services for Mercy Medical Center in Redding, California. He is interested in participating in the rulemaking in his personal capacity and not as a representative of Mercy Medical Center. In his personal capacity, Mr. Fikes is active with a number of small rural ambulance services in Northern California. The interest he seeks to represent is that of small rural providers, many who, he states, could be severely adversely affected and possibly put out of business by fee schedules that do not cover their costs. Due to the fact that Mr. Fikes does not represent an interest group per se we do not recommend his participation. FIRST END RESPONDERS EMS CONSULTANTS This is a Medicare consultant in the southeastern US. His clients mostly include small governmental entities (counties) that depend on Medicare reimbursements. According to the owner of EMS Consultants, there is no formal national organization that represents the interests of small rural government ambulance service providers and they are not adequately represented by other existing organizations. We believe the needs of rural governments could be represented by the National Volunteer Fire Council, and National Association of State EMS Directors. Of particular concern is the fact that this consultant does not represent a formal organization of rural county providers. Therefore, we do not recommend this group's inclusion. INTERNATIONAL ASSOCIATION OF FIRE CHIEFS IAFC represents local fire chiefs and would represent the interest of ambulance services which are provided by fire services. Some parties questioned whether the fire chiefs and the firefighters union actually represented different interests with regard to ambulance fee schedules. We recommend exploring with these two groups the possibility of forming a coalition for purposes of participation in the negotiated rule making. NATIONAL VOLUNTEER FIRE COUNCIL According to NVFC nearly 70% of the nation's fire service is provided by volunteer organizations. Even though this service is a volunteer service, funding is a critical issue. Most volunteer services are currently not billing Medicare. Their interests are the conditions under which volunteer services would bill Medicare for ambulance service and what impact would the entrance of volunteer services will have on the overall Medicare system. We recommend the inclusion of this group. EMERGENCY PERSONNEL AMERICAN COLLEGE OF EMERGENCY PHYSICIANS This group represents the interests of physicians who are concerned with the well being of patients. They have expressed the interest that fees not create barriers to emergency medical treatment and the payments not be based on final diagnosis which would constitute the practice of medicine. We recommend the inclusion of this group. NA TIONAL ASSOCIATION OF EMERGENCY MEDICAL SERVICE PHYSICIANS This organization is a professional society of out-of-hospital emergency service physicians; many of its members are also medical directors. They oversee emergency services in their state; for example, they approve protocols. Their interest is ensuring the medical well being of the patient, and the integrity of the emergency medical system. We recommend the inclusion of this group. EMERGENCY MEDICAL SYSTEM AUTHORITIES NATIONAL ASSOCIATION OF STATE EMS DIRECTORS This organization represents state EMS Directors. Their interests would be in ensuring that reimbursements are consistent with state standards and ensure compatibility with state laws and licensing rules. We recommend the inclusion ofthis group. NORTH CAROLINA ASSOCIATION OF EMS ADMINISTRATORS This is a association of county EMS administrators, representing 68 out of 100 counties in North Carolina (by state law counties are responsible for providing ambulance service). They would represent the interests of rural counties who would bill under Part B. We believe the interests of rural governments could possibly be represented by the National Association of State Emergency Medical Services Directors. The interests of the states is an important one, however, the committee should focus on the interests of all 50 states; this group's expertise is mostly with the state of North Carolina. Therefore, we do not recommend this group's inclusion. LABOR UNIONS INTERNATIONAL ASSOCIATION OF FIREFIGHTERS This is the union that represents firefighters. Their interest is in representing the personnel who directly provides first end response. They have expressed an interest in the "prudent person" standard, when responding to emergency calls. See discussion regarding the International Association of Fire Chiefs. We recommend exploring with these two groups the possibility of forming a coalition for purposes of participation in the negotiated rulemaking. OTHER FLORIDA REGIONAL EMERGENCY MEDICAL SERVICES This is a consulting firm whose