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Wrong Rates Being Paid for Some BLS Non-Emergencies

November 12, 2013
AAA Member Advisory
TO: AAA Membership
FROM:      David M. Werfel, Esq.
RE: Wrong Rates Being Paid for Some BLS Non-Emergencies

Effective October 1, 2013, Medicare Administrative Contractors began to reduce the allowable for BLS non-emergency base rates and mileage, for transports to and from dialysis. CMS issued a Transmittal notifying the contractors of the required change. The Transmittal can be accessed at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2703CP.pdf

The Transmittal advises the Medicare Administrative Contractors to apply the 10% reduction when claims with A0428 (BLS non-emergency) are billed with an origin/destination modifier that contains a "G" or "J", since those are the modifiers for dialysis facilities. Unfortunately, this has also resulted in the allowable being reduced by 10% for some non-dialysis BLS non-emergency claims, when the "GW" (hospice patient, transport unrelated to the terminal illness) or any other modifier with "G" is used (e.g. GM, GA, GZ, GY, etc.), although those are much less likely to occur. Thus, payment for claims with A0428 HE GW, A0428 HR GW, A0428 NH GW, etc. are being reduced, incorrectly, even though they do not involve dialysis.

The problem was first detected in Florida on November 7, 2013. At first, it was believed to only apply to claims billed A0428 HE GW. Then, with assistance of companies in Florida, we realized it was more than just claims billed A0428 HE GW. After some research, First Coast Service Options, the MAC for Florida, was notified and the problem was resolved, on the same day for claims billed after November 7th. First Coast will be making a mass adjustment for those claims paid incorrectly. They will issue a notice to providers in their jurisdiction as to the problem, when the adjustments will be made, etc.

On November 8, 2013, I started asking companies in other states if they experienced the same problem. At first, no one else noticed it, but upon further review of the rates allowed, it is now clear the problem is not limited to Florida. It is a national problem. As of the writing of this article (Nov. 12), I know it applies to Part B BLS non-emergency claims, where GW, GM, GA, etc. are used. I am investigating further to see if Part A claims are affected as the fields used to bill Part A claims are different than Part B claims.

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