March 16, 2016
A sudden medical emergency or when the patient's health is in danger, ambulance transportation is called for. But, whether or not Medicare will cover and under what situations, healthcare providers should always be in the know. Not just patients, but many healthcare providers and caregivers are often unsure if Medicare Part B (Medical Insurance) will cover the medical transportation expenses or not. Medicare coverage depends on the seriousness of the patient's medical condition and whether they could have been safely transported by other means.
Medicare does cover ambulance services to or from a hospital, critical access hospital (CAH), or a skilled nursing facility (SNF) but only when other transportation could endanger patient's health. In some cases, Medicare may also cover ambulance services if the patient has End-Stage Renal Disease(ESR D), needs dialysis, and needs ambulance transportation to or from a dialysis facility but again it all depends on the times and situations prevalent. However, if patients choose to be transported to a facility farther away, Medicare's payment will be based on the charge to the closest appropriate facility. But, if no local facilities are able to give the patient the care needed, then Medicare will pay for transportation to the nearest facility outside their local area that's able to give them the necessary care. Here one has to have diligent documentation to support. But, what happens in non-emergency Medical transportation? Does Medicare part B coverage work then too?
Why is all this necessary to know? Because as a healthcare provider, if and when you arrange such a transportation for your patient, and you later find that the patient has not been covered under Medicare for this, then when you bill, you will not be paid and will have to bear the cost, which could affect your Revenue Cycle Management (RCM) process and thereby undergo some financial loss. So it is always better to be aware of what Medicare will pay and under what "medical necessity" it will pay for ambulance services for your patients, more so under non-emergency situations, before you code and raise the bill!
And yes, there are times when Medicare will and can pay for non-emergency medical transportation but under certain conditions only:
Patient's health endangered: When transportation is needed to obtain treatment or diagnose the health condition of a patient and the use of any other transportation method could endanger the patient's health, or even when no transportation is available, especially in rural areas and ground conditions are bad that could endanger the health further
Medical Necessity: It may cover limited but "medically necessary", non-emergency ambulance transportation if the patient has a written order from the doctor stating that ambulance transportation is necessary due to their medical condition and should be dated no earlier than 60 days before the ambulance service is requested, but thorough and supportive document should be available to support the "medical necessity" and prior approval is sought from Medicare especially when
The patient is confined to the bed (unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair); or
When the patient needs vital medical services during the trip that are only available in an ambulance, such as administration of medications or monitoring of vital function
Location: Even in non-emergency medical cases, if no transportation is present, especially in certain rural areas, then even though the situation is not an emergency, "ambulance transportation may be deemed a medically necessary" due to the medical condition
Medicare may cover unscheduled or irregular non-emergency trips, if you live in a skilled nursing facility (SNF), only after a doctor's order is given within 48 hours after the transport. But, if you are receiving SNF care under Part A, any ambulance transport should be paid for by the SNF, who then should not bill Medicare for this service.
It also needs to be noted that lack of access to alternative transportation alone does not justify Medicare coverage. Medicare will never pay for ambulance services, like a wheelchair-accessible van that provides non-emergency transportation for people with disabilities.
Repetitive Non- emergency trips : It needs to be checked if a patient has been scheduled, non-emergency, medically necessary ambulance transportation 3 or more times in a 10-day period or at least once a week for 3 weeks or more, especially if the patient and you, the ambulance company, is based in New Jersey, Pennsylvania, or South Carolina, as both could be affected by a new 3-year demonstration. Under this demonstration, you need to get a prior approval process (called "prior authorization") from the Medicare Administrative Contractor (MAC) and send a request for prior authorization before the fourth trip in a 30-day period, to know if Medicare will cover your services.
Hence it is very essential for healthcare providers to be aware of the relevance of Medicare payment when medically billing and coding for non-emergency medical transportation.
Best Billing and Coding Practices