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:
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~ 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/
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POSTED
ATTACHMENT 2
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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
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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
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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