1. Payment Reform In EMS & Mobile Integrated Healthcare:
Presented by:
G. Christopher Kelly, Esq.

2. Community Paramedicine/ Mobile Integrated Healthcare
What is it?
“The provision of healthcare using patient- centered, mobile resources in the out-of- hospital environment that are integrated with the entire spectrum of healthcare and social service resources available in the local community.” (NAEMT, NASEMSO, NAEMSP, ACEP, NEMSMA, AAA…)
MIH can use EMTs, nurses, PAs, MDs…and yes, even Paramedics

3. Mobile Integrated Healthcare
The Goal- Institute for Healthcare Improvement’s (IHI) “Triple Aim Initiative”:
Improving the Patient Experience
Improving the Health of Populations
Reducing the per capita cost of healthcare

4. Mobile Integrated Healthcare
Getting the right patient, to the right care, at the right time.
Being more than a transport benefit- being a partner:
ACOs- shared cost savings model
MCOs- Medicaid cost savings model
Bundled Payment models- based on H stays

5. Mobile Integrated Healthcare- Payment & Funding:
Grants- (“Seed Money”)
State and/or Federal
Cost/Loss Avoidance-
Internal- the uninsured patient
Hospital-
Uninsured patients
Readmissions
Hospice- Disenrollment incentives
Insurance Payors-
Frequent Flyers
Observational Admissions

6. Mobile Integrated Healthcare
Can’t get traction without ties to payment:
Hospital readmission prevention:
CHF
Heart Attack
Pneumonia
Chronic Lung Disease
CABG surgery
Example: $100M in Medicare + 1.5% penalty = $1.5M annual cost for readmits
ar=p4p

8. SCA example- Provider ID 040134 Provider Name Arkansas Heart Hospital
State AR
Zip Code 72211
Base Operating Amount $ 39,930,409
Medicare IP Revenue $ 43,397,127
Estimated P4P Net Impact
Total Impact ($) -$ 926,385
Total Impact (%) %
Hospital Readmission Reduction Program (HRRP)
Final Readmissions Adjustment Factor
Readmission Impact ($) -$ 926,385
Value Based Purchasing (VBP)
Final VBP Adjustment Factor No Data

9. Mobile Integrated Healthcare
Could there be more?
Insurance payment for EMS under cpt codes
Payment for treatment without transport
Payment for emergency transport to MD
Payment for transport to minor med/clinic

10. Possible CPT codes: 9-1-1 Nurse Triage Services
98967: Telephone assessment and management service provided by a qualified non-physician healthcare practitioner.
Mobile Healthcare Paramedic Visit – Routine
99349: Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:
A detailed interval history;
A detailed examination;
Medical decision making of moderate complexity.
Mobile Healthcare Paramedic Visit – Episodic/Emergent
99341: Home visit for the evaluation and management of a new patient, which requires these 3 key components:
A detailed history;
A detailed examination; and
Medical decision making of moderate complexity

11. Payment for Treat-No Trans.
A0998- ambulance response and treatment- no transport
Anthem/BCBS-
Hospital Emergencies- no pay unless needed
On scene treatment = $360
Cheaper than an ER bill!

12. Possible Alt. Dest. Codes-
Ambulance Transport, Emergency, Alternate Destination
A0429 (modifier)
D: Diagnostic or therapeutic site other than P or H when these are used as origin codes
E: Residential, domiciliary, custodial facility
H: Hospital
N: Skilled nursing facility
P: Physician’s office
R: Residence
S: Scene of accident or acute event
Examples:
HCPCS Code
9-1-1 Ambulance, Scene, Transport to Urgent Care
A0429 SD
9-1-1 Ambulance, Scene, Transport to Primary Care Clinic
A0429 SP
9-1-1 Ambulance, Home, Transport to Urgent Care
A0429 RD
9-1-1 Ambulance, Home, Refer to PCP, scheduled App’t
A0998 RP

13. Minnesota – Treat, but No Transport
MHCP covers no transport calls ONLY if ambulance staff provides medically necessary treatment to patient at the pickup point.
When billing, use procedure code A0998 (ambulance response and treatment, no transport)
Do not use a modifier
As of Jan 1, 2017, BCBS of MN follows same guidelines.

14. California Alternate Destination Project
(Details to come)

15. PA House Bill 1013
Proposed legislation requires reimbursement even if patient refuses transport but following conditions are met:
ALS or BLS unit is dispatched by county 911 center
EMS provider MUST have provided medically necessary treatment even if patient declines transport.
Bill is currently pending in PA Senate’s Banking and Insurance Committee.

16. Other Payment Reforms? Alternate Destinations- Emergency to Physician
Emergency to Clinic
Emergency to Mental Health Facility
Why Non-traditional Destinations?
Quicker Access
Lower Cost
New Challenges- Not the ER experience

17. Contract Template Between EMS and Alternative Destination Sites
Getting to an understanding- Avoiding uncertainty
Things to consider:
Operating hours
Volume limits
Stretcher accessibility
Scheduled unavailability- Doc on Diversion
Getting home

18. Patient Consent Form Similar to refusal form Can be combined
Must show a clear understanding of the patient
Must allow for acceptance of alternate destination
Should provide financial impact information
Should allow for higher level of care if necessary

19. Telemedicine- calling EMS
Telemedicine= “origination site” to “destination site” via live audio/video feed
“Telecommunications System”- Not cell phones or Skype
Origination= Health Provider Shortage Area (“HPSA”)
Destination= MD/Practioner, hospital, or clinic
Ga Medicaid allows EMS to be “telemedicine facility”
Q3014= $25 80%)
Modifiers:
GT = interactive audio/video telecommunications
GQ = asychronous (store and forward) telecomm.
Facility fee, professional fee, or both?

20. Questions, comments, concerns: