V225--VETERANS HEALTH ADMINISTRATION (VHA) AMBULANCE INDUSTRY DAY MAY 25, 2023

The purpose of this amendment to the special notice is to: Notify interested parties of the next Industry Day for Ambulance Service Providers tentatively scheduled for July 20, 2023 at 10:00 am eastern. The next Industry Day event details will be posted under the new SAM.gov ID number, 36C24523Q0749. 2. Provide the presentation slides used during the Industry Day event held on May 25, 2023. 3. Provide responses to the unanswered questions received in the chat box during the question-and-answer period for the Ambulance Industry Day event held on May 25, 2023. Both questions and answers are provided below. Question 1: Does the rule apply to all emergency Community Care transports, or just transports where the patient is either being picked up or dropped off at a VA facility, or just non-emergent transports? Answer 1: AP89 governs non-contracted transports (emergent and non-emergent) under the authority of title 38, United States Code, Section 111 - Payment or Allowances for Beneficiary Travel; not included are the emergency travel authorities found under VA's Community Care authorities of 38 USC 1725 - Reimbursement for Emergency Treatment, 38 CFR 17.1003, or 38 USC 1720J - Emergent Suicide Care, 38 CFR 17.1230. ? Question 2: We understand that providers are encouraged to contract with the VA.? Will the VA contract with all available providers and will providers be able to enter into one national contract, will separate contracts with each VISN be required, and please provide contact information for the specific individual(s) we should contact to begin this process.? Answer 2: VHA Procurement and Logistics, Veterans Transportation Program and Category Management will initially focus on facility level contracts. The second phase will focus on VISN, regional or national contracts. Requests for solicitation of offers for contracts may be found at: www.sam.gov ? Question 3: Does the VA have sufficient resources to meet the timeline necessary to contract with all willing air ambulance providers before the rule goes into effect on 2/16/24? Answer 3: VA does have sufficient resources which are being coordinated collaboratively by the VHA Procurement and Logistics Office (P&LO) and Veterans Transportation Program (VTP). ? Question 4: In recent testimony, the Secretary stated that two-thirds of VA hospital facilities have contracts with air ambulance providers, however we know that the largest air ambulance providers - representing about [70%] of the market - do not have contracts with the VA.? Can you tell us how many air and ground providers are under contract and what percentage of VA transports are covered under existing contracts? Answer 4: A report of current air and ground ambulance contracts provided by the VHA Procurement and Logistics Office (P&LO) indicates 230 active contracts across all Veterans Integrated Services Network (VISN)s/VA Medical Centers. Current Contracts Number of VAMCs Number of Contracts Air-Ambulance 13 11 Ground Ambulance 81 219 ? Question 5: Did the VA assume that no air or ground ambulance bases would close following the implementation of this rule and, if this assumption is wrong, and veterans lose access to care due to this rule change, will the VA reconsider implementation of the rule? Answer 5: VA addressed similar comment/concern during the rule making stages and addressed these concerns in the Final Rule (see link below) https://www.federalregister.gov/documents/2023/02/16/2023-03013/change-in-rates-va-pays-for-special-modes-of-transportation Question 6: If our contracting dept doesn't know about this new rule who can we refer them to so that they do the right thing? Answer 6: VHA Procurement and Logistics will ensure this new rule is communicated to the VHA Contracting Offices. Question 7: Will the VA now use Medicare rates as the standard for - Fair and Reasonable pricing for contract evaluations? Answer 7: No, the Contracting Officer Representative (COR)/Mobility Manager will conduct Market Research. Vendors interested in contracting with the VA will have the opportunity to submit a Rough Order of Magnitude (ROM)/Pricing information package. Question 8: Could you address the value of the 72 hr notification process in assuring access to care for Veterans. It seems to be a hinderance and not an effective managed care initiative. Ambulance providers are disadvantaged in knowing if the notification has been made by the hospital or Veteran and therefore, we are stuck in the middle. Answer 8: VA allows for 72-hour notification of emergency services which provides the Veteran the same statutory benefits as if the care was preauthorized. Question 9: Will there be an announcement when contract opportunities become available via SAM.gov and will they open for bids simultaneously or VISN by VISN? Answer 9: Once solicitations are ready to be publicized, posting should be available on SAM.gov. The solicitation method will ultimately be determined by the Network Contracting Office (NCO) which directly supports the respective VISNs. Regional Procurement Offices (RPOs) - VHA Procurement & Logistics Office (P&LO) (va.gov) Question 10: Will there be more education for veterans regarding the 72-hour rule for emergencies? We oftentimes have veterans that are not aware of this rule that would therefore prevent us from being reimbursed at a contract rate and we would instead receive the Medicare rate for the service. Answer 10: Yes, the VA will provide additional information in reference to 72-hour notification. Question 11: How is the VA incorporating State and Local regulations limiting an EMS provider's service area when considering the one provider for a VISN? Answer 11: VA will need to review and consider each provider's Request for Proposal (RFP) response with regard to their stated service area and may possibly have to enter into multiple awards for each VA Medical Center to ensure the entire