Part 2 September 12, 2017 - PWW Media Inc. · 2019-12-17 · Part 2 September 12, 2017 Presented by...

Part 2

September 12, 2017

Presented by -

Amanda Stark, Esq., CAC, CACO, CAPO and

Dan Pedersen, Esq., CAC, CACO, CAPO

www.pwwemslaw.com

5010 E. Trindle Road, Suite 202 Mechanicsburg, PA 17050

717-691-0100 717-691-1226 (fax)

[email protected] [email protected]

© COPYRIGHT 2017, PWW MEDIA, INC. ALL RIGHTS RESERVED. REPRODUCTION BY ANY MEANS EXPRESSLY PROHIBITED WITHOUT THE WRITTEN

CONSENT OF PWW MEDIA, INC.

mailto:[email protected]


2017

Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050

www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226

Amanda Stark

Attorney

[email protected]

Amanda Stark is a senior attorney at Page, Wolfberg & Wirth, LLC. Her work for PWW includes representing private, public and nonprofit EMS agencies, billing companies and others that serve the nation’s ambulance industry on Reimbursement and Compliance issues Amanda is a speaker on all things compliance as well as a variety of other topics at PWW’s signature abc360 conference series and other seminars and webinars. Amanda co-developed and is now the main instructor for NAAC’s Certified Ambulance Compliance Officer Course. She is also one of the primary authors of the Ambulance Compliance Program Toolkit and helps to develop many of the firm’s other articles, books, presentations and programs that are widely used by EMS providers throughout the United States. Amanda is passionate about policies and enjoys helping clients implement and improve their compliance programs. Prior to joining PWW, Amanda was the in house counsel and Compliance Officer for a large ambulance service where she created, implemented and oversaw the company’s first formal compliance program. Amanda has significant experience advising both public and private ambulance services and third party billing agencies concerning reimbursement and compliance issues. She also has experience reviewing claims and advising entities regarding best practices for reimbursement compliance. Amanda is familiar with the employment and contractual issues affecting the ambulance industry and is able assist ambulance services as they navigate those matters. Amanda is admitted to practice law in California and holds a certification in healthcare compliance from the Compliance Certification Board. Amanda is a graduate of the University of Illinois College of Law and Millikin University where she majored in Marketing. When she’s not writing policies, Amanda enjoys spending time with her husband and children and cheering for the Illini. She has also volunteered extensively with various organizations including her children’s schools and the Junior League.

2017

Page, Wolfberg & Wirth, LLC ● 5010 E. Trindle Rd., Ste. 202 ● Mechanicsburg, PA 17050

www.pwwemslaw.com ● 717-691-0100 ● Fax – 717-691-1226

Daniel J. Pedersen Attorney [email protected] Daniel Pedersen is a Senior Attorney with the nationally recognized law firm of Page, Wolfberg & Wirth, LLC. The firm represents ambulance services, municipalities, fire departments, hospitals, and other organizations in a wide range of medical transportation issues.

Daniel joined PWW in 2004, after spending several years at a health care firm in Harrisburg, PA. At Page, Wolfberg & Wirth, Daniel concentrates his legal practice in the areas of compliance, Medicare reimbursement, HIPAA, and federal and state regulatory issues that affect ambulance services, including the false claims act and anti-kickback statute. Daniel spends much of his time performing compliance and claim reviews, including on-site visits and training sessions, and handling Medicare appeals on behalf of clients around the country. Daniel is admitted to practice law in Pennsylvania.

