1. GEMT
Ground Emergency Medical Transport
A.P. Triton LLC©

2. Ground Emergency Medical Transport Supplemental Reimbursement
Opportunities exist that allow public ambulance providers to receive supplemental reimbursement from the Federal Government
These programs are part of the Federal Medicaid program
Each state participates in the Medicaid program so each state is eligible
#2. The Federal Government is required to provide assistance for medical care for qualified individuals that meet certain criteria. This is known as Medicaid. Each state that adopts a Medicaid program is “entitled” to receive federal funds to assist that state with providing this healthcare coverage. Washington State’s Medicaid plan is Washington Apple Health. As an entitlement it is not subject to federal appropriations.

3. Ground Emergency Medical Transport Supplemental Reimbursement
Program draws down Federal Medicaid dollars to help offset the cost of providing emergency ambulance and transport for Medicaid patients
Two primary mechanisms for drawing down money are CPE’s and IGT’s
#3. The fire department as a recognized unit of government is allowed to participate in the recovery of costs associated with providing medical services which includes transportation of Medicaid beneficiaries when the state Medicaid program does not cover the full cost of the service. The two most common ways that this occurs are through Certified Public Expenditure “CPE” and Inter-Governmental Transfers “IGT”.

4. Ground Emergency Medical Transport Supplemental Reimbursement
CPE’s are Certified Public Expenditures for use in Fee For Service
Cost sharing program 50/50 split of the uncompensated cost of the service
Entitlement program that is mandatory, is not subject to federal appropriations
 #4. There are many programs within the state of Washington that use these methods to drawdown federal money for the same objective as GEMT. The most common are public health programs and schools.

5. Ground Emergency Medical Transport Supplemental Reimbursement
IGT’s are Inter-Governmental Transfers
Cost sharing program 50/50 split of the total cost of the service
Entitlement program that is mandatory, is not subject to federal appropriations
 #4. There are many programs within the state of Washington that use these methods to drawdown federal money for the same objective as GEMT. The most common are public health programs and schools.

6. Ground Emergency Medical Transport Supplemental Reimbursement
Example
Your state has 20% population of Medicaid assistance
Your state pays average of $180 per transport
Your FFS cost is $1,180…..your UCC is $1,000…..your CPE share is $500
#5. These programs only apply to patients enrolled into Washington Apple Health (WA Medicaid). The average WAH transport coverage is $168 base rate. However, under federal guidelines the cost of providing the transport includes all the associated costs with providing the service. This includes both direct and indirect costs. As a result the actual cost of transport can be significantly higher than the reimbursable rate.
In the example given, we used a 9,000 call per year EMS provider and a WAH percentage of 20% (remember even if your WAH population is lower these groups tend to have a higher percentage of usage. The same applies to our aging population. The elderly may have a lesser population but due to health issues in the aged they use the system more)
If the WAH base rate is $168 and the calculated cost of services is $2,200 we subtract the $168 from the $2,200 which leaves an uncompensated cost of $2,032 which is the amount that the provider cost shares at 50/50 with the Feds. Next we multiply the $1,016 by the 1,800 WAH patient contacts and will receive $1,828, in new revenue.

7. Ground Emergency Medical Transport Supplemental Reimbursement
CPE/IGT all inclusive costs can average $2,000 per transport
Based upon a 9,000 call EMS system at 20% FFS/MC (HMO), new revenue would exceed $1.8 million per year
(9k x 20% = 1,800) 1,800 x $1,000 = $1,800,000.00
#6. These amounts can be adjusted to your actual numbers to give a more realistic representation of the money you would receive. I would still use the $2,200 cost as your base line for now. .

8. Ground Emergency Medical Transport Supplemental Reimbursement
QAF ‘s are Quality Assurance Fees
The program places an assessment (or tax) on each Medicaid transport
The assessment is used to draw down a Federal match
Distribution of funds creates winners and losers in reimbursement amounts
Typically requires mandatory participation
#6. These amounts can be adjusted to your actual numbers to give a more realistic representation of the money you would receive. I would still use the $2,200 cost as your base line for now. .

9. Ground Emergency Medical Transport Supplemental Reimbursement
9,000 calls per Medicaid rate
Current reimbursement 1,800 x $180 = $324,000
GEMT / IGT = $1,800,000.00
560% increase to revenue
#6. These amounts can be adjusted to your actual numbers to give a more realistic representation of the money you would receive. I would still use the $2,200 cost as your base line for now. .

10. Ground Emergency Medical Transport Supplemental Reimbursement
Every state participates in CPE or IGT programs
The Medicaid programs have existed for more than 30 years
Not likely to change in the near future, even with the ACA. In fact they may expand.
#7. As stated, every state participates in these types of programs to my knowledge. Most of these programs have been running for more that 30 years. Until California (through Kurt and myself) implemented an ambulance transport CPE/IGT program it was just never thought of to apply this to Medicaid ambulance transport.

