When it comes to ambulance transport services, there’s a difference between what’s reasonable and what’s medically necessary. Until the COVID-19 pandemic, I’d always struggled to find an example of this distinction that was something EMS providers might actually encounter in the field. Now, thanks to expanded options for where telehealth calls can originate, I have an excellent example.
Prior to COVID-19’s designation as a public health emergency, a patient had to leave their home in a designated rural area and travel to a clinic or other approved origination site to initiate a telehealth call. However now, at least temporarily, telehealth calls can be made from a patient’s home, and that home does not have to be in a rural area—telehealth calls can be made from any patient’s residence.
But let’s go back a step and talk about that distinction between what is reasonable and what is medically necessary.
Think of it this way: Before determining what type of vehicle a patient needs to go from point A to point B (which is to say, whether transport by ambulance is medically necessary), you first have to determine if the patient needs to leave point A at all. If you determine the patient does not need to leave point A to get the medical services they need, then obviously you don’t have to be concerned with what type of vehicle is used for transport, because moving the patient is not reasonable—there is literally no reason to do so.
So, back to my example, if the patient can be screened by telehealth in their house, then taking them by ambulance (or any other mode of transportation) is not reasonable and therefore not a covered service for Medicare beneficiaries—even those beneficiaries who would clearly need an ambulance if they needed to be transported.
This is something ambulance services have not had to be concerned with in the past, because even in rural areas where telehealth was an option, the patient still had to go somewhere to receive it. But in our new COVID-19 reality, patients are being encouraged to get telehealth services instead of presenting at facilities. This all leads to the question, how does EMS fit into this model?
Well, for one, we may be the messenger. When patients call 9-1-1 and EMS responds, we’ll likely be explaining new protocols to them, including requirements for them to get screened before being transported to an ED. We will need to be ready to articulate these options. We may also be the ones initiating telehealth calls for patients who lack their own audio/video communication equipment. Finally, if patient screening ultimately results in a decision not to transport, then we may be providing some assessment and treatment of the patient at their residence.
If and how we get reimbursed for the services we render to the patient while on site is still up in the air. And while this is a current reality, it is also possible the expansion of telehealth options allowed as part of this public health emergency may remain in place even after the event is over, especially if they prove beneficial to patients and the system as a whole. Therefore, for now and quite possibly from here forward, we will have to be aware of those circumstances where moving a patient is not reasonable because telehealth options are available in their home. When that is the case, ambulance transport will not be a covered service.
Of course, not paying us for what we did on scene is also not very reasonable, and that issue will need to be addressed soon.
G. Christopher Kelly is an attorney with the law firm of Page, Wolfberg & Wirth, which focuses on the ambulance industry. He writes regularly for EMS World and sits on the magazine’s editorial advisory board. Contact him at firstname.lastname@example.org.