Thursday, July 23, 2015

would insurance pay if Transport of Persons Other Than the Beneficiary in ambulance?

Transport of Persons Other Than the Beneficiary

No payment may be made for the transport of ambulance staff or other personnel when the beneficiary is not onboard the ambulance (e.g., an ambulance transport to pick up a specialty care unit from one hospital to provide services to a beneficiary at another hospital). This policy applies to both ground and air ambulance transports.

Effect of Beneficiary Death on Medicare Payment for Ground
Ambulance Transports
Because the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare-covered service. In general, if the beneficiary dies before being transported, then no Medicare payment may be made.

Thus, in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements.

The chart below shows the Medicare payment determination for various ground ambulance scenarios in which the beneficiary dies. In each case, the assumption is that the ambulance transport would have otherwise been medically necessary.

Ground Ambulance Scenarios: Beneficiary Death
Time of Death Pronouncement Medicare Payment Determination
Before dispatch. None.
After dispatch, before beneficiary is
loaded onboard ambulance (before
or after arrival at the point-ofpickup).
The provider’s/supplier’s BLS base rate, no
mileage or rural adjustment; use the QL
modifier when submitting the claim.
After pickup, prior to or upon arrival
at the receiving facility.
Medically necessary level of service furnished.

The Destination
An ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) as well as the return transport. In addition to all other coverage requirements, this transport situation is covered only to the extent of the payment that would be made for bringing the service to the patient.

Medicare covers ambulance transports (that meet all other program requirements for
coverage) only to the following destinations:
• Hospital;
• Critical Access Hospital (CAH);
• Skilled Nursing Facility (SNF);
• Beneficiary’s home;
• Dialysis facility for ESRD patient who requires dialysis; or
• A physician’s office is not a covered destination. However, under special
circumstances an ambulance transport may temporarily stop at a physician’s
office without affecting the coverage status of the transport.

As a general rule, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered. However, if two or more facilities that meet the destination requirements can treat the patient appropriately and the locality of each facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to any one of the facilities to which the beneficiary is taken is covered. Because all duly licensed hospitals and SNFs are presumed to be appropriate sources of health care, only in exceptional situations where the ambulance transportation originates beyond the locality of the institution to which the beneficiary was transported, may full payment for mileage be considered. And then, only if the evidence clearly establishes that the destination institution was the nearest one with appropriate facilities under the particular circumstances. The institution to which a patient is transported need not be a participating institution but must meet at least the requirements of the Social Security Act (the Act.).

Institution to Beneficiary’s Home
Ambulance service from an institution to the beneficiary’s home is covered when the home is within the locality of such institution or where the beneficiary’s home is outside of the locality of such institution but the institution, in relation to the home, is the nearest one with appropriate facilities.

Institution to Institution

Occasionally, the institution to which the patient is initially taken is found to have inadequate or unavailable facilities to provide the required care, and the patient is then transported to a second institution having appropriate facilities. In such cases, transportation by ambulance to both institutions would be covered to the extent of the mileage to be the nearest institution with appropriate facilities. Responsibility for payment would follow the rules in § 10.3.3. In these cases, transportation from such second institution to the patient's home could be covered if the home is within the locality served by that institution, or the locality served by the first institution to which the patient was taken.

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