Wednesday, September 23, 2015

Ground Transport, Hospital Transport and Air Ambulance Transport

Time Needed for Ground Transport

Differing Statewide Emergency Medical Services (EMS) systems determine the amount and level of basic and advanced life support ground transportation available. However, there are very limited emergency cases where ground transportation is available but the time required to transport the patient by ground as opposed to air endangers the beneficiary’s life or health. As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport a beneficiary whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the beneficiary’s illness/injury, contractors should consider air transportation to be appropriate.

Hospital to Hospital Transport
Air ambulance transport is covered for transfer of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the beneficiary’s health and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. A patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. Coverage is not available for transport from a hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or physician.

Special Coverage Rule
Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician’s office, or a beneficiary’s home.

Special Payment Limitations
If a determination is made to order transport by air ambulance, but ground ambulance transport would have sufficed, payment for the air ambulance transport is based on the amount payable for ground ambulance transport.

If the air transport was medically appropriate (that is, ground transportation was contraindicated, and the beneficiary required air transport to a hospital), but the beneficiary could have been treated at a hospital nearer than the one to which they were transported, the air transport payment is limited to the rate for the distance from the point of pickup to that nearer hospital.

In order to determine the medical appropriateness of air ambulance services the
contractor may request that documentation be submitted that indicates the air ambulance services are reasonable and necessary to treat the beneficiary’s life-threatening condition. The contractor’s medical staff may consider reviewing all claims for air ambulance services.

Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilot’s Control

The chart below shows the Medicare payment determination for various air ambulance scenarios in which the flight is aborted due to bad weather, or other circumstance beyond the pilot’s control.

Air Ambulance Scenarios: Aborted Flights
Aborted Flight Scenario  Medicare Payment Determination
Any time before the beneficiary is loaded onboard (i.e., prior to or after take-off to point-of-pickup.) None.
Transport after the beneficiary is loaded onboard. Appropriate air base rate, mileage, and rural adjustment.

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