clients are mostly 911 providers in Florida, Texas, and Georgia. They manage a number of rural hospital based ambulance systems and do their accounting and billing. They believe that they can represent the interests of rural ambulance providers better than the AHA who as a lobbyist for hospitals in general has not yet developed expertise in the issues associated with billing for ambulance services under Part B. Again, this consulting firm does not represent a formal organization. Therefore, we do not recommend the inclusion of this company NATIONAL HERITAGE INSURANCE COMPANY This is an insurance carrier for HCF A. This organization is primarily concerned with issues of coverage. To the extent the insurance carriers would administer the fee schedule, their institutional expertise may be an asset to the committee. It is our understanding that this group has indicated to HCF A that it may not desire to participate in the reg neg. We recommend that this group be invited to participate on an as needed basis to provide technical advise, if the committee agrees to do so. NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION, US DEPT. OF TRANSPORTATION In our interviews, NHTSA was not sure they would participate. OTHER POTENTIAL PARTICIPANTS In the course of our interviews, a number of other organizations were identified as potential participants. They are listed below. We have not interviewed any of these groups. Obviously, we cannot include all of them on the committee. The area of greatest concern is that of rural providers. While many of the recommended providers include rural providers in their membership, there is no one voice that appear to speak solely for rural providers. We have previously discussed the possibility of including the Association of County Governments. One group of potential participants that stood out in its absence is that of consumers of ambulance services. For this reason, we suggest that serious consideration be given to including a representative of the actual consumers. Additionally, serious consideration should be given to including other emergency personnel such as National Association ofEMTs and the Emergency Nurses Association since emergency physicians have been included. Also, the participation of the two other unions (AFSCME and SEIU) should be explored. Consideration should also be extended to the Association of Health Plans, representing the managed care industry. AMBULANCE SERVICE PROVIDERS Dialysis Services - also have ambulance services HEALTH CARE PROVIDERS Association of Health Plans (representing the managed care industry) EMERGENCY PERSONNEL Emergency Nurses Association National Association ofEMTs National Registry ofEMTs American Academy of Pediatrics, Emergency Medical Division American College of Surgeons, Committee on Trauma and Pre-Hospital Service EMERGENCY MEDICAL SYSTEM AUTHORITIES National Association of Public Utility Models LABOR UNIONS Service Employees International Union American Federation of State, County and Municipal Employees "OTHER" MEDAPHIS - billing agent CONSUMERS American Heart Association American Association of Retired Persons National Rural Health Association American Trauma Society GOVERNMENT Association of County Governments/ National Association of County Governments National League of Cities ISSUES FOR NEGOTIATION At the first meeting we will need to spend considerable time formulating and reaching consensus on the issues to be addressed by the negotiated rulemaking. Most of the parties we interviewed had a good grasp of the Part B billing process and the issues that needed to be addressed there. However, there appeared to be a great deal of confusion over the inclusion of "coverage" issues. The participants were aware that HCF A had issued a NPRM on coverage of ambulance services in 1997. The difficulty seemed to come with separating out what should be part of the August, 1997 NPRM and not part of the current negotiated rulemaking. In fact, some parties did not believe the coverage issue could so easily be separated out and would need to be addressed in this rulemaking before a fee schedule could be developed. It is also possible that the parties are using the term "coverage" to address what may be confusion over definitions. For example, a number of parties cited the need for clearer defmitions of "bed ridden, critical care transport, and medical necessity". AAA in its written submission to the convenors stated that it did not believe that the committee should be concerned with coverage of services not now covered by Medicare but advocated including definitions. To the extent HCFA believes that "coverage" is not appropriately part of these negotiation and that it has the authority to determine what will be subject to negotiated rulemaking, it should be prepared to spend time at the first meeting educating committee members of its position. Other issues identified include the following: 1. How to determine the appropriate level of care and who should determine it. 2. What coding system should be used. 3. Under what circumstances should "add on" payments or adjustments be allowed to address different type of services or geographic differences. 