Medicare’s Ambulance Data Provisions: 2022 Physician Fee Schedule
The Centers for Medicare and Medicaid Services (CMS) released its 2022 Medicare Physician Fee Schedule (PFS) payment proposal on July 13, and CMS included proposed several provisions related to Medicare’s ground ambulance data collection program.
Click here to view CMS’s proposal. The ground ambulance discussion begins on page 532.
Data Collection Periods
Some delays were necessary due to the public health emergency. However, per CMS (page 556):
When finalizing our policies in regard to ground ambulance collection and reporting of data, we did not intend to have approximately 75 percent of ground ambulance organizations collect and report data at the same time. To provide MedPAC with the data needed for analysis, acknowledging that due to the COVID-19 delay there will be a delay in CMS providing that data, we believe that we should revise the data collection period and data reporting period for selected ground ambulance organizations in year 3.
CMS goes on to propose:
Accordingly, we are proposing to revise the data collection period beginning between January 1, 2022 and December 31, 2022 and data reporting period beginning between January 1, 2023 and December 31, 2023 for selected ground ambulance organizations in year 3. Under this proposal, there will be a new data collection period beginning between January 1, 2023 and December 31, 2023 and a new reporting period beginning between January 1, 2024 and December 31, 2024 for selected ground ambulance organizations in year 3. With this proposal, we plan to do the sample in 2022 for selected ground ambulance organizations in year 3 rather than the current plan in 2021.
CMS also commented:
Due to the delay caused by the COVID-19 PHE, we examined the possibility of extending the data reporting to encompass 4 years as planned instead of 2 years. We concluded that it would not be feasible to extend the data reporting period over 4 years. Extending the data reporting to encompass four years would further delay MedPAC receiving the data required to analyze for its report to Congress, which is required to be submitted by March 15, 2023. The sampling for year 1 and year 2 selected ground ambulance organizations has already been completed and the lists for the selected ground ambulance organizations in year 1 and year 2 are posted on the CMS website.
Proposed Change to the Notification Process for Selected Ground Ambulance Organizations to Report
Per CMS on page 557:
We propose to make a technical revision to § 414.626(b)(1) to state that the selected ground ambulance organization provide the start date of the data collection period to CMS or its contractor instead of the Medicare Administrator Contractor. This change will provide CMS with flexibility to have the MACs or other contracted entities provide written notifications and collect information from the selected ground ambulance organizations. If we find the response rate is low, having the flexibility to contract with other entities that could employ additional outreach resources may be useful. This revision would not preclude CMS from including the MACs in the notification process.
Payment Reduction for Failure to Report
Per CMS on page 559:
We stated in the CY 2020 PFS final rule (84 FR 62895) that we would make a determination that the ground ambulance organization is subject to the 10 percent payment reduction no later than the date that is 3 months following the date that the ground ambulance organization’s data reporting period ends. In this final rule, we provided examples of when the determination will be made based on calendar year and fiscal year data collection period beginning in 2020. Due to the delay caused by the COVID-19 PHE, we did not receive data collected in 2020. We will begin to follow this timeline to make a determination that the ground ambulance organization is subject to the 10 percent payment reduction when data collected in 2022 is required to be reported in 2023 for selected ground ambulance organizations in year 1 and year 2.
Public Availability of Data
Per CMS on page 560:
Due to the COVID-19 delay, we are proposing to revise § 414.626(f) to state that we will make the data collected under § 414.626 publicly available beginning in 2024. We invite comments on our proposal to revise the timeline when the public availability of data will begin.
Proposed Change to the Shared Services Questions in Section 2 (Organizational Characteristics)
Per CMS on page 537, CMS is proposing the following change:
Based on feedback from ground ambulance organizations, we believe the specific wording of Section 2, Question 9 may be confusing. The question asks respondents whether they share operational costs with “one of the following,” implying respondents are limited to a single response, even though in some cases respondents may wish to select multiple responses. Furthermore, ground ambulance organizations may have difficulty interpreting the phrase “share any operational costs.” We received questions from some ground ambulance organizations asking whether renting space from a fire department qualified as a “shared operational cost.” The intent of the question was to ask about shared ownership and accounting, not renting facility space, sharing a physical space with a separate organization, or similar business and logistical arrangements.