A 1998 Graduate of Franklin & Marshall College in Lancaster, PA, Daniel majored in Biology and English before attending law school. While at Franklin & Marshall, Daniel was involved with the yearbook, Pep band, golf team, Biology club, and served as an Orientation Advisor. He earned his J.D. from Pace University School of Law in White Plains, NY in 2002, and spent his third year of studies as a visiting student at Widener School of Law in Harrisburg, PA. While at both Widener and Pace, Daniel was a research assistant for law professors. While on sabbatical from law school in 1999, Daniel worked as a Quality Assurance Analyst for Wyeth-Ayerst Laboratories in Marietta PA. Daniel resides in Hummelstown, PA with his wife and three children. As a family, they enjoy such activities as reading, swimming, and skiing, as well as playing or coaching golf, tennis, lacrosse, volleyball, and hockey. The family also enjoys vacationing in Myrtle Beach and Disney World.

http://www.pwwemslaw.com/


Attendee License Agreement

Once you (Licensee) register for and/or attend any PWW Media, Inc. (Licensor, hereinafter “PWW Media) Event (including but not limited to abc360, The PWW Executive Institute and any PWW Media webinars), you agree to be bound by the terms of this License. This License covers

any information, materials or training that PWW Media provides, whether written, electronic or oral, and whether accessed directly or indirectly through attendance at a conference or access via the Internet (Licensed Materials). Licensee is permitted to print one copy of the Licensed Materials and/or keep one electronic copy as backup. Unless Licensee obtains Licensor’s prior written permission, Licensee may not:

Permit anyone but you to use a password or share a link to access Licensed Materials; Provide or forward any Licensed Materials in whole or in part to anyone else; Copy, duplicate or in any manner reproduce or rebroadcast any Licensed Material or use it to train anyone; Copy, modify, sell, distribute, rent, lease, loan or sublicense any Licensed Materials; Record any PWW Media Event (including presentations, questions and answers, individual consultations, etc.)

by audio, video, electronic or any other means; Use any Licensed Materials for any commercial purposes whatsoever.

All Licensed Materials are the Copyright of PWW Media, Inc. unless otherwise noted. All rights are reserved. No claim is made with regard to any governmental works or the works of any third parties used by permission. No part of this material may be duplicated, reproduced or distributed by any means.

Although Licensor attempts to provide accurate and complete information at all PWW Media Events, Licensor cannot guarantee it. Errors and omissions may occur. Therefore, Licensor presents all Licensed Materials “as is” and disclaims any warranties of any kind, express or implied. The Licensee acknowledges that the Licensed Materials are subject to change based on changes in law and agrees that Licensor is not responsible to update and/or supplement any of the Licensed Materials at any time. None of the Licensed Materials constitute legal advice or a definitive statement of the law and are not a substitute for individualized legal advice under an attorney-client relationship. Licensed Materials are for educational purposes only. Licensee is instructed to consult the official sources of materials from governmental agencies. Licensor is not responsible in any manner for any billing, compliance, reimbursement, legal or other decisions you make based in whole or in part upon any Licensed Materials, and Licensee hereby forever releases Licensor from any and all claims and liability of any kind related to Licensee’s use of any Licensed Materials. Any examples of documentation, coding scenarios and other teaching illustrations contained in any Licensed Materials are examples for illustrative purposes only. Licensor waives any and all claims, lawsuits or other actions against PWW Media, its principles and employees and all related entities. In all cases, you agree that the liability of PWW Media, Inc. is limited to any amounts paid by Licensee for registering for the PWW Media Event. This Agreement is governed by Pennsylvania law and any disputes hereunder shall be brought exclusively in the Commonwealth of Pennsylvania, County of Cumberland.

Licensee acknowledges that Licensor, nor anyone else on its behalf, made any representations or promises upon which you relied that are not in this Agreement. This Agreement constitutes the entire understanding between Licensee and Licensor and cannot be altered unless signed in writing by the principals of PWW Media, Inc. If any part of this Agreement is declared invalid, it will not invalidate the remaining parts. If Licensor does not enforce any part of this Agreement for any reason, Licensor does not waive its right to enforce it later.

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Copyright Statement

Disclaimer

Entire Agreement

© Copyright 2017, PWW Media, Inc.

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2017 SERIES- PART 2 OF 3

September 12, 2017 WARNING

The unauthorized reproduction or distribution of this copyrighted work is

illegal. Criminal copyright infringement, including infringement without monetary gain, is investigated by the FBI, and is punishable by up to 5 years in federal

prison and a fine of $250,000.

