,i #aacth ,,congress #b;d ,session ,h4 ,r4 #edfj ,,in ,,the ,,house ,,of ,,representatives ,september #aa1 #bjad ,mr4 ,walden 7for himself1 ,mr4 ,welch1 ,mr4 ,nunes1 and ,mr4 ,neal7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to increase access to ambulance services under the ,medicare program and to reform payments for such services under such program4 #a4 ,short title 7a7 ,short title ,this ,act may be cited as the ,medicare ,ambulance ,access1 ,fraud ,prevention1 and ,reform ,act of #bjad4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title4 ,sec4 #b4 ,reform to the ,medicare ambulance fee schedule4 ,sec4 #c4 ,prior authorization for ambulance transports of ,,esrd beneficiaries4 ,sec4 #d4 ,requiring ambulance providers to submit cost and other information4 #b4 ,reform to the ,medicare ambulance fee schedule 7a7 ,in general ,section #ahcd7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77 is amended by adding the following new paragraphs3 7#af7 ,increase in conversion factor for ground ambulance services ,in the case of ground ambulance services furnished on or after ,april #a1 #bjae1 for purposes of determining the fee schedule amount for such services under this subsection1 the conversion factor otherwise applicable to such services shall be increased by-- 7,a7 with respect to ground ambulance services for which the transportation originates in a qualified rural area1 as identified using the methodology described in paragraph 7#ab77;,b77iii71 #be4f percent2 7,b7 with respect to ground ambulance services not described in subparagraph 7,a7 and for which the transportation originates in a rural area described under paragraph 7#i7 or in a rural census tract described in such paragraph1 #c percent2 and 7,c7 with respect to ground ambulance services not described in subparagraph 7,a7 or 7,b71 #b percent4 7#ag7 ,increase in mileage rate for ground ambulance services ,in the case of ground ambulance services furnished on or after ,april #a1 #bjae1 for purposes of determining the fee schedule amount for such services under this subsection1 the payment rate for mileage otherwise applicable to such services shall be increased by-- 7,a7 with respect to ground ambulance services for which the transportation originates in a qualified rural area1 as identified using the methodology described in paragraph 7#ab77;,b77iii71 #c percent2 7,b7 with respect to ground ambulance services for which the transportation originates in a rural area described under paragraph 7#i7 or in a rural census tract described in such paragraph1 #c percent2 and 7,c7 with respect to ground ambulance services not described in subparagraph 7,a7 or 7,b71 #b percent4 4 7b7 ,study and report 7#a7 ,study ,the ,secretary of ,health and ,human ,services shall conduct a study on how the conversion factor applicable to ground ambulance services under the ambulance fee schedule under section #ahcd7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l771 as adjusted under paragraph 7#af7 of such section 7as added by subsection 7a771 should be modified1 if at all1 to take into account the cost of providing services in urban1 rural1 and super-rural areas4 ,in determining such costs1 the ,secretary shall use the data collected through the data collection system under paragraph 7#ah7 of such section1 as added by section #d4 7#b7 ,report ,not later than ,january #a1 #bjai1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on the study conducted under paragraph 7#a71 together with recommendations for such legislation and administrative action as the ,secretary determines appropriate4 #c4 ,prior authorization for ambulance transports of ,,esrd beneficiaries 7a7 ,in general ,section #ahcd7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l771 as amended by section #b1 is amended by adding at the end the following new paragraph3 7#ah7 ,prior authorization of coverage for ambulance transports of ,,esrd beneficiaries 7,a7 ,process 7i7 ,in general ,for applicable ,,esrd ambulance services furnished on or after ,january #a1 #bjaf1 by an ambulance provider1 the ,secretary shall establish and implement a process under which the ,secretary shall determine1 in advance of furnishing such a service to an individual1 whether payment for such service may not be made because such service is not covered or because of the application of section #ahfb7;a77#a74 7ii7 ,denial of payment ,subject to subparagraph 7,b77ii77,,ii71 no payment shall be made under this part for the service unless the ,secretary determines pursuant to such process that the service meets the applicable requirements for coverage4 7,b7 ,elements of process ,the process described in subparagraph 7,a7 shall include the following elements3 7i7 ,in order to obtain a prior authorization1 the ambulance provider shall submit-- 7,i7 a valid physician certification statement 7,,pcs7 for non-emergency ambulance transport2 and 7,,ii7 any other documentation determined appropriate by the ,secretary4 7ii7 7,i7 ,the ,secretary shall respond to a prior authorization request within #g business days of receiving the request4 7,,ii7 ,if the ,secretary does not make a prior authorization determination within #g business days of the date of the ,secretary's receipt of medical documentation needed to make such determination1 subparagraph 7,a77ii7 shall not apply4 7iii7 ,in making the determination under subparagraph 7,a7 with respect to a service and individual1 the ,secretary shall evaluate the medical necessity of the service by determining-- 7,i7 whether the individual is unable to get up from bed without assistance1 unable to ambulate1 and unable to sit in a chair or wheelchair2 7,,ii7 whether the individual has a medical condition that1 regardless of bed confinement1 is such that transport by ambulance is medically necessary2 or 7,,iii7 whether the individual meets other criteria as determined appropriate by the ,secretary4 7iv7 ,if the prior authorization request is approved1 such request shall be retroactive to the date on which such request was received4 7v7 ,an approved prior authorization shall be valid for a #fj-;day period4 ,the ,secretary may provide for an extension of such period if the ,secretary determines such an extension is appropriate4 7vi7 ,an approved