Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015

To amend title XVIII of the Social Security Act to increase access to ambulance services under the Medicare program and to reform payments for such services under such program, and for other purposes. 1. Short title (a) Short title This Act may be cited as the Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015 (b) Table of contents The table of contents of this Act is as follows: Sec. 1. Short title. Sec. 2. Reform to the Medicare ambulance fee schedule. Sec. 3. Prior authorization for ambulance transports of ESRD beneficiaries. Sec. 4. Requiring ambulance providers to submit cost and other information. 2. Reform to the Medicare ambulance fee schedule (a) In general Section 1834(l) of the Social Security Act ( 42 U.S.C. 1395m(l) (16) Increase in conversion factor for ground ambulance services In the case of ground ambulance services furnished on or after April 1, 2015, for purposes of determining the fee schedule amount for such services under this subsection, the conversion factor otherwise applicable to such services shall be increased by— (A) with respect to ground ambulance services for which the transportation originates in a qualified rural area, as identified using the methodology described in paragraph (12)(B)(iii), 25.6 percent; (B) with respect to ground ambulance services not described in subparagraph (A) and for which the transportation originates in a rural area described under paragraph (9) or in a rural census tract described in such paragraph, 3 percent; and (C) with respect to ground ambulance services not described in subparagraph (A) or (B), 2 percent. (17) Increase in mileage rate for ground ambulance services In the case of ground ambulance services furnished on or after April 1, 2015, for purposes of determining the fee schedule amount for such services under this subsection, the payment rate for mileage otherwise applicable to such services shall be increased by— (A) with respect to ground ambulance services for which the transportation originates in a qualified rural area, as identified using the methodology described in paragraph (12)(B)(iii), 3 percent; (B) with respect to ground ambulance services not described in subparagraph (A) and for which the transportation originates in a rural area described under paragraph (9) or in a rural census tract described in such paragraph, 3 percent; and (C) with respect to ground ambulance services not described in subparagraph (A) or (B), 2 percent. . (b) Study and report (1) Study The Secretary of Health and Human Services shall conduct a study on how the conversion factor applicable to ground ambulance services under the ambulance fee schedule under section 1834(l) of the Social Security Act ( 42 U.S.C. 1395m(l) (2) Report Not later than January 1, 2020, the Secretary of Health and Human Services shall submit to Congress a report on the study conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines appropriate. 3. Prior authorization for ambulance transports of ESRD beneficiaries (a) In general Section 1834(l) of the Social Security Act ( 42 U.S.C. 1395m(l) (18) Prior authorization of coverage for ambulance transports of ESRD beneficiaries (A) Process (i) In general For applicable ESRD ambulance services furnished on or after January 1, 2017, by an applicable ambulance provider, the Secretary shall establish and implement a process under which the Secretary shall determine, in advance of furnishing such a service to an individual, whether payment for such service may not be made because such service is not covered or because of the application of section 1862(a)(1). (ii) Denial of payment Subject to subparagraph (B)(ii)(II), no payment shall be made under this part for the service unless the Secretary determines pursuant to such process that the service meets the applicable requirements for coverage. (B) Elements of process The process described in subparagraph (A) shall include the following elements: (i) In order to obtain a prior authorization, the applicable ambulance provider shall submit— (I) a valid physician certification statement (PCS) for non-emergency ambulance transport; and (II) any other documentation determined appropriate by the Secretary. (ii) (I) The Secretary shall respond to a prior authorization request within 7 business days of receiving the request. (II) If the Secretary does not make a prior authorization determination within 7 business days of the date of the Secretary's receipt of medical documentation needed to make such determination, subparagraph (A)(ii) shall not apply. (iii) In making the determination under subparagraph (A) with respect to a service and individual, the Secretary shall evaluate the medical necessity of the service by determining— (I) whether the individual is unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair; (II) whether the individual has a medical condition that, regardless of bed confinement, is such that transport by ambulance is medically necessary; or (III) whether the individual meets other criteria as determined appropriate by the Secretary. (iv) If the prior authorization request is approved, such request shall be retroactive to the date on which such request was received. (v) An approved prior authorization shall be valid for a 60-day period. The Secretary may provide for an extension of such period if the Secretary determines such an extension is appropriate. (vi) An approved prior authorization shall be deemed to constitute medical necessity but shall not eliminate the documentation requirements necessary to support a claim for the transport. (vii) Other elements determined appropriate by the Secretary. (C) Reliance upon contractors The Secretary may rely upon contractors to implement the requirements of this paragraph. The contractor’s compensation shall be limited to a demonstration that it has reduced the number of non-emergency basic life support services involving individuals with end-stage renal disease for renal dialysis services (as described in section 1881(b)(14)(B)) furnished other than on an emergency basis. (D) Applicable ESRD ambulance services In this paragraph, the term applicable ESRD ambulance services (E) Ambulance provider; applicable ambulance provider defined In this paragraph: (i) Ambulance provider The term ambulance provider (ii) Applicable ambulance provider The term applicable ambulance provider (F) Implementation (i) In general Subject to clause (ii), the Secretary may carry out this paragraph through program instruction or otherwise. (ii) Sufficient notice to prepare Not later than June 30, 2016, the Secretary shall make the aspects of the process under this paragraph available to the public. . (b) Conforming amendments Section 1834(l) of the Social Security Act ( 42 U.S.C. 1395m(l) (1) in paragraph (1), by striking a supplier or provider or under arrangement with a provider an ambulance provider (as defined in paragraph (18)(E)(i)) or under arrangement with an ambulance provider (2) in paragraph (8), in the matter following subparagraph (B), by striking provider or supplier of ambulance services ambulance provider (as defined in paragraph (18)(E)(i)) (3) in paragraph (9), in the heading, by inserting ambulance rural (4) in paragraph (12), in the heading, by inserting ambulance rural (5) in each of subparagraphs (B)(ii) and (D)(ii) of paragraph (14), by striking entity ambulance provider (as defined in paragraph (18)(E)(i)) 4. Requiring ambulance providers to submit cost and other information Section 1834(l) of the Social Security Act ( 42 U.S.C. 1395m(l) (19) Submission of cost and other information (A) Development of data collection system The Secretary shall develop a data collection system (which may include use of a cost survey and standardized definitions) for ambulance providers to collect cost, revenue, utilization, and other information determined appropriate by the Secretary. Such system shall be designed to submit information— (i) needed to evaluate the appropriateness of payment rates under this subsection; (ii) on the utilization of capital equipment and ambulance capacity; and (iii) on different types of ambulance services furnished in different geographic locations, including rural areas and low population density areas described in paragraph (12). (B) Specification of data collection system (i) In general Not later than July 1, 2016, the Secretary shall— (I) specify the data collection system under subparagraph (A) and the time period during which such data is required to be submitted; and (II) identify the ambulance providers who would be required to submit the information under such data collection system. (ii) Respondents Subject to subparagraph (D)(ii), the Secretary shall determine an appropriate sample of ambulance providers to submit information under the data collection system for each period for which reporting of data is required. (C) Penalty for failure to report cost and other information Beginning on July 1, 2017, a 5-percent reduction to payments under this part shall be made for a 1-year prospective period specified by the Secretary to an ambulance provider who— (i) is identified under subparagraph (B)(i)(II) or (D)(ii) as being required to submit the information under the data collection system; and (ii) does not submit such information during the period specified under subparagraph (B)(i)(I). (D) Ongoing data collection (i) Revision of data collection system The Secretary may, as determined appropriate, periodically revise the data collection system. (ii) Subsequent data collection (I) In general In order to continue to evaluate the appropriateness of payment rates under this subsection, the Secretary shall, for years after 2017 (but not less often than once every 3 years), require ambulance providers to submit information for a period the Secretary determines appropriate. The penalty described in subparagraph (C) shall apply to such subsequent data collection periods. (II) Sample For each period described in subclause (I), the Secretary shall determine an appropriate sample of ambulance providers to submit information under the data collection system for such period. In determining which ambulance providers would be required to submit information for such period, the Secretary may not require an ambulance provider who has already submitted information for a previous period to submit information for a subsequent period unless all of the ambulance providers who the Secretary determines are the same type as such ambulance provider have either submitted information or been penalized under subparagraph (C) for not doing so. (E) Consultation The Secretary shall consult with stakeholders in carrying out the development of the system and collection of information under this paragraph, including the activities described in subparagraphs (A) and (D). Such consultation shall include the use of requests for information and other mechanisms determined appropriate by the Secretary. (F) Definition of ambulance provider In this paragraph, the term ambulance provider (G) Administration Chapter 35 (H) Limitations on review There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the data collection system or identification of respondents under this paragraph. (I) Funding for implementation For purposes of carrying out subparagraph (A), the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $1,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for fiscal year 2016. Amounts transferred under this subparagraph shall remain available until expended. .

Summary: Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015 Amends part B (Supplementary Medical Insurance Benefits) of title XVIII (Medicare) of the Social Security Act with respect to the ambulance fee schedule to: (1) increase the conversion factor for ground ambulance services in the formula for determining the appropriate fee, and (2) increase the mileage rate for such services. Directs the Secretary of Health and Human Services to study how the conversion factor should be modified, if at all, to take into account the cost of providing ambulance services in urban, rural, and super-rural areas. Directs the Secretary to establish a process to determine, in advance of furnishing end stage renal disease ambulance services, whether payment for them may not be made because they are not covered or because they are excluded from coverage. Prohibits any payment unless the Secretary determines, pursuant to this process, that the service meets coverage requirements. Directs the Secretary to develop a data collection system for ambulance providers to collect cost, revenue, utilization, and other appropriate information.