Georgia Medicaid to Pay for Treatment on Scene, Alternative Destinations

In early 2017 the Georgia State Office of Rural Health (SORH) submitted three proposals to the Georgia Medicaid office requesting changes to reimbursement for EMS. The proposals requested consideration of reimbursing EMS for 1) treatment of patients without transport, 2) transporting patients to destinations other than hospitals, and 3) mobile integrated healthcare/community paramedicine (MIH-CP) programs. Traditionally EMS services have only been paid when a patient was picked up and taken to an emergency room. These changes would allow for payment to EMS providers for the care they give, regardless of where that care takes place or where the patient needs to go. 

Georgia Medicaid has now approved treatment without transport and transport to alternative destinations for reimbursement. It will submit the MIH-CP proposal to the Centers for Medicare and Medicaid Services (CMS) for approval in the coming months. 

Assuming no unforeseen barriers, treatment-without-transport payments will be effective beginning April 1, 2018. Submission of claim for reimbursements under code A0998 will require that the response originate through a 9-1-1 call and that the patient receive treatment with pharmaceuticals before refusing transport to the hospital. The intent behind this proposal is to allow EMS to recover some of the costs associated with providing medications to patients who ultimately choose not to be transported for continuation of care. The payment for this service will be set at $48.28. Medicaid is the second major healthcare payer to announce payment for this service in Georgia, following the January announcement that Anthem/BCBS would pay for EMS treatment of patients without transport. 

Payments for transport to alternative destinations is targeted to start July 1, 2018. Submission of claims will require that the response originate through a 9-1-1-type call; the existence of an approved protocol signed by the agency medical director specific to patient evaluation and transport to an alternative facility; documentation of the patient’s agreement to go to an alternative facility; and a written agreement between EMS and the receiving facility. The intent behind this proposal is to allow EMS an opportunity to transport properly screened patients who have noncritical conditions to facilities appropriate for their needs, thereby reducing overcrowding of hospital emergency departments and allowing patients to receive medical attention in a less costly setting. This option may also allow counties with no local hospital and/or limited ambulance coverage to shorten turnaround times and keep resources within county borders for longer periods while at the same time giving their patients a level of care commensurate with their condition. The payment for these transports will be the same as other Medicaid transports for the same code.

Please keep in mind that all Medicaid claims are subject to review and audit; therefore, proper documentation on the patient care report is essential, and all required supporting documents must be maintained and provided upon request.

Georgia has long been on the leading edge of innovative changes in EMS models, in 2015 becoming one of the first states to add EMS as an “origination site” for telemedicine. Currently only four states have received approval from CMS for Medicaid reimbursement for MIH-CP programs: West Virginia, North Carolina, Minnesota, and California. Georgia Medicaid will submit a proposal that’s structured similarly to those that have received CMS approval and anticipates this proposal will also be approved later this year. However, this is still uncertain, and confirmation of this change will be contingent upon CMS approval. If approved, Georgia will take yet another step into the future of more effective ambulance service models. The State Office of Rural Health will keep EMS partners informed of the progress of this proposal as it works its way through CMS review.

The State Office of Rural Health and EMS Consultants have put together a “tool kit” with documents necessary to take advantage of these changes. For model forms and training/educational materials, go to www.emscltd.com/gaemstoolkit. 

Christopher Kelly is a lawyer who focuses on regulatory healthcare law as it relates to the EMS and ambulance industry. This article is not intended as legal advice. For more information, contact Chris at EMS Consultants, Ltd., 800/342-5460, or e-mail ckelly@emscltd.com.