11. Ground Emergency Medical Transport Supplemental Reimbursement
Create enabling legislation to facilitate a State Plan Amendment SPA
SPA creates the program that establishes the “rules” for participation
#9. The biggest issue with developing these types of programs is getting the enabling legislation to create a State Plan Amendment or SPA. In some cases you may be able to do an IGT without legislation and only a SPA but you are limited to the parameters of that existing IGT program. This is occurring now in CA where I have just IGT’d $18,000, but more than half of the fire service cannot due to restrictions in certain counties.
The best recommendation is to draft legislation specific to what you want to accomplish. This provides the guidelines for the SPA. If the legislation does not specify certain things you can not include them in the SPA. Once you have obtained legislation the money is in the bank so to speak meaning you will get a program and you will get money. The state will draft the SPA language and insure that it meets Washington regulations but they will only include what you want to include. The SPA process is very labor intensive and establishes all the rules for what can be included in the Washington GEMT program. They do not have the background to know what is all inclusive in your delivery system.

12. Ground Emergency Medical Transport Supplemental Reimbursement
Providers must develop the SPA, the State will ensure it meets state regulations
The State will present the SPA to CMS for Federal approval
The State and Feds will only approve what is asked for (don’t ask/don’t receive)
#10. The state will then submit the SPA for approval to CMS. Once CMS has approved the program providers can begin to submit their reports for reimbursement.

13. Ground Emergency Medical Transport Supplemental Reimbursement
All costs associated with the development of the program are applied to the cost of service
Participation is always voluntary
#11. All of these programs are voluntary and do not require any provider to participate. Because there are numerous providers in the state that will be eligible it is not practical for everyone to work the legislation through the process and participate in the SPA development.

14. Ground Emergency Medical Transport Supplemental Reimbursement
Participation is not granted unless reimbursement of shared program development is paid to the Host Agency
Cost of participation will never exceed the revenue received
#12. It is much more efficient and effective to have a single agency assume the position of the “host” or lead agency for program development. This includes the cost of full program development. As the host agency you have the only guaranteed seat in the house which happens to be the driver’s seat. When developing the legislation and SPA language will be inserted that insures that any provider who chooses to participate in the program will be required to reimburse the host agency a prorated share of the costs of program development and implementation. The more participates the lower the cost. It should be remembered that the cost of program development and participation is considered an allocated cost to the services provided. So if an agency spends $200,000 in administrative costs that goes on top of the cost of providing the services for reimbursement.

15. Questions that you may see
Q: Who pays for this?
A: This money comes out of the Federal Medicaid budget. Once a state has adopted
Statewide Medicaid program CMS is required to provide supplemental reimbursement to that state and their governmental providers of services
Q: How much money is in this pot?
A: There is not a fixed dollar amount for theses programs. Medicaid supplemental reimbursements are an entitlement and not an appropriation. CMS is required to finance these types of programs.
Q: Is it a first come first serve process?
A: No, these are entitlements that if a provider is entitled to participate then they can receive their approved amount
Q: How are the amounts approved?
A: The SPA establishes the rules of the program and Federal spending regulations determine what can be included in the costs submitted for reimbursement.

16. First responder fee Treat and release fee
A.P. Triton LLC©
FRM 2015

17. FRF / TRF
What is it?
Legal, ethical, honest billing for services that are recognized by most private insurance companies
Is charged for all encounters that result in a patient assessment
Has NOTHING to do with ambulance transport
Is not regulated by your LEMSA

18. FRF / TRF What is it not? It is NOT a “crash tax”
It is NOT a money grab
It is NOT a scam

19. FRF / TRF Methodology Average time on task E/T = 20 minutes
Average hourly rate per unit = $150.00/hr.
67,200 calls/3 (20) = 22,400/hrs. on task
22,400 x $ = $3,360,000.00

20. FRF / TRF Actual reimbursements to date Collection rate is about 17%
17% collection = 11,424 billable calls
11,424 x $ = $3,141,600.00

21. FRF / TRF What is the backlash and how do we handle it?
Since introduction in February 2012 – 67 complaints
Most will come from senior groups – most vocal
Explain that taxes do Not cover the full cost of service
Explain the cost of response and treatment of “individuals” medical cost

22. FRF / TRF What is the backlash and how do we handle it?
Most will come from senior groups (continued)
“Individual treatment above and beyond suppression is costing ALL taxpayers
Without supplemental payments the service would be cut back or eliminated
“Individual” service that can be covered offsets the cost and allows continuation of medical services
Because 20% of patient has FRF/TNT coverage it allows us to wave the fee for those who do not

23. Putting it all together

24. 2010 Metro Fire Operations Operated thirteen 24-hr. ambulances
1/3 of the engines were ALS
EMS operating budget of $14.6 million
Revenue $13.8 million
Began working on GEMT

25. 2011 Operational changes Converted all units including trucks to ALS
Began feasibility study for FRF/TRF fees
Began feasibility study for phasing out private contractor

26. 2012 change in fee structure
Reassessed transport fees
Instituted FRF/TRF
Began detailed RAS/AMA review

27. 2013 Operational changes Replaced our private contractor with SRP’s
Placed seven SRP units into service
Instituted twelve-hour staffing on SRP units

28. 2014 results Increased service coverage to 100% ALS
Increased number of units from 13 to 24
Increased system costs from $14 million to $24 million

29. 2014 results
Increased EMS revenue from $13 million to $31,845,000 million
GEMT / IGT revenue collected = $8.4 million
Total EMS revenue collection FY14/15 = $40,245,000