4. Under what circumstances should Medicare pay for advanced versus basic life support, and what about local rules that mandate that all ambulances be advance life support. 5. Should fees be available for non-transport when responding and awaiting transport. 6. Should there be a differential for volunteers versus paid staff. Should there be a differential when rendezvous' take place between BLS and ALS. INFORMATION NEEDS Information will probably playa critical role in this negotiated rulemaking. In this regard, the AAA is soliciting its members and other potential committee members to develop information it believes will be helpful to the negotiation process. Some of the other information needs identified by the parties are as follows: 1. What is the status of current billing: are there breakdowns of runs available for each state? 2. What is the data on trips (rural and urban), e.g., numbers, types, costs of air and ground services? 3. What are the allowable charges in each region? 4. What are the demographics across the country upon which services are provided? 5. What are the current prevailing charges in the private sector? 6. What is the amount of money that will be paid in 1999, (in order to determine the pool of money that would be available in 2000)? 7. What data will be used to support estimates of what is "budget neutral"? 8. How many new providers are coming into the system? Is there a reliable estimate? 9. What will be the added costs of hospitals billing for ambulance services under Part B? SCHEDULES All participants have indicated that they are available to attend the first meeting on October 20-22, 1998. The first meeting should cover the following: o Orientation by the facilitator/mediators o Adoption of group protocols, including a definition of consensus o Agreement on meeting schedule o Discussion and agreement on statement of issues to be addressed in the rulemaking o Agenda for the next meeting o Time permitting, further discussion PROTOCOLS The participants will be provided with examples of group protocols and a recommended group protocol which will outline in more detail items they may adopt as part of their operating procedures. Consensus decision making will be one of the protocols under which the committee must operate. In a consensus dialogue, all parties must be willing to live with any agreement. The committee should at this juncture also discuss what may happen if consensus is not reached. E) Return to Ambulance Fee Schedule Last Updated March 18, 1999 HCFA Beneficiaries Plans & Providers States Researchers Students MecUcare MecUcald CHIP Custom.er Service FAQs Search . ~~>~~':2 <l; . .~r..fl?"i..~ De~l"tment oJ Health '~~1-.c1 'i~:, ~ . ,',', & uman Senric:e31 "~1.-.tj:J ATTACHMENT 3 I Item # /3 SEMINOLE COUNTY GOVERNMENT AGENDA MEMORANDUM SUBJECT: . Ambulance Transport Services Fees DEPARTMENT: Fiscal Services DIVISION: o.J!cONTACT: Cindy Hall EXT. 7172 Agenda Date April 25. 2000 Regular 0 Consent ~ Work Session 0 Briefing 0 Public Hearing - 1 :30 0 Public Hearing - 7:00 0 MOTION/RECOMMENDA TION: Approval and authorization for the Chairman to execute a resolution allowing for charges for emergency and non-emergency transport services to be automatically adjusted to coincide with the maximum Medicare approved rate(s). BACKGROUND: Medicare regularly reviews and adjusts the maximum allowable amount for reimbursement of fees for emergency and non-emergency transport services. In order to remain current, staff requests Board adoption of the attached resolution allowing charges for ambulance transport services to be automatically adjusted to coincide with the maximum Medicare approved rate(s). Reviewed by: Co Atty: DFS: Other: ~~~:~ C:\TEMP\2OOOtransportfeeresolutionagenda.doc File No.t 1=5 A o~ RESOLUTION NO. 200o-R- THE FOLLOWING RESOLUTION WAS ADOPTED AT THE REGULAR MEETING OF THE BOARD OF COUNTY COMMISSIONERS OF SEMINOLE COUNTY, FLORIDA, ON THE 25TH DAY OF APRIL, A.D., 2000. WHEREAS, the Board of County Commissioners of Seminole County has the authority to issue Certificates of Public Convenience and Necessity for the provision of emergency and non- . emergency ambulance transport services for the geographical boundaries of Seminole County, and WHEREAS, the Board of County Commissioners has the authority to regulate fees for services within the geographical boundaries of unincorporated Seminole County; and WHEREAS, Medicare regularly reviews and adjusts the maximum allowable amount for reimbursement of fees for emergency and non-emergency ambulance transport services; and WHEREAS, the Board of County Commissioners has determined that the maximum allowable charge for emergency and non-emergency ambulance transport services should not exceed the maximum allowable charge, as determined by Medicare, and NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Seminole County, Florida, that the fees and charges for ambulance transport and loaded mileage shall not exceed the maximum allowable charge, as determined by Medicare,.and henceforth charges for these services shall automatically be adjusted to coincide with the Medicare approved rate(s). BE IT FURTHER RESOLVED that other resolutions or parts of resolutions in conflict herewith by establishing fees inconsistent with those established herein are hereby repealed. All fees established herein shall go into effect May 1, 2000, with a sunset of May 1, 2003. ADOPTED this 25th day of April, 2000 ATTEST: BOARD OF COUNTY COMMISSIONERS SEMINOLE COUNTY, FLORIDA MARY ANNE MORSE, Clerk to the Board of County Commissioners of Seminole County, Florida. CARLTON D. HENLEY, Chairperson RESOLUTION NO. 97 R 14700-R- THE FOLLOWING RESOLUTION WAS ADOPTED AT THE REGULAR MEETING OF THE BOARD OF COUNTY COMMISSIONERS OF SEMINOLE COUNTY, FLORID~ ON THE 24:rH DAY OF JUNE, A.D., 1997. THE 25TH DAY OF APRIL, A.D., 2000. \^JHEREAS, on June 10,1997, the Board of County Commissioners of Seminole County instructed the Department of Public Safety, EMS/Fire/Rescue Division, to begin providing ambulance tr:::msport services in unincorpoF3ted Seminole Count)' and the municipal areas provided service by the private provider; WHEREAS, the current contF3ctBoard of County Commissioners of Seminole County has the authority to issue Certificates of Public Convenience and Necessity for the provision of ememency and non-emeraency ambulance transport service is due to expire effective midnight July 15, 19Q7;services for the aeoaraphical boundaries of Seminole County. and WHEREAS, the Board of County Commissioners has the authority to reaulate fees for services within the aeoaraphical boundaries of unincorporated Seminole County: and EMS/Fife/Rescue Di'.'ision '.vill begin providing ambulance transport services in unincorporated Seminole County and the mLJnicip31 areas pre'{iously provided service by the pnvate providers, as r~uestecJ, effective concurrently with the expiF3tion of the private provider's contract; WHEREAS. Medicare reaular1y reviews and adiusts the maximum allowable amount for reimbursement of fees for ememency and non-emeraency ambulance transport services: and WHEREAS, the Board of County Commissioners has determined that thefollollJing foes shall be adoptecJ to cover all or a pOrtion of the costs of administF3tion and opeF3tion by the County; and maximum allowable chame for ememencv and non-emeraency ambulance transport services should not exceed the maximum allowable chame. as determined by Medicare. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Seminole County, Florida-, that thefollowing fees and chargesarea establishod: 1.$280.00 per ambLJlanoo transport. 2:- A fee of $6.00 per loaded mile \NiII be added to for ambulance transport and loaded mileaae fef patients transportecJ to facilitieslocated outside of Seminole and Orange Counties shall not exceed the maximum allowable chame. as determined bY Medicare. and henceforth charaes for these services shall automatically be adiusted to coincide with the Medicare approved rate(s). BE IT FURTHER RESOLVED that other resolutions or parts of resolutions in conflict herewith by establishing fees inconsistent with those established herein are hereby repealed. All fees established herein shall go into effect midnight JUhl 1 i. 1997.Mav 1. 2000. ADOPTED THIS 24~ DAY OF JUNE 1997.this 25th day of April. 2000 Tim Lallathin From: Sent: To: masbury@co.seminole.f1.us Wednesday, April 26, 2000 1 :06 PM firechief@casselberry.org; gaston@altamontefire.org; cchapman@ci.longwood.f1.us; lallathi@digital.net; oviedofd@atlantic.net; tschenk@co.seminole.f1.us; shanley@orlandosanfordairport.com; chaun@lakemaryfl.com; fireguy889@aol.com Ambulance Transport Resolution Subject: ~ ~ ~ 2000lransportfeeresolu 2000lransportresol ulion lionagen... .doc Chiefs, Ken Roberts has asked that I provide you with the attached agenda item and resolution regarding charges for transport to coincide with the Medicare allowable rate for Seminole County. For your information, the current rate for Region 2 (which is what we are) is $304.51 for transport and $4.81 per mile. This item was approved by the BCC yesterday, 4/25/00. Should you have any questions, please let us know. Thank you. (See attached file: 2000transportfeeresolutionagenda.doc) (See attached file: 2000transportresolution.doc) 1