A fact of life is that people get cancer and need chemotherapy and/or radiation. Others get serious kidney disease and need life-sustaining dialysis. Both types of people often require repeated treatments to respond to their serious health needs. Sadly, many of those patients will become sick enough that it will be medically necessary for them to be transported by ambulance to their essential health services. Once that happens, the patient becomes classified as “repetitive.”

According to Medicare, a repetitive ambulance service is a medically necessary ambulance transportation that is provided three or more times during a 10-day period; or at least once per week for at least three weeks.

Getting paid for repetitive transports is a BIG challenge in the ambulance business. A prior authorization is required from Medicare in many states (and expected to expand further in 2017). To obtain authorization means having all the necessary documentation, including proper supporting documentation in the form of a Physician Certification Statement (PCS) from the patient’s doctor.

Though the PCS has been around since 1998, there are still physicians and facilities who push-back when asked to cooperate by giving us this critical document in a timely manner. CMS has a nice one-page tool for dealing with facilities available here. The CMS stamped document shows nursing homes the importance of their participation in the process to obtain the PCS for repetitive patients (it also addresses the requirement that such a form be signed by an ordering physician.) You may find it helpful to have the weight of CMS behind you (via the use of the document) to help in your efforts with facilities and physicians.

Check your Medicare contractor and the CMS websites for the information that is available regarding the prior authorization process. Here is some good basic information to get you started. Palmetto also published a Documentation Decision Tool to offer a checklist to help providers ensure they have all the necessary information prior to submitting a request for prior authorization. The rate of denial for prior authorization requests tends to be high, particularly in the early days of the program in a new state. It is wise to check and double-check that you have every drop of information needed --- and that the forms are completely properly --- prior to submitting your request.

If your request for authorization is denied, take the necessary steps for combat the denial. It won’t be easy, but persistence will help.

Though repetitive patients may be a reimbursement challenge, they still need you. Keep yourselves educated on the twists and turns you must follow to get to the payment that you deserve.


About the author:  Maggie Adams is the president of EMS Financial Services, with over 20 years’ experience in the ambulance industry as a business owner and reimbursement and compliance consultant. Known for a practical approach and winning presentation style, Maggie has worked with medical transportation providers and billing companies of all kinds to support their billing, auditing, and documentation training efforts. Check out our newest documentation training webinars and billing webinars on our website.Friend EMS Financial on Facebook, or for more info, contact Maggie directly at maggie@ems-financial.com or visit www.ems-financial.com