Lessons from a Successful Medicare Program Integrity Demonstration | Episode 60

Lessons from a Successful Medicare Program Integrity Demonstration | Episode 60

Almost seven years ago, the Centers for Medicare & Medicaid Services (CMS) launched an initiative to test a possible solution to improper use of ambulance rides, long cited as a major source of waste and abuse in the Medicare program. The idea was pretty simple: Require companies that provide patients with repetitive, scheduled, non-emergent ambulance transport (RSNAT) for certain types of health care, such as dialysis or cancer treatments, to get prior authorization from CMS before providing service and submitting a claim for payment.

Mathematica evaluated impacts of the initiative, which was implemented in the District of Columbia and eight states. Because non-emergency ambulance service use is rare in the Medicare program, the study focused on Medicare beneficiaries who are most likely to use RSNAT services—those with end-stage renal disease and/or severe pressure ulcers. Those two groups account for about 85 percent of Medicare RSNAT claims, so any change in use and spending would be most detectable among those patients.

The most recent Mathematica evaluation found that, as a result of prior authorization, RSNAT costs declined by over 70 percent since the initiative started. Importantly, spending less on RSNAT services resulted in a decrease in overall Medicare fee-for-service spending of more than 2 percent, equal to about $1 billion since the initiative started. All of this occurred without any evidence of a decline in access to care or the quality of care beneficiaries received.

Late last year, CMS announced that it would expand the use of prior authorization for RSNAT services nationwide. On this episode of On the Evidence, guests Amy Cinquegrani of CMS and Andrew Asher of Mathematica discuss lessons that could inform the national rollout as well as novel approaches for using data analytics to further reduce improper health care use and payments.

Cinquegrani directs the Division of Payment Methods and Strategies at the Center for Program Integrity within CMS.

Asher is a senior fellow at Mathematica, where he focuses on using data to help health care payers strengthen the integrity of their programs, realize cost savings, monitor programs, and improve program outcomes.

Find a full transcript of the episode here: mathematica.org/blogs/lessons-from-a-successful-medicare-program-integrity-demonstration-soon-to-expand-nationwide

Read a short fact sheet summarizing findings from the evaluation of the Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport: https://innovation.cms.gov/data-and-reports/2021/rsnat-finlevalrpt-fg

Read the CMS announcement that the Medicare Prior Authorization Model for RSNAT would expand nationwide: https://www.cms.gov/newsroom/press-releases/cms-expand-successful-ambulance-program-integrity-payment-model-nationwide

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