By Ryan S. Stark, Esq., Partner, Attorney at Law, Page, Wolfberg & Wirth, LLC
When CMS announced the new Emergency Triage, Treat and Transport (ET3) model on Feb. 14, 2019, the EMS industry cheered. Then, predictably, the questions began rolling in.
While many details still need to be ironed out before the first Request for Applications this summer, we did learn a few new things about the program during the recent CMS webinar: Emergency Triage, Treat, and Transport (ET3) Model - Overview.
1. You don’t need a low acuity medical triage line to participate
One of the ways ET3 aims to reduce unnecessary emergency room (ER) trips is by establishing medical triage lines for low-acuity 911 calls. These medical triage lines will be restricted to regions where there are ET3 ambulance service participants. But according to CMS, not every ambulance service participating in the ET3 model will be in a region with a low acuity medical triage line. CMS is offering only a limited number of cooperative agreements to entities that operate 911 dispatch centers. The bottom line for ambulance services is that you do not have to operate in an area that has a low acuity medical triage line to participate in the ET3 model.
2. The patient will not have a choice in alternative destination
Another way ET3 proposes to reduce unnecessary ER transports is to provide Medicare reimbursement for transportation to alternative destinations – such as a federally qualified healthcare centers, doctor’s offices and urgent care clinics.
CMS said that beneficiaries will not have the choice of alternative destination. Ambulance services must have agreements in place with alternative destinations and ambulance services can limit transportation to those locations in the ET3 model.
3. If the patient wants to go to the ER, the patient must go to the ER
In cases where the patient is determined to be eligible for transport to an alternative destination, but the patient chooses to go to the ER, CMS said the ambulance service should always honor the patient’s request to go to the ER.
4. Medicare requirements govern for patient choice trips to the ER
When CMS noted that the beneficiary always has the right to select the ER, even when the patient is determined to be eligible for transport to an alternative destination, we wondered if those trips to the ER would be covered by Medicare. CMS said that patients have the choice to go to the ED “as long as they meet medical necessity for emergency ambulance transport under Medicare rules.” This statement implies that when the beneficiary chooses to go to the ER when they could have gone to an alternative destination, the trip must meet Medicare’s coverage guidelines in order for Medicare to pay for the transport. CMS’s statement also begs the question of whether CMS will require that Medicare’s medical necessity requirements be met to obtain reimbursement for transports to alternative destinations under the ET3 model. CMS has not yet weighed in on that question.
5. ET3 is ambulance only
CMS stated that reimbursement for transport to an alternative destination must be in an ambulance vehicle. The ET3 model does not pay for transport in alternate vehicles.
6. Medicare will not pay for ride home from alternative destinations
While Medicare Part B pays for ambulance transportation from a hospital or skilled nursing facility to the beneficiary’s home when all applicable coverage criteria are met, CMS says there will be no Medicare reimbursement for transport home from one of the alternative destinations under the ET3 model.
7. Treatment in place must always involve a qualified healthcare practitioner
ET3 also provides reimbursement for “treatment in place” if a beneficiary meets eligibility requirements – based on clinical protocols approved by the medical director. But, treatment in place must always include a qualified healthcare practitioner (QHP) either rendered on-site or via telehealth.
Although CMS has not yet issued a list of QHPs, CMS said that a QHP is someone other than an EMT or paramedic. In other words, a QHP would likely need to be physician, nurse practitioner, physician’s assistant or another provider besides a prehospital practitioner. CMS made clear, ET3 is not a community paramedicine model. “Community paramedicine models, where a paramedic is allowed to assess the patient and treat and release the patient without telehealth or the involvement of a QHP, are not eligible for ET3 reimbursement.”
8. You must have an agreement with a QHP
CMS said that QHPs are providers that have entered into a voluntary agreement with a participant to render such services through the ET3 model. So, your ambulance service must have some agreement in place with a QHP to be eligible for reimbursement for treatment in place under ET3.
9. The QHP will bill separately for treatment in place
QHPs are separately enrolled independent health practitioners who will bill Medicare separately for any telehealth or in-person services that they provide to beneficiaries who are treated in place. A QHP will not be paid out of the reimbursement paid to the ambulance service for treatment in place services. Instead, Medicare will pay both the ambulance service and the QHP for eligible ET3 treat in place services.
10. Payment will be at BLS rate for ET3 services
CMS indicated that reimbursement for treatment in place and transport to alternative destinations would be at the Medicare Part B ambulance fee schedule base rate for Basic Life Support (BLS) in addition to any mileage. CMS also seems to be saying that even if the call qualifies as an ALS call based upon an ALS assessment or ALS intervention, Medicare will only reimburse the ambulance service at the BLS rate for treatment in place or transport to an alternative destination.
Over the coming weeks, ambulance services who want to participate in the ET3 model need to seek partnerships with alternate destinations and QHPs. They will also need to talk to their medical director about protocols for treatment in place and transport to other destinations. For more information about ET3 and for assistance in participating in this model, contact Page, Wolfberg & Wirth.
