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Medicare rule draws sharp criticism from ambulance industry

November 16, 2015
FROM:     Lauren Sausser, The Post and Courier
RE:         Medicare rule draws sharp criticism from ambulance industry

Private ambulance company owners in South Carolina have become increasingly critical of a Medicare experiment designed to eliminate insurance fraud and save the federal government money.

Scot Parsick owns Shoreline Medical Transport in Ridgeland. He said the one-year-old program even contributed to a Bluffton man’s death.

 “He was a patient of ours that we took to dialysis on and off for a couple years,” Parsick said. “As he got older, he kept getting worse and worse.”

Medicare implemented the new rule in South Carolina almost a year ago. It requires patients to obtain prior authorization before the government pays for routine, non-emergency ambulance transportation. In theory, the rule makes sure only the sickest patients who can’t transport themselves qualify for the expensive service.

But ambulance owners have complained that the company designated to administer Medicare in South Carolina seems to approve and deny transportation requests at whim.

“The process is arbitrary,” said Josh Watts, who owns MedTrust Medical Transport in Charleston. “The same patient may be approved this period, and the next period you submit the exact same paperwork ... and get denied. What worked two months ago won’t work now, and you don’t know why.”

Palmetto GBA, a subsidiary of BlueCross BlueShield of South Carolina, administers Medicare in South Carolina. The federal government defines repetitive ambulance service as “medically necessary ambulance transportation that is furnished three or more times during a 10-day period; or at least once per week for at least three weeks.” It’s often used by patients who need dialysis treatment or chemotherapy.

Patti Embry-Tautenhan, a spokeswoman for Palmetto GBA, pointed out that the criteria didn’t change when the new rule was implemented. The only difference is that patients now need permission before Medicare will pay.

“This oversight safeguards the Medicare Trust Fund and ensures that taxpayer dollars are spent appropriately for these services,” Embry-Tautenhan said in a prepared statement.

She would not specify how much money prior authorization has saved Medicare on ambulance transportation since the rule was implemented on Dec. 1 last year. She cited a 2013 federal report that shows ambulance transportation for dialysis patients increased by 269 percent across the country between 2002 and 2011. In South Carolina, ambulance transportation for these patients skyrocketed by 6,920 percent, by far the highest increase in the United States. The report did not determine if some of that growth was tied to fraud.

Parsick and other ambulance company owners say they don’t mind the new prior authorization rule, but they believe Palmetto GBA refuses to approve transportation for patients who clearly need help.

Richard Linder, for example, suffered a stroke and from diabetes. He should have easily qualified for routine ambulance transportation, Parsick said, but his requests were repeatedly denied or delayed.

“The family was getting very worried that they would end up with these huge bills,” he said.

Richard’s wife, Arlene Linder, couldn’t afford to pay for the ambulance out-of-pocket as it costs more than $400 round trip. And she couldn’t drive her husband to dialysis appointments in a regular car. He would slip and fall without the help of trained medics.

“He couldn’t move at all. He couldn’t walk.,” Linder said.

She eventually moved her husband into a Walterboro nursing home because she couldn’t wait for the ambulance approvals any longer. He died within three weeks.

“His body was really failing,” she said. “I think he gave up.”

A spokesman for the federal Centers for Medicare & Medicaid Services did not answer questions about the program.

For now, the rule is only enforced in South Carolina, Pennsylvania and New Jersey, but Medicare will roll it out in six more states, including North Carolina, in January. Eventually the program could become national policy, potentially saving the government hundreds of millions of dollars.

Randy Bowers, a private ambulance company owner in Easley and president of the South Carolina Ambulance Providers Association, said it’s a good idea, but he thinks Palmetto GBA is botching the program to save money at all costs.

“It’s just very inconsistent, extremely inconsistent,” Bowers said. “It’s not about fraud and abuse, it’s about reducing spending.”

Linder insisted her husband needed an ambulance to get to dialysis appointments and that the new rule contributed to his downfall.

“What are these people supposed to do? Crawl there? This is ridiculous,” she said. “Maybe Medicare didn’t want him to live that long ... I really believe these politicians just want all the old people to die because that’s basically what will happen.

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