Appendix 1 - Response to 60-day comment

Appendix 1 – Response to Public Comments

The Centers for Medicare and Medicaid Services (CMS) received three comments in response to the 60-day Federal Register Notice for CMS-10708: Proposed Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Process and Requirements for a Potential National Model. This is the reconciliation of the comments.

Comment:

CMS received comments from three ambulance-related associations, all expressing support of expanding the RSNAT Prior Authorization Model nationwide. One commenter described the impact of the current model to ambulance suppliers in his state as positive and stated that, for RSNAT services, a pay first and review later system does not benefit CMS or ambulance suppliers. Another commenter called the current model a success, and thanked CMS for minimizing administrative burden on ambulance suppliers and for protecting access to medically necessary care.

Response:

CMS appreciates the commenters providing feedback on the potential nationwide expansion of the RSNAT Prior Authorization Model, as well as their first-hand experience with the current model. We agree that the current model has reduced fraud, waste, and abuse in the model states, resulting in substantial savings. We also agree that the current model helps to stop unscrupulous ambulance suppliers from submitting claims for payment, as they are not typically able to provide the necessary documentation to show the services meet Medicare coverage criteria.

If such a national model moves forward, the use of prior authorization would not create new clinical documentation requirements. Instead, it would require the same information that ambulance suppliers are already required to maintain to support Medicare payment. We agree that the proposed prior authorization process aims to minimize administrative burden by allowing ambulance suppliers to address coverage issues prior to rendering services, providing some assurance of Medicare payment. The proposed model would also offer unlimited opportunities to resubmit requests to include all necessary and relevant documents needed to obtain a provisionally affirmed decision, protecting beneficiary access to medically necessary care.

Comment:

One commenter recommended that CMS phase-in the roll-out of the nationwide model. The commenter also suggested that CMS work closely with the Medicare Administrator Contractors (MACs) to ensure consistent and appropriate adherence of the medical necessity requirements for RSNAT services.

Response:

CMS agrees with both recommendations. CMS believes a multiple phase roll-out would be the best implementation approach for the proposed nationwide model.

As the MACs would administer the proposed model, we agree in the importance of both consistent and accurate prior authorization decisions among and within the MACs. If such a national model moves forward, CMS would provide close oversight of MAC decisions and ensure robust provider education.

Comment:

Two commenters asked CMS to consider using the savings generated from a nationwide RSNAT Prior Authorization Model to improve reimbursement to ambulance suppliers and providers who provide legitimate and medically necessary ambulance transportation.

Response:

This comment is outside the scope of this information collection request and has been shared with the relevant policy group within CMS.