If you are a provider in California (or a state that is soon to implement a similar program), your first question about this program is – how will this effect my bottom line?
While this may seem to be a simple question, I get many of our providers asking me about the financial impact of this program. And as is often the case, the simple questions have simple answers, but we wonder– is there more to it?
The good news is: no, there is not more to it–it actually is a simple calculation. The one variable, of course, is how many runs you do that qualify for the fee-to-the-state by you and how many qualify for the extra revenue (meaning the extra payment from the state).
Fortunately, this is a very simple process, and I am assuming any good billing software can produce a payer mix report with the runs that qualify for the fee or the revenue. For example, in the California GEMT QAF program it is only Emergency Transport codes A0429, A0427, A0433, A0225 and A0434 that will qualify. The next step in generating the report is to produce this data for a specific time period (example below is a quarter since that is what the invoices are for).
In this simple report you can see a total of 210 runs that qualify.
This would result in fee of 210 * $32.30 (current rates), or a total of $6.783.
The income you should have been paid by Insurance Payers that are either Medicaid Fee for Service insurance or Straight Medicaid in our report would include Medicaid, and Medicaid HMOs. A total of 40 transports (7 and 33) for the Quarter. 40 * $220.80 (Current rate for the extra payment since the program started) or $8832 more.
Therefore your net gain in this quarter is $2079 ($8832 less $6783).
Roughly a $8,000 gain each year. From this example (see report below):
Hopefully, generating this report is simple in your system and you can check monthly, quarterly, or yearly to track and forecast the gain or loss from this program.
If you are unfamiliar with the terms GEMT QAF (or not in California or anywhere such a program is being considered), the below section provides some information on this type of program. This one is the California specific one:
CA GEMT QAF Program.
A short summary is this program provided a higher payment to those who provided emergency transports to Medicaid/Medi-CAL and Medicaid HMO patients. The extra payment was funded with a fee for each emergency run done.
A GEMT QAF Rate was calculated for FY 2020-21, in accordance with SB 523. The QAF is assessed on each qualified emergency medical transport, regardless of payer type. DHCS adjusted the QAF based on the transport data submitted for calendar year 2019 for emergency transport codes A0429, A0427, A0433, A0225, and A0434. The QAF rate in effect for FY 2020-21 will be assessed on ground emergency medical transports with dates of service beginning January 1, 2020 through December 31, 2020. The FY 2020-21 QAF rate amount is as follows:
FY 2020-21 QAF Rate: $32.30
Fee applies to all public and private, while most 911 territories have a larger mix of Emergent runs, they also have a better chance of getting higher paying commercial runs to help offset this. They also get a higher number of Medicaid runs, which bring the state reimbursement payment of $220.80 for all qualified Emergent runs.
Private payers without 911 territories use Emergent runs from a skilled nursing facility to an Emergency room visit and by nature of the age of the patient will end up with more Medicare which does not bring the reimbursement of $220. So, they pay the added fee of 32.30 without the added reimbursement.
These numbers are done quarterly with payment and can greatly affect the cash flow of small-to-midsize private ambulance companies.