Ready or not, reporting to the nearest tenth of a mile begins Jan. 1
On Nov. 2, the Centers for Medicare and Medicaid Services issued an advanced copy of its Final Rule affecting Medicare Part B payment policies, including the Ambulance Fee Schedule. CMS is accepting comments on the Final Rule until Jan. 3, but both the American Ambulance Association and the EMS law firm Page, Wolfberg & Wirth, LLC said it’s unlikely CMS will change course. Therefore, all ambulance services should be ready for the new fractional mileage reporting standards come Jan. 1.
Reporting mileage to the nearest tenth of a mile presents logistical challenges for many providers and will result in lower reimbursements. (The new requirements only apply to mileage totaling up to 100 miles). Exactly how much it will cost the industry in Medicare reimbursements is yet to be determined, but CMS estimates it will save $40 to $80 million a year.
“Implementation of the fractional mileage will be an enormous burden, both financially and operationally, on ambulance providers,” said Tristan North, vice president of government affairs for AAA, adding that the association is pressing the point with CMS that any savings achieved through the policy should be reinvested back into the Ambulance Fee Schedule through higher reimbursement rates.
“We believe there is still an opportunity to persuade CMS to put the money back into the Fee Schedule, so that’s where our efforts are focused on moving forward,” North said, adding that they wrote a comment letter to CMS on the Proposed Rule, along with hundreds of ambulance service providers and EMS organizations. In October, they met with the CMS officials in charge of the policy and officials from the General Counsel’s office at CMS to discuss their viewpoint that it is burdensome on ambulance service providers to comply with the policy change. At that time, they also argued that any savings from changes with the Fee Schedule need to be reinvested. “And now we’re taking our argument to Capitol Hill to help persuade CMS,” North said.
CMS asserts that Congress didn’t intend for the Fee Schedule to be budget neutral, North said. The AAA disagrees. “We think it will be helpful to have members of Congress weigh in on the fact that it was their intent for it to be budget neutral. Not to mention the fact that Congress has seen fit over the past couple of years to actually bolster Medicare reimbursement for ambulance services. To take money out of the system goes against Congressional intent to try to bolster ambulance service reimbursement, in light of the GAO’s cost study.”1
Practical implications
Recording and billing for mileage to the nearest tenth of a mile “is going to create logistical nightmares that I’m not sure Medicare has fully considered,” said Doug Wolfberg of Page, Wolfberg and Wirth. “For example, many vehicles don’t have tenths of miles on their odometers.”
Agencies are scrambling to figure out how to conveniently and accurately record fractional mileage. Some are having crews reset the ambulance’s trip odometer, which often record tenths, with each run. Global positioning systems devices or even MapQuest calculations, with printouts attached to billing documentation, are other potential solutions.
Figuring out how to accurately track mileage in tenths is only part of the challenge Many billing software systems don’t currently document mileage in tenths.
“We’re suggesting that everybody contact their billing software vendors and their ePCR software vendors to make sure that their systems can document mileage in tenths, because the whole issue about fractional versus rounded mileage becomes moot if your software is incapable of reporting the mileage in tenths,” Wolfberg said.
If a simple software update can’t accommodate the new rule, and purchasing a new billing software isn’t in the budget, services will have to round down to the nearest whole mile to be compliant.
Wolfberg also suggests that providers and billing companies contact their clearinghouses to make sure the clearinghouses can translate claims with tenths. Finally, ambulance services need to make sure their insurers are capable of accepting them.
Private insurance billings
It remains to be seen how private insurers will interpret the new fractional requirements or whether they’ll expect ambulance services to treat their billings the same as Medicare’s.
“The conundrum with private insurers is that there is no central law or regulation, like there is with Medicare, that governs these decisions,” Wolfberg said. “Usually, at the state level, there is no statute or regulation that governs how you bill mileage to commercial carriers. So, oftentimes the Medicare rules seem to just de facto supply the standards that providers use to bill commercial payers.
“The concern here is that if Medicare requires fractional mileage and a provider continues to round up for a commercial payer, then a commercial payer could then turn around and claim that’s insurance fraud or some form of overpayment. Even though there is not a statute or a regulation that would mandate the same thing be done, we’ve seen enough insurers just take the position that the Medicare rule essentially becomes the standard for billing other insurers. Frankly, whether that has merit under the law or not, it could be an expensive argument to test,” he said.
The most conservative thing to do is bill commercial payers consistently with Medicare. “If the insurers will not or cannot accept fractional mileage, then the most conservative thing for the provider to do in that case is round down,” Wolfberg said. “Probably the most sensible thing to do would be to use conventional rounding, so if the mileage is five tenths or above, round up to the next whole number, and if it’s below five tenths round it to the next lowest number. I think it’s defensible to use conventional rounding.”
Billing for fractional mileage or rounding down mileage on private insurance claims, on top of those for Medicare, could obviously raise the cost to ambulance services well beyond CMS’s $40 to $80 million estimate, Wolfberg said. “The downstream consequences of the change were not taken into consideration by the cost estimates in the Proposed Rule.”
Reference
- Government Accounting Office. Ambulance Providers: Costs and Expected Medicare Margins Vary Greatly. www.gao.gov/products/GAO-07-383.