DISCLAIMERS

This information is presented for educational and general information purposes and should not be relied upon as legal advice or definitive statements of the law.

Consult applicable laws, regulations and policies for officials statements of the law.

No attorney-client relationship is formed by the use of these materials or the participation in this seminar. The

user of these materials bears the responsibility for compliance with all applicable laws and regulations.

AUDIO OR VIDEO RECORDING OF THIS

WEBINAR IS STRICTLY PROHIBITED

Thank You to Our Webinar Sponsor!

877-367-9111 officewww.emsbillingservices.com

Questions During the Webinar

• “Questions” feature on your GoToWebinar control panel

• Fax: 717-691-1226



Today’s Webinar:

To enter your CEUs log into your NAAC account at www.AmbulanceCompliance.com

Hershey, PA

Register at: pwwmedia.com

We’re covering items since the July 12, 2017 update

webinar

Final 2017 Update Webinar

• December 12, 2017 3-4pm EST

Today’s Webinar

• Response to Hurricanes Harvey and Irma• Reimbursement Updates• Compliance Updates

Hurricanes Harvey and Irma



Hurricane Harvey

Federal disasters declared in TX and LA, effective August 25, 2017

Hurricane Irma

• Public health emergency declared Puerto Rico U.S. Virgin Islands Florida Georgia South Carolina

All Hurricane Waivers

• For transports when Medicare payment is conditioned on the presence of a “formal waiver” Use “DR” condition code when billing on

a UB-04 Use the “CR” modifier when billing on a

CMS-1500

Non-Emergency Ambulance

• CMS lifted temporary enrollment moratoria on Part B non-emergency ambulance suppliers in Texas

• Applies to Medicare, Medicaid and the Children’s Health Insurance Program

• Effective on September 1, 2017

This Does NOT Change

• Statewide moratoria on all newly enrolling Part-B non-emergency ground ambulance suppliers in New Jersey and Pennsylvania that went into effect July 29, 2016



Screening in TX & LA

• CMS established a toll-free hotline for non-certified Part B providers and suppliers to initiate provisional temporary Medicare billing privileges

1-855-247-8428• As of Sept.11, 2017 can initiate

temporary Medicare billing privileges over-the-phone on the same day

Screening in TX & LA

• CMS waiving the following enrollment requirements: Payment of the application fee Finger print based criminal background

checks Site visits In-state licensure requirements

HIPAA Waiver in TX & LA

• These requirements are waived during the emergency declaration: Obtain a patient's agreement to speak with family

members or friends involved with care Honor a request to opt out of the facility

directory Distribute a notice of privacy practices. Patient’s right to request privacy restrictions Patient's right to request confidential

communications

EMTALA Sanctions Waived

• Florida only• EMTALA waivers in effect for 72 hours

after hospital initiates disaster protocol• CMS should be notified

Thank You to All Those Assisting Hurricane Victims



Reimbursement Updates

What’s Up With Obamacare Repeal?

First, the House Bill

• Repeal individual mandate• Medicaid funding to per capita allotment• State waivers to modify coverage for Pre-existing conditions Essential benefits Lifetime and annual dollar limits

Passed by House May 4, 2017

Then, the Senate Bill

• Mostly similar provisions to the House bill

• Would allow insurers to offer minimal coverage plans

• Block grant funding for the Medicaid

No Vote on BCRA

Then, the “Skinny Bill”

• Repeal individual mandate• Repeal employer mandate• Increases to amounts for

health savings accounts

Skinny Bill Fails on July 27, 2017 49-51



Bottom Line on ACA Repeal

• Senate ruled that Republicans have September 30, 2017 deadline to repeal and/or replace ACA with only 50 votes

• ACA may remain intact at least for this year

Ambulance Reimbursement Items

New Medicare Cards What’s Happening?