We propose to revise Section 2, Question 9, to read, “Does your organization provide any of the following services or operations (select all that apply)?” retaining the current response options. This change clarifies that the intent of Section 2, Question 9 is to collect information on services or operations provided by the sampled organization. We invite comments on our proposal regarding reporting shared services.
Proposed Change to Average Trip Time Question
Per CMS on page 539:
We are proposing that this question be revised to ask for “average time on task” defined as “from the time an ambulance begins its response to the time when the ambulance is available to respond to another call (that is, time on task)” to better capture interfacility transfers and situations when an ambulance is already out and responds from a site other than the central station. We believe this change in the wording of the question would be clearer to respondents and would result in higher-quality reported data. We invite comments on our proposal to change the definition of the average trip time.
Proposed Change to Secondary Service Area Instructions
Per CMS on page 540:
We propose to add the following text to the Section 3, Question 4 instructions: “Some, but not all, ground ambulance organizations regularly provide service outside of their primary service area, for example through mutual or auto-aid agreements with nearby municipalities. If this applies to your organization, please report areas that are outside your primary service area but where you regularly provide services as part of your secondary service area. You do not need to
report areas where you provide services very rarely or only under exceptional circumstances (for example, when participating in coordinated national or state responses to disasters or mass casualty events). Use your judgment as to whether your organization regularly serves a secondary service area. For example, you may choose to consider ZIP codes outside your primary service area but where you had 5 or more responses during the data collection period as part of your secondary service area if you believe these transports have a significant impact on your organization’s costs.” Even with this added text, ground ambulance organizations could still determine whether they do or do not have a secondary service area for the purposes of reporting in the Medicare Ground Ambulance Data Collection System. We invite comments on our proposal to revise the secondary service area instructions.
Proposed Change to the 90th Percentile Emergency Response Time
Per CMS on page 541:
Based on feedback from ground ambulance organizations that we have received on this question since we finalized the instrument, we believe most ground ambulance organizations will find it challenging to interpret this question and report the requested information. Several ground ambulance organizations have indicated that they would misinterpret this question, describing a shorter 90th percentile emergency response time compared to average response time, which, while mathematically possible, is not the intent as we were interested in characterizing outlier emergency responses with unusually long response times.
Thus, we propose to revise the question to ask: “what is your best estimate of the share of responses (enter percentage) that take more than twice as long as the average response time as reported in the prior question?” We believe this would be an easier question for ground ambulance organizations to understand. The goal of this question is to help CMS understand whether the organization has some response times that are much longer than its typical response time. Although the question language would be different, the reported information would still help CMS understand the extent to which a small number of emergency responses may be substantially longer than the average response for each organization. We invite comments on our proposal to revise the question to ask respondents to report the share of responses with more than twice the average response time instead of their 90th percentile emergency response time.
Proposed Change to Reporting Paid Ambulance Transports
Per CMS on page 542:
Based on questions and feedback from ground ambulance organizations that we have received since we finalized the instrument, we believe respondents may have different interpretations of this question, which could lead to inconsistent reported data, including the reported total ground ambulance transports during the data collection period (Section 5, Question 6). The intent of this question was to capture the reported number of ground ambulance transports during the data collection period, provided such transports were paid by the time the information was prepared for reporting to CMS. We did not intend for organizations to report the total number of ground ambulance transports for which they received the payment itself during the data collection period.
We recognize that there is a temporal disconnect between when services are provided and when initial and final payment may be received. In order to standardize the information that is reported by all ground ambulance organizations, and to align the reported information on the number of responses and transports during the data collection period with information reported on the number of paid transports, we propose to clarify Section 5, Question 7 to ask “Of the ground ambulance transports your organization provided in calendar year 202X [or fill fiscal year as appropriate], how many were paid (either in part or in full) across all payer types and regardless of the level of service or geography by the time you are reporting data to CMS?”
