05-B Recognizing ALS-Level - Laserfiche WebLink

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Page, Woltberg & Wirth, LLC Page 2 of 4 beneficiary is loaded onto the ambulance, NOT by the location of your ambulance service's station or the jurisdiction of the Medicue carrier. Once you determine your GPCI, your base rate under the new fee schedule is calculated by taking 70% of the appropria[e unadjus[ed base ra[e (from one the 7 levels of service above), and multiplying that by the GPCI for your area. Then, add in the remaining 30% of the unadjusted base rate to determine the base rate for your service. Remember, as discussed below, between April I, 2002 and December 31, 2005, your actual payment amount will be determined by "blending" your fee schedule paymen[ wi[h your existing paymen[ amount. The fee schedule payment amount will be phased in in percentages over Ihis time period accotding to the phase-in schedule below. As of Ianuary 1, 2006, it's 100% fee schedule, ready or not! An important note: if your actual charge, that is the amoun[ you actually bill Medicare for the service, is LESS than the fee schedule payment, Medicare will pay the lesser of your actual chazge or the fee schedule amount. Providers should review their charge sdvc[ures to ensure they aze billing at appropriate levels to ensure they receive the revenue to which they are entitled. PHASE IN PERIOD EXTENDED TO 5 YEARS: There is now a FIVE YEAR phase-in period instead of a four-year phase in period as originally proposed. During the phase-in period, your paymen[s will be determined by blending a portion of your existing payment rate with a portion of the fee schedule payment rate as calculated above. The phase-in schedule is as follows: I YEAR EXISTING PAYMENT FEE SCHEDUI.E PAYMENT % 2002--80%--20% (Note: this blend is in effect from April 1, 2002 - December 31, 2002) 2003--60%-40°h 2004--40°k--60% 2005--20%--80% 2006--100°lo fee schedule amount MANDATORY ASSIGNMENT: Assignment is mandatory under the new fee schedule, but will NOT be phased in. That means that EFFECTIVE APRIL 1, 2002 you must accept the Medicare amount as paymen[ in full and may only bill the patient for unmet copayment and deductible amounts, NOT your full chazges. Mandatory assignment will NOT apply [o non-covered services. So, for example, you would not be precluded from billing a Medicaze beneFiciary for non-covered mileage if you hansport them to a facility that is not the closest appropriate faciliTy under Medicare guidelines. You can also bill beneficiaries directly for your full chazges for other non-covered services like wheelchair vans or ambulance transports ro docror's offices. In some instances, an advance bene£ciary notice (ABN) may be desirable, bu[ the ABN rules are not changed at all by the fee schedule final rule. MEDICAL NECESSITY: for payment [o be made, the pa[ienPs condition must meet medical necessity requirements for ambulance transport a[ the level of service billed. For non-emergency hansports, the patient must be EITHER (1) bed confined (under the current definition); OR (2) have a medical condition, "regazdless of bed confinement," such that "transportation by ambulance is medically required." Therefore, bed confinemen[ is not the SOLE determinan[ of inedical necessity for non-emergency transports. MANDATORY ALS PROVIDERS: In some azeas, local law may require that the ambulance service provide all services at the ALS leveL Medicare has recognized these local ordinances as binding and in the pas[ has paid such ambulance services at the ALS rate even when the patient required only BLS. Once the fee schedule is fully implemented, payment at the ALS rate can be made only when the 6eneficiary's condition requires an ALS intervention (or an ALS assessment, as discussed below). However, Medicaze will phase in this policy by blending the ALS-level paymen[s with the new fee schedule BLS rates underthe blending percentages discussed above. PHYSiCIAN CERTIFICATION STATEMENTS: Medicare has changed the rules for physician certification statements (PCS). Effective April 1, ambulance services must have a PCS form signed by the attending physician BEFORE rendering a http://www.pwwemslaw.corrJPWWFeeSchedAnalysis 2/28/2002