EMS ACT 2001

[Guest guest]

Sustaining Access to Vital Emergency Medical Services Act of 2001

April 20, 2001

Today Congressman Mark Kennedy (R-MN) announced that he introduced HR.1353,

the " Sustaining Access to Vital Emergency Medical Services Act of 2001 " in

Congress on April 3, 2001. This is the House companion bill to S.587

introduced by Senator Conrad (D-ND) on March 21. Both bills provide $50M in

rural EMS grants 2002-2007 and contain Prudent Layperson provisions for

ambulance service for Medicare, Medicare+Choice and Medicaid Managed Care.

Original cosponsors for S.587 included Senators Craig (R-WY), Senator

Daschle (D-SD), Senator Tim (D-SD) and Senator Pat

(R-KS). Since it's introduction, Senator Zell (D-GA) and Senator

Leahy (D-VT) have signed on as cosponsors.

When Congress returns to Washington on April 23, Congressman Kennedy expects

that Congressman Gil Gutknecht (R-MN) and Congressman Earl Pomeroy (D-ND) to

sign on as cosponsors. This week, the Minnesota EMS Regulatory Board,

Minnesota Ambulance Association and Minnesota Rural Health Association

endorsed these companion bills.

Congressman Kennedy wanted to publicly announce this bill introduction in

his district while Congress was in recess. He chose to make the announcement

at a Rural Health Forum sponsored by the Minnesota Rural Health Association

in Redwood Falls today. 62 Minnesotans attended the Rural Health Forum, some

traveling almost 3 hours to participate. Congressman Kennedy's Minnesota

district is almost entirely rural, comprises 16,690 square miles (more than

twice the geographical size of the state of Massachusetts) and has 93

ambulance services, most of which are community operated by volunteers.

Every 20 minutes an ambulance service in the district responds to a 911 call

for assistance.

In his remarks regarding the need for this legislation, Congressman Kennedy

praised the individual efforts of EMS volunteers, recognized the impending

problems with the structure and funding of the proposed Medicare ambulance

fee schedule and expressed dismay at the current payment practices of HCFA

for ambulance service. In describing the need for an ambulance Prudent

Layperson standard within the Medicare program, he shared the following

story of the family of Dr. Mark Lindquist, an emergency room physician and

ambulance service medical director in Detroit Lakes, Minnesota:

" In late July, 2000, my father collapsed suddenly while staining a gazebo.

My mother was trapped in the gazebo for a short time, as he was lying

unconscious against the door, bleeding from a head wound. She was

eventually able to push him away enough to go to the phone and call 911. FM

Ambulance paramedics arrived quickly, just as my father was becoming

conscious, confused and agitated. He was brought by ambulance to the ED at

Dakota Heartland Hospital in Fargo, where a work-up showed the presence of a

large, complex brain aneurysm. His sudden collapse was caused by a sentinel

bleed from the aneurysm, which in most cases will go on to complete rupture

and subarachnoid hemorrhage in 10-14 days after the sentinel event.

Because of the size and complexity of the aneurysm, he was referred to a

neurosurgeon at the University of Minnesota, and he underwent surgery a week

later. The surgery resulted in a serious secondary brain injury, and when

his post-op condition was stabilized, he was transferred back to Dakota

Heartland Hospital in Fargo by ambulance. It was felt that he would require

extensive hospital care and rehabilitation. He was unable to walk more than

a few feet unassisted, and he was confused, impulsive and required constant

monitoring.

Subsequently, he sustained further ischemic injuries to his brain, became

septic, and died on August 13 at the age of 70. Prior to this illness, he

had no medical problems.

Since his death, Medicare has denied the initial 911 ambulance bill, stating

that the ambulance wasn't necessary, (he was unconscious and bleeding

profusely when my mother called 911.) Apparently, my mother should have

been able to load his body into a car and drive him to the hospital.

Medicare denied the ambulance bill for transfer back to Fargo for further

care and rehabilitation, over-ruling the neurosurgeon's judgment that my

father needed continuous care and monitoring during the transfer. In both

cases, my father's physicians wrote letters to Medicare explaining his

serious medical condition and the need for care in-transit, but again the

claims were denied.

Most recently, Medicare has denied payment of the neurosurgeon's bill,

stating that the surgery was unnecessary and therefore not covered. We wish

we'd had the benefit of Medicare's infinite wisdom before the surgery.

Presumably, my father would still be alive and well if he'd had the advice

of the HCFA clerk.

Needless to say, my mother has been perplexed. She cannot understand why

the claims were denied, and unfortunately, I have learned that she has paid

the ambulance bills on her own. Neither of my parents are the type of

people to allow bills to go unpaid.

I am frankly disgusted with the callous disregard for competent medical

judgment shown by HCFA. I have had a hard time explaining to my mother that

Medicare treats everyone this way, and that this is not a case of poor

decision making on her part (in calling an ambulance) or on the doctor's

part (operating to try and save my father's life.) Naturally, she is

shocked to learn that HCFA holds everyone in such low regard. I hope that

radical Medicare reform can follow soon.

Sincerely,

Mark D. Lindquist, MD "

Unfortunately, stories like Dr. Lindquist's are all too common in the

Midwest and in other parts of the country. Last year the US General

Accounting Office reported that the denial rates of emergency ambulance

claims in the US to be between 2% and 20% for the carriers who process 2/3

of all ambulance claims. It singled out Noridian, which is the carrier for

11 states including North and South Dakota, as having the highest denial

rate at 20%. Florida Blue Shield and Trailblazers both denied 15% of

emergency ambulance claims in 1998. In Minnesota, non-hospital ambulance

services (claims processed by WPS) are reporting increasing numbers of

denied emergency claims this year, while hospital-based providers (claims

processed by Noridian) are reporting their Medicare receivables have almost

tripled between January 1st and April 15th, mostly due to denied emergency

ambulance claims.

The best way to assure the proper payment of emergency ambulance claims is

for HCFA to adopt the condition coding system developed during Negotiated

Rule Making for the ambulance fee schedule and mandate its use by carriers

and intermediaries, and for Congress to enact the Prudent Layperson

standard.

EMS providers are encouraged to contact their members of Congress and ask

them to cosponsor S.587 or HR.1353. Rural providers should include

information regarding the need for EMS grants and how they might utilize

them. All providers are encouraged to include the stories of one or two

beneficiaries who have had necessary emergency medical transport and whose

claims have been denied. To find out how to contact your state Senators, go

to http://www.senate.gov. To find out how to locate and contact your

Congressman, go to http://www.house.gov. To find the text of these bills or

other ambulance-related bills before Congress, go to http://thomas.loc.gov

and do a keyword search on the word ambulance.