prior authorization shall be deemed to constitute medical necessity but shall not eliminate the documentation requirements necessary to support a claim for the transport4 7vii7 ,other elements determined appropriate by the ,secretary4 7,c7 ,reliance upon contractors ,the ,secretary may rely upon contractors to implement the requirements of this paragraph4 ,the contractor's compensation shall be limited to a demonstration that it has reduced the number of non-emergency basic life support services involving individuals with end-stage renal disease for renal dialysis services 7as described in section #ahha7;b77#ad77;,b77 furnished other than on an emergency basis4 7,d7 ,applicable ,,esrd ambulance services ,in this paragraph1 the term applicable ,,esrd ambulance services means ambulance services consisting of non-emergency basic life support services involving transport of an individual with end-stage renal disease for renal dialysis services 7as described in section #ahha7;b77#ad77;,b77 furnished other than on an emergency basis4 7,e7 ,ambulance provider ,in this paragraph1 the term ambulance provider means a provider of services 7as defined in section #ahfa7u77 or other entity that furnishes ambulance services under this title4 7,f7 ,implementation 7i7 ,in general ,subject to clause 7ii71 the ,secretary may carry out this paragraph through program instruction or otherwise4 7ii7 ,sufficient notice to prepare ,not later than ,june #cj1 #bjae1 the ,secretary shall make the aspects of the process under this paragraph available to the public4 4 7b7 ,conforming amendments ,section #ahcd7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77 is amended-- 7#a7 in paragraph 7#a71 by striking a supplier or provider or under arrangement with a provider and inserting an ambulance provider 7as defined in paragraph 7#ah77;,e77 or under arrangement with an ambulance provider2 7#b7 in paragraph 7#h71 in the matter following subparagraph 7,b71 by striking provider or supplier of ambulance services and inserting ambulance provider 7as defined in paragraph 7#ah77;,e772 7#c7 in paragraph 7#i71 in the heading1 by inserting ambulance after rural2 7#d7 in paragraph 7#ab71 in the heading1 by inserting ambulance after rural2 and 7#e7 in each of subparagraphs 7,b77ii7 and 7,d77ii7 of paragraph 7#ad71 by striking entity and inserting ambulance provider 7as defined in paragraph 7#ah77;,e774 #d4 ,requiring ambulance providers to submit cost and other information ,section #ahcd7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l771 as amended by section #c1 is amended by adding at the end the following new paragraph3 7#ai7 ,submission of cost and other information 7,a7 ,development of data collection system ,the ,secretary shall develop a data collection system 7which may include use of a cost survey and standardized definitions7 for providers and suppliers of ambulance services to collect cost1 revenue1 utilization1 and other information determined appropriate by the ,secretary4 ,such system shall be designed to submit information-- 7i7 needed to evaluate the appropriateness of payment rates under this subsection2 7ii7 on the utilization of capital equipment and ambulance capacity2 and 7iii7 on different types of ambulance services furnished in different geographic locations1 including rural areas and low population density areas described in paragraph 7#ab74 7,b7 ,specification of data collection system 7i7 ,in general ,not later than ,july #a1 #bjae1 the ,secretary shall-- 7,i7 specify the data collection system under subparagraph 7,a7 and the time period during which such data is required to be submitted2 and 7,,ii7 identify the providers and suppliers of ambulance services who would be required to submit the information under such data collection system4 7ii7 ,respondents ,subject to subparagraph 7,d77ii71 the ,secretary shall determine an appropriate sample of providers and suppliers of ambulance services to submit information under the data collection system for each period for which reporting of data is required4 7,c7 ,penalty for failure to report cost and other information ,beginning on ,july #a1 #bjaf1 a #e-percent reduction to payments under this part shall be made for a #a-year prospective period specified by the ,secretary to a provider or supplier of ambulance services who-- 7i7 is identified under subparagraph 7,b77i77,,ii7 as being required to submit the information under the data collection system2 and 7ii7 does not submit such information during the period specified under subparagraph 7,b77i77,i74 7,d7 ,ongoing data collection 7i7 ,revision of data collection system ,the ,secretary may1 as determined appropriate1 periodically revise the data collection system4 7ii7 ,subsequent data collection ,in order to continue to evaluate the appropriateness of payment rates under this subsection1 the ,secretary shall1 for years after #bjaf 7but not less often than once every #c years71 require providers and suppliers of ambulance services to submit information for a period the ,secretary determines appropriate4 ,the penalty described in subparagraph 7,c7 shall apply to such subsequent data collection periods4 7,e7 ,consultation ,the ,secretary shall consult with stakeholders in carrying out the development of the system and collection of information under this paragraph1 including the activities described in subparagraphs 7,a7 and 7,d74 ,such consultation shall include the use of requests for information and other mechanisms determined appropriate by the ,secretary4 7,f7 ,administration ,chapter #ce of title #dd1 ,united ,states ,code1 shall not apply to the collection of information required under this subsection4 7,g7 ,limitations on review ,there shall be no administrative or judicial review under section #ahfi1 section #ahgh1 or otherwise of the data collection system or identification of respondents under this paragraph4 7,h7 ,funding for implementation ,for purposes of carrying out subparagraph 7,a71 the ,secretary shall provide for the transfer1 from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda1 of #a1jjj1jjj to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for fiscal year #bjae4 ,amounts transferred under this subparagraph shall remain available until expended4 4