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Thursday, June 11, 2015

Read this through carefully and your mind will expand with possibilities. A reading Rainbow!

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CMS Finalizes Rules for Medicare Shared Savings Program


It is. Now, the Earth turns on "take your medications, because you're crazy."

Obviously, the Holocaust never, ever happened, etc.


And how are women like Hitler? They hit people. Riiiiiighhhhhhhht.....

Just as your eyesight is going and you REALLY need this:

Non-Emergent Ambulance Transport: Don’t Lose Out on Coverage

Al Sharpton will eat his Red Black and White, one of these oh already?

Part B of Medicare will generally cover up to 80% of emergent and non-emergent ambulance transports when medically necessary and when transport by any other means could endanger your health. There are also origin/destination requirements; Medicare will typically only cover transports to the nearest appropriate medical facility that can provide the level of care necessary to treat your illness or injury. In a true medical emergency, as long as the transport was to the nearest facility capable of providing the appropriate level and type of care for the patient’s condition then payment should generally be made. However, when the transport is considered non-emergent there are some additional caveats.

Beneficiaries frequently experience denials for non-emergent transports because Medicare regulations require that either the beneficiary be bed-confined and that the beneficiary’s condition is such that other methods of transportation are contraindicated, OR, if his or her medical condition, regardless of bed confinement, is such that transportation by an ambulance is medically required.

Medicare regulations consider “bed confinement” to mean that the beneficiary is
Unable to get up from bed without assistance;
Unable to ambulate; and
Unable to sit in a chair or wheelchair.

Often, when a patient is due for discharge, nurses or other staff help the individual get ready to leave the hospital. This often includes assisting the patient to get dressed and transferring them to a chair or recliner and packing their belongings. This would appear to expedite the discharge process, and be helpful to both the patient and the ambulance crew when they arrive. Common sense dictates that it is easier to stand and pivot a patient onto a stretcher rather than manually lift them from one bed to another. Often, neither nurses nor patients are knowledgeable regarding specific Medicare coverage requirements, and are therefore unaware that these simple actions could cause billing issues going forward.

Ambulance crews are trained to document a beneficiary’s appearance upon their arrival. The “run sheets” they complete will note, for example, whether a beneficiary is found in a chair, or whether they were able to stand and get on the stretcher. Unfortunately, these narratives can be incomplete by failing to note such key facts as whether the beneficiary was actually in reclined position (not actually sitting upright), required total assistance for any transfers, or was unable to walk unassisted. Even more troubling, the absence of specific communication by the staff at the discharging facility could lead to the ambulance crew erroneously documenting that the transport was not medically necessary, all of which could lead to an eventual denial of the claim by Medicare.

Often cases such as these are won on appeal, and coverage for the transport is granted once the details have been explained to an Administrative Law Judge (ALJ). However, the current backlog for Medicare hearings means that getting such a decision granting coverage could potentially takeyears.

How Can a Medicare Beneficiary Ensure Appropriate Coverage for Non-Emergent Ambulance Transport?

When in a medical facility awaiting transport, a beneficiary should assess whether he or she meets the definition of “bed confined.” Is the beneficiary:
Unable to transfer without assistance;
Unable to ambulate (walk), and
Unable to sit upright due to pain or medical contraindication? (An example of “medically contraindicated” would be an individual immediately following hip fracture repair surgery)

If all of the above are true, it may be wise to question the nurses preparing the beneficiary for discharge, and politely, but firmly, request that he or she remain in bed while awaiting ambulance pickup.

If the beneficiary is not “bed confined” it may be worth discussing with the doctor or nurse whether transport via ambulance is medically necessary - meaning that transport by any other means could jeopardize the patient’s health. An ambulance crew is specially trained to monitor and address changes in a person’s condition during transport, while the driver of, for example, a wheelchair van, is not. If the transport is medically necessary, request that the doctor or nurse communicate this clearly to the ambulance crew so their documentation will reflect this when they submit the bill to Medicare.