• Removing SSNs from Medicare cards• CMS will issues new cards with unique

Medicare Beneficiary Identifier (MBI) • Start mailing cards in April 2018• All Medicare cards replaced by April

2019

What You Need to Know

• New MBI lookup tool is coming• 21-month transition period where

providers can use either MBI or old Medicare HICN for billing purposes

• Systems will need to be able to accept new MBI by April 2018

Bonuses Will End on 12/31/17 Unless Congress Acts



Recent Ambulance MLN Matters

• Locality: Your MACs have discretion to define “locality” in their service area

• ALS Assessment: If an ALS assessment is performed, the services will be covered at the ALS emergency level if medically necessary and all other coverage requirements are met

Reminder About Revalidations

• CMS has assigned due dates

• If you haven’t yet been assigned it will show “TBD”

https://data.cms.gov/revalidation

Revalidation

• CMS will notify providers or suppliers by email within 2-3 months of their due date via email

Revalidations

• Providers or suppliers permitted to submit revalidations up to 6 months prior to their scheduled due date Check with your MAC, some have not

allowed revalidation to start that early

Revalidations

• Revalidations can be submitted either on paper or by using the online through PECOS

Prior Auth Update



Current Status

• Started in 3 states (PA, NJ, SC) December 2014

• Expanded in January 2016 to DE, DC, MD, VA, WV, NC

• Supposed to go nationwide in 2017, but still not happened

Delay in Nationwide Expansion

• CMS must issue report stating: Reduces expenditures AND Does not create access to care issues

Prior Auth Data From CY 2015

• Total spending on dialysis transports was down 22% from 2014

• Cost savings of $158 million• $137 million (86%) of those savings

came from the PA, NJ & SC, the states that participated in the demonstration project

Payment Data From CY 2016

• NJ saw increase in spending by 14.7% • PA saw 3.7% increase• Possible explanations: Novitas, may have been overly restrictive Suppliers now familiar with process

• Rates are still 75% below pre-2015 levels in these states

CY 2016 Data From Expansion States

• Reductions in Novitas States: Delaware 72.3% Maryland 68.0%

• Reductions in Palmetto States: North Carolina 27.8% Virginia 45.4% West Virginia 36.0%

The Take Home

• Significantly smaller reductions in Palmetto states

• Novitas is taking a more strict stance• The size of reduction appears to be

more dependent on the Medicare contractor than perceived level of overutilization



Compliance Updates

Work Plan Updated to Include Consolidated Billing

OIG Letters - Consolidated Billing

• OIG conducting national review of services possibly subject to SNFconsolidated billing

• DOS from July 2014 through June 2016

OIG Letters – Consolidated Billing

• OIG requests documentation on several round trip transports for SNFpatients

• Letter indicates that services were furnished to a beneficiary’s in Part A SNF stay, and “may be subject to consolidated billing”

OIG Letters – Consolidated Billing

• OIG asking:Whether transport was paid by Medicare Point of pickup and destinationWho requested the transport How the ambulance supplier determined

whether the patient was in the Part A stayWhat information supplier obtained to

determine claims payable under Part B



Tips for SNF Patients

• General rule -bill SNF during Part A stay• Know the exceptions Dialysis Excluded hospital outpatient services Emergency services

• Not necessarily 100 consecutive days• Ask SNF if patient is in Part A stay at

time of call intake

Recent Ambulance Cases

Oklahoma Case – Alleged Ambulance Kickbacks

General Allegations• The government alleges that the

ambulance contractor paid $20 million in “kickbacks” during contract Reimbursements for costs incurred by the

public agency Political contributions to local politicians at

request of the public agency’s president Money to the public agency around contract

renewal times Interest-free cash payments and loans Gifts to employees of the public agency

Defendants’ Response

• The defendants are aggressively contesting the allegations, claiming that the payments to the public agency were a legitimate “profit-cap” arrangement under which it would refund to the public agency profits exceeding a certain percentage of its gross revenues

Defendants’ Response

• There have been EMS systems that have gone into financial distress because of excessive profit-retention and insufficient system re-investment

• The theory behind the profit-sharing arrangement was the ensure ongoing system viability – a worthy goal



Kickback Risk Areas

• It is too soon to tell how this will come out – court motions are pending

• But remember, “financial support” from a private ambulance company to a municipal entity can attract AKS scrutiny