We recognize that the “runout period,” that is, the time from when services are provided to the time when data is being analyzed, will be short and variable across organizations,
particularly for transports towards the end of organizations’ data collection periods. Despite this limitation, we believe this approach is preferable to alternatives where (a) respondents have variable interpretations of Section 5, Question 7 and (b) where respondents are asked to report the number of transports for which payment was received during the data collection period, even if the transports for which payment was received happened prior to the data collection period. In the latter case, the number of paid ground ambulance transports could not be directly compared to the number of total ground ambulance transports reported in Section 5, Question 6.
We also are proposing to revise the general instructions in Section 5 to delete the following text as it will no longer be relevant: “Depending on how your organization collects data, you may report (a) the number of transports furnished during the data collection period that were also paid during the data collection period, or (b) the number of transports paid during the data collection period even if some transports occurred prior to the data collection period.”
Proposed Changes to Questions Related to Labor Hours
Per CMS on page 544:
Based on questions received by ground ambulance organizations since we finalized the instrument and feedback through testing on Section 7 questions, we learned that some ground ambulance organizations may misinterpret the Section 7 questions. Specifically, we believe some organizations may assume the question is asking for hours “related” rather than “unrelated” to ground ambulance or public safety responsibilities given the focus of the data collection effort, despite instructions to the contrary. Relatedly, we were notified that some organizations were confused that the Section 7 questions did not provide an opportunity to report total hours worked related to ground ambulance responsibilities, which they assumed was an unintentional omission from the instrument.
We propose to change the instructions in Section 7 to ask respondents to report hours worked on different activities in such a way that the sum of hours worked across different activities equals total hours worked annually. We believe this approach would be easier for respondents to understand and estimate, resulting in less burden for respondents and higher quality reported information.
For stand-alone ground ambulance organizations, we propose to ask respondents to report each of the following per staff category: (a.) Total annual compensation; (b.) Total hours worked annually; (c.) Total hours worked annually related to ground ambulance operations; and (d.) Total hours worked annually related to all other responsibilities. With this change, the instructions in Section 7 would note that “total hours worked annually related to ground ambulance operations” plus “total hours worked annually related to all other responsibilities” should equal “total hours worked annually.”
For fire department or other public safety-based ground ambulance organizations, we propose to ask respondents to report each of the following per staff category: (a.) Total annual compensation; (b.) Total hours worked annually; (c.) Total hours worked annually related to
ground ambulance operations; (d.) Total hours worked annually related to fire, police, or other public safety operations; and (e.) Total hours worked annually related to all other responsibilities. The Section 7 instructions would note that the sum of total hours worked related to ground ambulance operations; fire, police, or other public safety operations; and all other responsibilities should equal total hours worked annually. We invite comments on our proposal to revise the labor hours.
Proposed Change to Instructions Related to Facility, Vehicle and Equipment Certain Expenses
Per CMS on page 546:
Although we believe most ground ambulance organizations depreciate facilities, vehicles, and capital medical equipment, we were notified that some ground ambulance organizations do not depreciate these items in their regular accounting practices. Upon a review of the instrument, we found that the instructions and opportunities to report costs for organizations using a cash basis for accounting were inconsistent across Sections 8, 9, and 10 of the instrument. In some instances, ground ambulance organizations are asked to report annual depreciation expenses only, without a clear question related to expenses should the organization not regularly depreciate a certain category of asset. In other cases, there are questions asking respondents to report annual expenses other than annual depreciation expenses, but the instructions provide incomplete guidance on what expenses are in scope.
After considering these options, we propose to add screening questions to the instrument asking individually whether the organization depreciates facilities, vehicles, and equipment. We believe this would not substantively affect response burden for organizations and may in some cases reduce burden by clarifying what and how information on expenses must be reported in Sections 8, 9, and 10.
Proposed Changes to Questions Related to NPIs Under Broader Parent Organizations
Per CMS on page 551:
There are four sections in the instrument that lack similar questions: Section 7.1 (Paid EMT/Response Staff Compensation and Hours Worked), Section 7.3 (Volunteer Labor), Section 9.1 (Ground Ambulance Vehicle Costs), and Section 10.1 (Medical Equipment/Supplies). Without these questions, total reported costs may be biased downward for NPIs that are part of broader parent organizations. We propose to add questions like the one reproduced above to the end of these four sections for completeness. The text would be the same as the above except for replacing “EMT/response staff labor costs,” “costs associated with volunteer labor,” “ground ambulance vehicle costs,” and “medical equipment and supply costs” for “administrative labor costs” in the respective sections.
