CMS taking prior authorization model for ambulance transport nationwide

The Trump administration is taking a prior authorization program for ambulance services nationwide.

The Centers for Medicare & Medicaid Services said in an announcement on Tuesday that the edicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) has saved the program $650 million over the past four years.

CMS analyses suggest that non-emergent ambulance transport is a frequent source of improper payments, with an estimated improper payment rate of 22.6% in 2017 and 18.6% in 2018.

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“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," Verma said. "The RSNAT model has proven a resounding success, and beneficiaries across the country deserve to benefit from it.”

In the first four years, CMS found that the pilot reduced RSNAT service use by 63% and RSNAT expenditures by 72% among beneficiaries with end stage renal disease or severe pressure ulcers.

This reduced overall costs in fee-for-service Medicare by 2%, or $650 million. CMS did not find indications that using prior authorization for RSNAT services negatively impacted care quality.

CMS first piloted the program in New Jersey, Pennsylvania, and South Carolina beginning in 2014 and then beginning in 2016 in North Carolina, Virginia, West Virginia, Maryland, Delaware, and the District of Columbia.

The model will be extended in those regions beginning Dec. 1, the previously scheduled end date for the pilots, and CMS is developing a timetable for further rollout while considering the impacts of COVID-19.