Letter to the Hon. Alex Azar, Secretary of Health and Human Services, and the Hon. Seema Verma, Administrator of the Centers for Medicare and Medicaid Services - Reps. Axne, Hill, and Larson Lead Call For Fair Reimbursements for Firefighters, EMS First Responders

Letter

Dear Secretary Azar and Administrator Verma:

During this COVID-19 health crisis, fire departments and Emergency Medical Service (EMS) agencies are providing invaluable service to our communities across the United States. We already knew that our first responders are heroes, but now our first responders are also having to provide emergency pre-hospital healthcare to COVID-19 patients. We are writing because our EMS and first responders are receiving inadequate reimbursements from the Center for Medicare and Medicaid Services (CMS).

As you are aware, these agencies are prohibited from seeking reimbursement opportunities that would support their operations while reducing strain on the overall healthcare system. Fire departments and EMS agencies transport tens of millions of patients to hospitals each year and treat countless others on-scene. However, CMS does not provide any reimbursements to ambulance service "suppliers" when a patient is not transported to a hospital.

While fire departments and EMS agencies have long struggled with incomplete federal reimbursements, the problem is becoming worse as the spread of COVID-19 is driving greater numbers of patients to refuse ambulance transportation to hospitals because they fear exposure to the SARS-CoV-2 virus. Because of CMS' reimbursement policies, this large reduction in ambulance transports is placing an enormous financial burden on fire departments and EMS agencies who have to maintain required levels of service and minimum response times while receiving significantly decreased reimbursements. Traditional local government budgets look like they will fall short this year across the country, as state and local revenues have been drastically limited due to the response to COVID-19. This failure to provide accurate reimbursements to fire departments and EMS agencies is forcing these agencies to consider actions such as laying off first responders in order to close budgetary gaps.

The health care landscape has changed with the arrival of COVID-19. That is why we encourage CMS to allow fire departments and EMS agencies to receive payments for providing treatment-in-place (TIP) to their patients as well as providing these agencies with direct reimbursement for facilitating emergency telehealth consultations. This request also includes providing TIP reimbursements for fire departments and EMS agencies which provide on-scene assessment and care but do not provide ambulance transportation.

CMS recently launched the "Hospitals Without Walls" program which offers flexibilities like expanded telehealth and the provision of care in non-traditional settings. We are concerned that CMS did not go further and permit Medicare-enrolled ground ambulance service "suppliers" to provide TIP or to facilitate emergency telehealth consultations. Emergency medical technicians and paramedics are highly trained and skilled healthcare providers who can efficiently assess and care for a variety of illnesses and injuries. CMS should recognize the abilities of these healthcare professionals by providing them with reimbursement for TIP-services to their patients. Providing TIP for these low-acuity patients will allow them to receive care at a more appropriate level in the healthcare system and reduce the strain that low acuity patients place on hospitals.

Furthermore, the concept of providing reimbursement for TIP already is recognized as a treatment option under the Center for Medicare and Medicaid Innovation's Emergency Triage, Treat, and Transport (ET3) program. Additionally, some commercial insurers utilize the A0998 HCPCS Code to provide reimbursement when their beneficiaries receive emergency response and treatment, without transportation, from fire departments and EMS agencies. CMS should consider this precedent and provide reimbursement opportunities to fire departments and EMS agencies providing emergency triage and treatment without transportation to low acuity Medicare and Medicaid beneficiaries.

CMS also should improve the financial reimbursements available to Medicare-enrolled ambulance service "suppliers" by allowing them to receive direct reimbursement for facilitating emergency telehealth consultations. In Section II(E) of CMS' recent interim final rule with comment (IFC), CMS recognized the value of EMS personnel as it pertains to telehealth by recommending that physicians consider collaborating with these agencies to facilitate telehealth consultations. However, the IFC leaves it up to the individual physicians to reimburse these personnel for these services. CMS should develop a payment methodology to reimburse these EMS agencies for facilitating the telehealth consultations associated with CPT codes such as 99281 99282, 99283, 99284, and 99285. As is the case with TIP-options, directly reimbursing fire departments and EMS agencies for facilitating telehealth consultations will provide much needed relief to these agencies and decrease the patient load on already over-stretched hospitals.

We appreciate your efforts to support our frontline firefighters and EMS personnel as they continue to serve in communities across the United States. We look forward to working with you to develop additional policies and funding opportunities to ensure fire departments and EMS agencies have the resources to continue confronting COVID-19 and caring for critically ill and injured patients.