(WINSTON SALEM, N.C.) April 15, 2025 –
There is no better phrase to describe the EMS industry than “ever-changing.”
First responders across the country must remain flexible and adapt to developments within their communities—both geographically and legislatively. Agencies in North Carolina and Georgia are currently facing similar shifts but have not had to navigate these changes alone.
NORTH CAROLINA CHANGES
EMS|MC, along with our Chief Client Advocacy Officer, Kim Stanley, and Regina Crawford, continues to play an active role in legislative and advocacy efforts concerning ongoing Medicaid issues in North Carolina.
In 2021, NC Medicaid transitioned approximately 63% of eligible patients to one of five Prepaid Health Plans (PHPs):
- AmeriHealth
- Carolina Complete
- Healthy Blue
- WellCare
- United Healthcare Community Plan
Municipal EMS agencies contracted with these PHPs are reimbursed using the Public Ambulance Provider (PAP) Fee Schedule. This schedule is based on historic Medicaid cost reports and includes a quarterly Intergovernmental Transfer (IGT) reimbursement component.
By 2024, NC Medicaid introduced Tailored Plans for patients with behavioral health or intellectual/developmental disabilities. These plans include:
- Alliance
- Trillium
- Partners
- Vaya
While only 5% of the NC Medicaid population was affected by this transition, these patients are typically higher users of ambulance services.
In early 2025, claim monitoring by EMS|MC uncovered several issues with PHP and Tailored Plan payments:
- Healthy Blue: Reverted some agencies to the standard NC Ambulance Fee Schedule.
- AmeriHealth: Applying “lesser-of” logic—paying the lower of billed charges or the PAP rate, despite PAP being the mandated payment floor, even when charges are lower.
- United Healthcare: Reverted certain agencies to the NC Ambulance Fee Schedule.
- ModivCare: Also using “lesser-of” logic for some claims.
- Tailored Plans: Recognizing agencies by Tax ID rather than NPI/PTAN, leading to misdirected or combined payments across multiple county agencies.
- Alliance: Claims are being rejected due to conflicting enrollment with the County Health Department under a different clearinghouse.
EMS|MC has been actively participating in monthly stakeholder meetings to address these issues.
In March 2025, a follow-up meeting was held with the Senior Manager of Medical Transportation. They agreed to set up individual meetings with plan administrators to resolve these various concerns.
Your Customer Success Executive (CSE) may have contacted you to request copies of your contracts. Please provide those as soon as possible as they are essential in resolving payment discrepancies.
GEORGIA CHANGES
EMS|MC is also deeply engaged in legislative and advocacy efforts in Georgia—specifically concerning Medicaid audit requests.
Many EMS providers recently received audit letters from HMS–Gainwell requesting recoupment of payments for ambulance transports. These audits cite cases where a hospital emergency room visit was not billed on the same date of service as the ambulance transport.
However, several legitimate reasons may explain why a hospital visit doesn’t appear on the same date:
- The patient was triaged but left before being seen in the emergency department.
- The transport occurred near midnight, and the hospital visit was recorded the following day.
- The hospital billed a different payor (e.g., Veterans Affairs, Third-Party Liability).
Upon receiving the audit letters, EMS|MC quickly submitted Patient Care Reports (PCRs) to request administrative reviews within the limited timeframes provided.
Additionally, we contacted the HMS Program Director of Government Services to challenge the validity of the audits. Notably, the GA Ambulance Services Manual does not require an emergency room visit for EMS reimbursement, provided the transport was medically necessary.
Key Updates from EMS|MC’s Conversations with HMS
- Missing Details in Initial Letters: HMS acknowledged that the original audit letters lacked claim detail pages. Corrected letters have since been issued, granting more time to respond.
- Appeals Process Gap: Some providers received final determination letters that upheld overpayments but did not include instructions for requesting an ALJ (Administrative Law Judge) hearing. HMS is now issuing updated letters to include this necessary information.
- Next Steps: EMS|MC has been invited to meet with HMS’s Clinical Review Team to discuss audit findings and clarify standards for upholding overpayment decisions. Kim Stanley will attend on your behalf and provide a follow-up update. HMS also confirmed that some audits have been overturned and rescinded, while others were upheld. We expect to gain more insight into the factors influencing these outcomes during the meeting.
If you receive any communication from HMS–Gainwell, please send it immediately to your CSE and to [email protected]. Time-sensitive deadlines apply to both the administrative review process and ALJ hearings, so prompt action is essential.
We will continue to monitor this situation closely and keep you informed of any new developments.