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Something Old, Something New


     One advantage of writing the Emergency 4-1-1 column quarterly instead of monthly is that there is more to write about. Of course, the flip side is that there are more things I would like to cover. As it happens, many of the things I think are important for you to be aware of are things we've touched on before. So, this month, we're going to look back at some things I warned you about last year and see how those are panning out.

HIPAA Audits Becoming Realities
     In June 2007, I suggested there was a "new HIPAA sheriff in town" and advised that the OIG would be conducting random HIPAA Security Rule audits. I based my conclusion on what little I knew about the first HIPAA audit that was conducted without warning on a large metropolitan hospital. It now appears that these audits will not only begin in earnest this year, but they may be more widespread than I initially anticipated. A couple of months ago, CMS sent to providers and suppliers who are on one of their e-mail list-servers a two-page document describing what to expect from HIPAA Security Onsite Investigations and Compliance Reviews. In that document, CMS formally put the provider community on notice that these compliance reviews are indeed coming and outlined the personnel who may be interviewed, policies and procedures that will be reviewed, and other documents that may be requested. To see the list of personnel and documents that may be reviewed (and to make sure you have them), go to

EMS Losing Money on Medicare Patients
     In August 2007, my column Medicare Margins discussed a Government Accounting Office report that found EMS was underpaid for Medicare patients by an average of 6% under the actual cost of providing a transport. There is nothing new to report regarding the government's study, but I closed that column with the hopeful thought that Congress might increase our fee schedule rates to compensate for the finding that, as an industry, EMS is losing money on Medicare patients. While Congress might still support us, the president's current proposed budget eliminates inflation increases for ambulance services for the years 2009 to 2011, along with cutting many other EMS-related programs. Coupled with the Medicaid programs in many states opting not to pay crossover balances, it appears that the future of EMS reimbursement from Medicare will continue to fall short of the cost-of-providing-the-service mark.

Medicare Watchdogs Revisited
     A topic I discussed in October also has a new twist on it. In that column, titled Medicare Watchdogs, I discussed Program Safeguard Contractors (PSCs) and the government's position that PSCs should be more aggressive in their auditing practices. I still see no sign of the momentum slowing as we swing into an environment of more post-payment audits. In fact, CMS has just recently published its findings on a demonstration program that occurred in 2007 in which recovery audit contractors (RACs) identified and collected more than $371 million in Medicare overpayments in just three states. The success of the RAC demonstration project has prompted Congress to order that RACs be implemented in all states by 2010. Please note that the RACs are not intended to replace the PSCs, Carriers, OIG or other groups that may identify Medicare overpayments. Instead, they are an additional mechanism for finding even more overpayments. In fact, I can see the RACs and PSCs being almost in competition with each other to identify the most overpayments. However, CMS assures us they will not be looking at the same claims, which really means there will be twice as many eyes looking for overpayments in twice as many claims, thereby doubling your chances of a post-payment audit in the near future. (For more on post-payment audits and how to prepare for them, see my July 2007 article, The Ways and Whys of Documentation.)

     While it may not seem that there are a lot of promising changes on the EMS horizon, keep in mind that you control much of your own destiny. Proper management of your organization will minimize your risk and stress in responding to HIPAA compliance reviews or post-payment audits, and working together through the various EMS associations will shed light on the need for proper funding. I hope you will do both.

G. Christopher Kelly is an attorney practicing in Atlanta, GA. Chris focuses on federal laws and regulations as they relate to the healthcare industry and specifically to the ambulance industry. He also lectures and advises ambulance company clients across the U.S. Contact him at

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