If the beneficiary is not bed confined and does not meet the criteria for medically necessary ambulance transport, it might be wise to consider other appropriate alternatives to an ambulance, or understand that he or she could likely be held responsible for the bill.

Finally, if Medicare inappropriately denies coverage of non-emergent ambulance transport, a beneficiary should appeal the decision by following the instructions on the Medicare Summary Notice (MSN). The Center for Medicare Advocacy also offers detailed instructions in our ambulance self-help packet, available at

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Deficiencies Upheld at Maryland Nursing Facility Based on Resident’s Placement on a Locked Unit

When the Centers for Medicare & Medicaid Services (CMS) cites care problems (called deficiencies) at a nursing facility and imposes financial penalties, the facility may file an administrative appeal with the Departmental Appeals Board. In the first case that the Center for Medicare Advocacy is aware of that discusses these issues, an Administrative Law Judge (ALJ) sustained three deficiencies cited at a Maryland nursing facility based on the facility’s placing a resident on a locked unit at the request of her power of attorney. In a summary judgment decision, ALJ Steven T. Kessel upheld civil money penalties totaling $380,750. NMS Healthcare of Hagerstown v. CMS, Docket No. C-14-1566, Decision No. CR3772 (Apr. 10, 2015),

The resident had lived at the nursing facility for three years when she was briefly hospitalized. On her return in January 2014, the facility placed her in a locked unit, based on the request of one of her daughters, who had power of attorney. The facility denied the resident access to other family members and to an attorney who was trying to help her challenge the power of attorney.

Following a survey by the state survey agency, CMS cited three deficiencies at the immediate jeopardy level (the highest level of noncompliance in the federal regulatory system): (1) denial of immediate access to resident to members of her immediate family, 42 C.F.R. §483.10(j)(1)(vii); (2) involuntary seclusion, §483.1; and (3) professional standards (use of least restrictive means possible), §483.20(k)(3)(i). CMS also cited four non-jeopardy deficiencies, one of which the ALJ addressed and sustained, for controlling the resident’s access to a telephone, in violation of 42 C.F.R. §483.10(k).

In a strongly-worded decision, Judge Kessel found no evidence that the facility had done any care planning or clinical evaluation to justify the resident’s placement on the locked unit. He rejected five after-the-fact declarations by health care professionals, which the facility submitted to justify the placement. The ALJ concluded:

The regulations governing skilled nursing facilities do not allow facilities to abdicate their responsibilities to residents in order to cater to the whims of residents’ family members, whether or not they have POAs. Otherwise, nursing facilities could be turned into prisons in which family members lock their relatives away purely for the sake of convenience. When a family member – even one holding a POA – requests a facility to confine a resident that facility continues to have the duty to ascertain that what is asked for is clinically necessary and that whatever is decided upon is the least restrictive approach that is reasonable to protect the resident and assure his or her health and safety. Doing anything less than [that] could be consent to imprisonment.

Decision 10.

CMS Finalizes Rules for Medicare Shared Savings Program

On June 9, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register its final rule for Medicare Shared Savings Program. The rule can be found at: (site visited June 9, 2015). See also 42 C.F.R. Part 425. Effective Dates: with the exception of the amendments to §§ 425.312, 425.704, and 425.708, the provisions of the final rule are effective on August 3, 2015. The amendments to § 425.312 and § 425.708 are effective November 1, 2015. The amendments to § 425.704 are effective January 1, 2016.

The rule concerns the workings of CMS’ Accountable Care Organizations (ACOs) as established by Section 3022 of the Affordable Care Act. See (site visited June 9, 2015). The Medicare Shared Savings Program is part of Medicare’s fee-for-service offerings and is designed to improve health care delivery, patient experience, and reduce costs. It is voluntary and accepts applications from ACOs on an annual basis. ACO contracts are for three years. See CMS’ description of the program located at: (site visited June 9, 2015).

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