• These arrangements can certainly have legitimate purposes – but structure them carefully and only with advice from qualified legal counsel

Kickback Risk Areas

• Political contributions • Anything of value being transferred

back to a referral source – including a public entity awarding a 911 contract

• Personal relationship between EMS agency and referral source – apply conflict of interest principles

Florida Case –Alleged False Claims

The Relator

• Former paramedic for the ambulance service

• Terminated after 5 months Claims he was terminated in retaliation for

reporting the company to the government The company maintains that the termination

was for stealing company files and putting computer virus on system

General Allegations

• Whistleblower alleged that the defendant billed for non-emergency transports that did not meet medical necessity

• Whistleblower alleged that the defendant coached, induced and/or instructed employees and others to document in a way that made ambulance transports appear to be medically necessary

Relator’s Specific Allegations

• Alleges he was instructed to: Not to let the patient “walk around” Document that the patient was

transferred by “soft stretcher and slide sheet” or “by upper extremity lift with two crewmembers assisting”



One Example Cited by Relator Alleged Communications From Billing Office

• Relator said he was told to rewrite a report because “it wasn’t good enough for [the company] to be reimbursed”

• Relator claimed he was instructed to make his reports look just like his field training officer’s reports

Alleged Memorandum – Instructions on How to Write PCRs Be Careful About the Message

• Be truthful and honest in your documentation

• Give us enough information so we can determine whether or not to bill it to insurance

Documentation Training

• Do not suggest or require EMS practitioners to write PCRs with certain language, wording or phrases

• Documentation should always be based on the individual patient condition and treatment at the time of service

Documentation Training

• No “cut and paste” documentation or “template” narratives

• But, it is ok to use a consistent format, such as “SOAP” or “CHART” or “DRAATT” This helps ensure that all critical

elements are documented



We’re Pleased to Announce… About

• Nation’s first – and only – EMS certification focused exclusively on PCR documentation

• Designed specifically for EMS practitioners

When is Available?

• As a one-day pre-conference workshop before October 23, 2017 - Hershey March 27, 2018 – Las Vegas April 24, 2018 – Orlando June 5, 2018 – St. Louis

When is Available?

• You can also bring CADS on-site to your agency for your own, one-day, in-house documentation training for one flat fee and get all your people certified on the spot! Contact:

[email protected]

Georgia False Claims Settlement

Allegations

1. Non-emergency ambulance transports between hospitals that the ambulance provider improperly billed at emergency rate

2. Non-emergency ambulance transports for discharged hospital patients to their residences, SNFs, hospital-based diagnostic clinics, or dialysis centers that the provider improperly billed as emergency transports



Data Analytics Drove Action

• Relator’s original FCA complaint focused on transports between hospitals

• But, OIG independently identified the provider’s billing of emergency ambulance transportation to other destinations

A Note About FCA Settlements

• When ambulance companies choose to settle these False Claims Act cases, it is typically to avoid the expense and uncertainty of litigation

• Settlements are not an admission of guilt or wrongdoing, and none of these allegations have been proven in court

A Note About FCA Settlements

• However, we present these cases as cautionary tales about the kinds of allegations that have landed ambulance services in legal jeopardy in the hopes that all ambulance companies can benefit from the compliance lessons raised in these cases

Questions

• Use the “Questions” feature on your GoToWebinar control panel

• Fax: 717-691-1226

this

Certificate of Completionis presented as evidence of completion, by the CAC, CAPO, CACO whose signature and Certification Number appear below, of the NAAC®

approved Continuing Education course entitled

2016-2017 - PWW Media - abc360 Update Webinar Series - Part 2

CEU Code: 5VmVsdCEU Units: 1.00

I hereby certify that I have completed the continuing education training as represented on thiscertificate.

Signed: ____________________ NAAC® Certification Number: ____________________

Jason J. LeetProgram Coordinator

09/12/17

Date of Training

Certificate is invalid without the signature and certification number of the attendee.

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