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CMS to expand ambulance program integrity payment model nationwide

The Centers for Medicare & Medicaid Services reported that the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) saved Medicare $650 million over 4 years

By Laura French

BALTIMORE — The Centers for Medicare & Medicaid Services (CMS) announced Tuesday that it will expand the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) nationwide.

The RSNAT Prior Authorization Model tests whether prior authorization — or advanced approval of a service before the service is furnished and before a claim is submitted for payment — helps save Medicare money while maintaining or improving the quality of care for repetitive, scheduled non-emergency ambulance transportation.

The model was originally rolled out in New Jersey, Pennsylvania and South Carolina in 2014 and North Carolina, Virginia, West Virginia, Maryland, Delaware and the District of Columbia were added in 2016.

According to CMS, the model has saved Medicare about $650 million over four years while preserving quality of care and access to essential services.

The model helps address the issue of improper Medicare payments for non-emergent ambulance transports, which occurred at a rate of 22.6% in 2017 and 18.6% in 2018, according to CMS.

“As part of CMS’s comprehensive approach to protect taxpayer dollars and target the most significant program integrity risks facing our health care programs, CMS is working to prevent, rather than chase, fraud, waste, and abuse through smart, proactive measures,” the CMS announcement read.

Based on the model’s First Interim Evaluation Report in 2018, the chief actuary of CMS certified that nationwide expansion of the RSNAT Prior Authorization Model would reduce net Medicare spending. The Second Interim Evaluation Report, released Tuesday, supports previous findings, CMS officials said.

The second report found that the model reduced RSNAT service use by 63% and RSNAT expenditures by 72% among beneficiaries with end stage renal disease and/or severe pressure ulcers during the first four years of the model. This decrease in RSNAT service expenditures, in turn, caused a total decrease of Medicare fee-for-service (FFS) expenditures of 2% (about $650 million over four years), according to CMS. The report did not find evidence that the model adversely affected quality of care.

“CMS program integrity functions allow us to hold the entire healthcare system accountable, protect beneficiaries from harm and safeguard taxpayer dollars,” said CMS Administrator Seema Verma in a statement. “When deployed appropriately, prior authorization can help ensure Medicare requirements are met before a service is provided and the claim is paid, without creating any new documentation requirements for providers. The RSNAT model has proven a resounding success, and beneficiaries across the country deserve to benefit from it.”

The model’s program integrity, patient safety and cost-savings elements will continue without interruption in the current states beyond December 1, 2020, when the model was originally scheduled to end in these states. CMS officials stated that more information on the national expansion and implementation dates for additional states will be released as it becomes available.

The national model will follow the same design as the current model. CMS will continue to monitor the COVID-19 pandemic and take it into account when determining the timeframe for expansion into additional states, officials said.