catchment area is covered. Question 12: For VA centers that are not currently using Vet Ride what is the expected time for them to transition to utilizing VetRide for daily operations? Answer 12: The expected time for all VAs Medical Centers to transition to VetRide is February 16, 2024, or at the initiation of a new or modified contract for ambulance services. Question 13: Will the VA disclose the data used to determine a - fair market rate for contracts so that provides have a transparent view of how the VA calculated the rate being offered? Answer 13: Please see the below Impact Analysis. The VA will determine price reasonableness based on the below analysis as well as market conditions and Federal Acquisition Regulation/VA Acquisition Regulation requirements. AP89 Impact Analysis Change in Rates VA Pays for Special Mode of Transportation https://www.regulations.gov/document?D=VA-2020-VHA-0022-0002 Question 14: Would you be able to explain how fair reimbursement will be evaluated? Medicare reimbursement does not consider quality of service, safety, and national accreditations, nor does the Qualified Payment Amount within the QPA. Our fear is that the VA will go the low-cost route to the detriment of those in which the partnerships are intended to benefit - the community, providers, and veterans. Answer 14: As with any other Request for Proposal, VA will evaluate all submissions for: fair and reasonable pricing, expected performance of contract requirements, reliability based upon past performance and other factors. Contracted vendors will be paid at 100% rate of their agreed contract rate for all authorized transports. Question 15.a.: Could you provide the reimbursement scenario for a non-contracted, governmental, 911 ambulance provider providing EMS care and transport to a non-VA local trauma center? What is the reimbursement rate? Answer 15.a.: For VA approved transports, the following apply. Contracted Vendor 100% Contracted Rate Contracted Vendor Pre-approved referrals to authorized VA or non-VA care/treatment 100% Contracted Rate 1725 (Reimbursement for Emergency Treatment) including transports to a 1703 facility 70% CMS AFS VAMC or approved 1703 approved in-network facility Depending on Veteran's eligibility, either paid as a 1725 claim or the lesser of Billed Charges, OR, 100% CMS Ambulance Fee Schedule (AFS) Non-Contacted Vendor Pre-approved referrals to authorized VA or non-VA care/treatment Lesser of Billed charges, OR, 100% CMS AFS rate 1720J (Emergent Suicide Care) 70% CMS AFS Question 15.b.: Does that service fall under the proposed change? Answer 15.b.: Based upon current regulations for Integrated Veteran Care and Beneficiary Travel, as depicted in the chart above, 911 services will fall either under Section 1725 and be reimbursed at 70% of Medicare rate or under Section 1703 and depending on the Veteran's eligibility status, the claim will be processed as a 1725 claim for non-eligible beneficiary travel Veterans or be reimbursed at the lesser of billed charges or 100% of Medicare rate for a beneficiary travel eligible Veteran. It should be noted that reimbursement for services which fall under Section 1725 have been operational for some time and are not affected by the new rule. Only 911 services which fall under Section 1703 are changed by AP89. Question 16: I see a troubling scenario taking shape here with talks of having issues contracting with multiple agencies in a specific region or area. In nearly all air ambulance operations, programs cover for each other meaning if one program is called but out on another call, a neighboring program may be called to provide that transport. Therefore, if only one contract is approved in each area, I see a situation where a veteran suffers demise if a neighboring program is not contracted with the VA and cannot respond to the patient if the contract agency is already on another call. Will the VA consider multiple contracts in an area given this scenario? Answer 16: The VA will consider multiple awards where appropriate for both ground and air ambulance services. Vendors are also able to subcontract for these services in accordance with FAR 52.218-8. Question 17: Our industry is in a critical financial and staffing crisis, costs are higher than they have ever been and still rising and we are hanging by a thread. There is a shortage of EMS clinicians nationwide. Many companies are going out of business across the country or so short staffed that they cannot meet their obligations. I'm concerned that there is any effort to move to Medicare rates for non-contracted providers which are at below industry costs per transport. All payers need to move to a fee for readiness plus fee for service model in order to reimburse companies enough to cover costs, provide high quality services with updated equipment, and for us to attract more clinicians to this Industry of Ems, which we are in dire need of. Answer 17: Centers for Medicare & Medicaid Services (CMS) posts its annual schedule nationally, which is the basis for VA's payment calculations. Fee schedules are created by CMS, and it is unclear whether CMS seeks input from vendors, but it appears that CMS provides a notice and comment period when publishing rates (https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AmbulanceFeeSchedule/). VA will seek to protect itself against savvy vendors increasing their prices to the maximum of the CMS fee schedule during schedule revisions. VA would undertake this activity because adopting the schedule protects VA from paying - actual charges that are typically higher than the CMS fee schedule. Additionally, VA would maintain its option to contract based on volume or other reasons which may entice rates even more favorable in some cases. AP89 Impact Analysis Change in Rates VA Pays for Special Mode of Transportation https://www.regulations.gov/document?D=VA-2020-VHA-0022-0002 See attached document: May 25 Ambulance Industry Day Presentation Slides.