Relatedly, for completeness, we propose to clarify in the instructions for Section 12 (Total Cost), Question 1, that organizations part of broader parent organizations should include an allocated portion of parent organization (or “central office”) costs when reporting their total costs in this question. We invite comments on our proposal to address questions related to NPIs under broader parent organizations.
Other Clarifications to the Medicare Ground Ambulance Data Collection Instrument
Per CMS on page 551, CMS is proposing to add 11 additional clarifications and updates to the instrument:
i. Replacing all first-person language (for example, “we”) with third-person language (for example, “CMS”) throughout the instrument for editorial consistency.
ii. Section 2, Question 17: There is a typo where this question referred to itself rather than, as is implied by the ordering and framing of the question, the prior item. The question currently asks, “other than what was reported in item 17…,” when it should read, “other than what was reported in item 16…”.
iii. Section 3, Question 2: This question currently asks, “are you the primary emergency ambulance provider…,” using “provider” more colloquially than elsewhere in the instrument where the same word is sometimes used to differentiate between Medicare providers of service and Medicare suppliers. We propose to reword this question to read, “are you the primary emergency ambulance organization…”
iv. Section 4, Questions 1 and 2 Clarification: The question currently defines response time as “the time from when the call comes in to when the ambulance or another EMS response vehicle arrives on the scene.” We propose clarifying this definition to say “the time from when the call comes in to dispatch to when the ambulance or another EMS response vehicle arrives on the scene.” Relatedly, for Section 4, Question 2, we propose adding a second answer option for this question that reads, “From the time our organization receives a call from dispatch to the time the ambulance or other EMS vehicle is at the scene.” Respondents would still have the option to write-in their own response in Section 4, Question 2, if neither of the pre-programmed options apply to their organization.
v. Section 5, Question 3a. Clarification: This question asks respondents to report the percentage of ground ambulance responses that involve a non-transporting agency and the percentage of ground ambulance transports in which the non-transporting agency continues to provide medical care in the ambulance during a transport. Based on feedback from ground ambulance organizations that we have received since we finalized the instrument, we believe many organizations do not currently track this data and will not easily be able to begin tracking it. We propose clarifying this question to note that estimated percentages are acceptable, as they are in response to certain other questions in the instrument (where noted). We specifically
propose to edit Section 5 question 3a. to read: “What is your best estimate of the percentage of total ground ambulance responses that involved a non-transporting agency? (Enter percentage)”
vi. Section 7.1 Instruction Clarification: We propose clarifying “You will report on these staff in a different section” to “You will report on these staff in a later section” to make it clear that the opportunity to report on these staff follows the current instruction.
vii. Sections 7.1 and 7.2 Instruction Clarification: We propose to add “employer payroll taxes” as an additional example of a component contributing to total compensation, without altering any of the definitions or other instructions in these sections.
viii. Section 7.2, Question 3 Clarification: We propose adding a clarification warning for respondents not to consider labor that was reported elsewhere when responding to this question.
ix. Section 7.3, Question 4 Clarification: We propose adding a clarification that medical director volunteer hours do not contribute to this response and a reminder that they are reported separately below (Section 7.3, Question 5).
x. Section 10 Instructions: We propose to correct a typo in the instructions where the instrument describes “operation expenses” rather than “operating expenses” as intended.
xi. Section 13, Question 3 Clarification: Based on the instructions for this question, organizations may report revenue from specific payers that include patient cost-sharing amounts. To ensure patient cost-sharing is not reported twice, we recommend clarifying the item in the chart that currently reads, “Patient self-pay (amount patients pay for deductibles, coinsurance, etc.) to read, “Patient self-pay (cash payment and the amount patients paid for deductibles, coinsurance, and other cost-sharing only if not reported in a row above.)” We invite comments on these proposed clarifications and updates to the instrument.