If your fire department provides ambulance transportation for EMS patients, you’ve likely seen a financial impact from COVID-19 responses. While some agencies in the COVID-19 hotspots have seen increases in transports, the majority of departments are seeing decreased call volumes (and corresponding reductions in reimbursements) due to fewer patients wanting to go to a hospital. At the same time, agencies are confronted with increased response costs relating to personal protective equipment (PPE) and decontamination requirements. These costs, coupled with increased staffing costs, can make it very difficult for a fire chief to manage their budget.
When Congress passed the CARES Act (P.L. 116-136) recently, it included $100 billion in financial support for the U.S. Department of Health and Human Services to provide to Medicare suppliers and providers. On April 10, the Centers for Medicare and Medicaid Service (CMS) began distributing the first $30 billion of these funds. The purpose of these funds, the CARES Act Provider Relief Fund, is to assist Medicare-participating entities in covering a variety of unreimbursed costs that are incurred in the course of caring for COVID-19 patients. On April 22, the U.S. Department of Health and Human Services (HHS) announced that they will release an additional $20 billion (pdf) to Medicare participating entities.
Round I Allocations of Funds
If your agency bills Medicare on a fee-for-service (FFS) basis, you’ll likely see a direct deposit from either CMS or UnitedHealth Group for an amount equal to 6.19% of the total Medicare FFS payments that you received in 2019. You may have even already received this payment from CMS. These payments are not loans and are not meant to be repaid. If your agency is eligible to receive these funds, you need to agree to some terms and conditions. One of these conditions is that your agency will not “balance bill” suspected or confirmed COVID patients. However, this is not a prohibition on “balance billing” in the traditional sense, but rather a requirement that agencies not seek more in out-of-pocket expenses from an out-of-network patient than would have been sought if they were “in-network.” While this will be a loss of reimbursements, the new payments from CMS should more than cover these lost reimbursements. Unfortunately, CMS only is providing these payments for Medicare-enrolled ambulance suppliers and providers. Fire departments that provide first response Advanced Life Support (ALS) services in conjunction with an ambulance provider as part of a pass-through agreement will not receive direct reimbursement from CMS.
However, since the private ambulance provider billed CMS at the ALS level on behalf of the fire department and received increased reimbursement due to the pass-through agreement, the fire department could request their portion of the funds be passed along to them by the ambulance company.
Agencies that have not yet received these funds are encouraged to contact their Medicare Administrative Contractor (MAC). While your agency’s MAC may not be distributing these funds, they should have more information on when/how to access these funds.
Lastly, it is essential to note that CMS distributed these funds based on Tax ID Numbers (TIN). Disbursement based on the TIN rather than national provider identification (NPI) number may have caused a fire department’s funds to be sent to a city’s general fund account and combined with supplemental payments for any other municipal agency that billed Medicare on a fee-for-service basis in 2019. In this case, fire chiefs should calculate how much their payment should be and then contact whoever maintains their city’s respective general fund. While the payment may be for an amount significantly more than your agency’s estimate (if you share a TIN with other agencies), CMS’ supplemental payment most likely will have originated from Optum Bank and have a payment description of “HHSPAYMENT, US HHS Stimulus or CARES Act Relief Payment.”
Round II Allocations of Funds
While CMS automatically provided the Round I allocations via direct deposit, the Round II allocations will be disbursed through a different mechanism. Similar to Round I, the funds from Round II will be allocated proportional to an entity’s share of 2018 Medicare FFS payments. Any agencies seeking funds through Round II must log onto CMS’ web portal and upload information on the amount of 2018 Medicare FFS payments that the agency received. The IAFC urges all fire departments which bill Medicare for ambulance transportation to log onto the CMS web portal and provide the necessary information to verify their eligibility to receive funds.
Terms and Conditions
Any agency accepting funds from HHS through either the Round I or Round II allocations must accept several terms and conditions from HHS. As was mentioned above, any entity accepting these funds must agree to bill all confirmed or suspected COVID patients as though they were in-network patients. This is not a prohibition on collecting a patient’s copay or their expected share of the bill. Instead, this is a prohibition on collecting different amounts from patients depending on whether they are “in-network” or “out-of-network.” Agencies who bill for a suspected or confirmed COVID encounter simply need to collect from the patient no more than what is outlined in their insurance plan as an “in-network” cost share or co-pay for medical transportation services. Additionally, it is incumbent upon the patient to provide the plan information when requested so that you can understand their share of cost.
Fire chiefs are encouraged to examine their reimbursement trends and make the calculations to ensure the award that they receive from HHS will more than offset the loss in reimbursements from being unable to bill out-of-network known or suspected COVID patients at out-of-network rates.
It is critically important that fire chiefs do their calculations for their own fire departments and ensure this policy change is sound for their respective fire department. This is especially important for fire departments which have an in-network agreement with a commercial insurer.
Reimbursements for Uninsured Patients
One final portion of the initial $100 billion from the CARES Act will be distributed by the Health Resources and Services Administration (HRSA) to healthcare providers who have cared for uninsured COVID patients (retroactive to February 4). Healthcare providers will be paid the Medicare rates for caring for these patients. While HRSA is expected to pay for ground transportation of uninsured COVID patients, HRSA has explicitly stated that these funds will not be available for transportation of uninsured COVID patients via air or water ambulance.
Agencies seeking payment from HRSA must register and submit their claims through a web portal that opened on April 27. HRSA will begin accepting claims on May 6 and will pay until the funds are exhausted. Agencies will be able to access this portal through HRSA’s webpage.
Similar to the CMS payments mentioned above, anyone accepting these funds must agree not to balance bill the patient for whom the agency is seeking payment from HRSA. These funds could be helpful in offsetting costs incurred due to not limiting the billing of out-of-network patients as is required in the Round I and II allocations from CMS.
Further Information
CMS also created a CARES Act Provider Relief Fund hotline, which can answer questions regarding payment status and eligibility. The hotline can be reached by phone at 866-569-3522.
On April 23, Congress passed legislation which contained an additional $75 billion for the HHS Public Health and Social Services Emergency Fund. The IAFC expects that these funds will be used to support Medicare suppliers and providers in further caring for COVID-19 patients and disbursed in a similar mechanism. The IAFC will provide additional information as soon as HHS and CMS release information on future allocation rounds.
The IAFC will be monitoring the status of these funds and encouraging HHS to use them to support fire and EMS agencies to their fullest extent. Make sure to regularly check back with the IAFC for additional updates as HHS releases more information.
Pete Lawrence is a division chief with the Oceanside (CA) Fire Department and is a subject matter expert in EMS reimbursement and Medicare payment policies.