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Jennifer Klein's Files
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Notice of Proposed enternating soon.
Public comment.
After election.
09/09/96 14:26 FAX 501 463 8591
PAFFORDAMBULANCE
001
Pafford Ambulance Service, Inc.
P.O. Box 130 214 Main Street
Hermitage, AR 71647
FAX TRANSMITTAL
TO
Julie Demeo
Domestic Colicy
FAX # 202 - 456 - 6687
DATE
9-9-96
PAGES (inoluding cover) Z
FROM JAMIE PAFFORD-GRESHAM
VICE PRESIDENT,
PAFFORD AMBULANCE SERVICE,
1-800-451-8036
FAX 1-800-532-7571
09/09/96 14:26 FAX 501 463 8591
PAFFORDAMBULANCE Jen Klein-
002
9-10 Pes. handle.
P
Carol - This
CAME into
Julie - her
Pafford Ambulance Service, Inc. ATHN.
P.O. Box 130 214 Main Street
Hermitage, AR 71647
I was going to
CAll her but
VIA FACSIMILE 1-202-456-6687
It Mr wolks
9-9-96
issue ordented,
50 I figured
TO:
Julie Demeo
FROM:
Jamie Pafford-Gresham Damie
to first Run 6x4 by you
Hey, just a quick line, I have been meaning to call and ask you
were you at the democratic convention? I thought I saw a zoom in
of you on TV Ben, (my husband), agreed, but of course we could be
wrong!
I was wondering if HCFA has defined "RURAL" as far as
ambulance services are concerned. (This relates back to an
exception the President made on our behalf, that a rural exception
be placed in the new guidelines for advanced life support ambulance
transports).
Has Jennifer seen anything come across her desk regarding
ambulance services? I know you both are busy, but If you have
heard anything I would appreciate knowing what's up.
I have a meeting in a couple of weeks in Chicago, if I can find
some Clinton buttons I'll be wearing them to show our support.
Everyone at the Arkansas and American Ambulance Association
realizes the President has stuck up for rural services and is on our
side. We appreciate that and will remember it come election time.
Take care, and thanks again for your help.
P.S. I was elected as Arkansas Ambulance Associations
President at our convention. I am the youngest and first women to
serve.
HEALTH CARE FINANCING ADMINISTRATION
NATIONAL HEADQUARTERS
7500 Security Boulevard
Baltimore, MD 21244-1850
FACSIMILE TRANSMISSION REQUEST
ADDRESSEE: (Name, Organization, Address) FROM: Jennifer Boulanger
Jennifer Klein
OFFICE OF THE ADMINISTRATOR
C5-26-11
Phone:
Phone: (410) 786-3151
TOTAL PAGES:
ADDRESSEE'S FAX MACHINE NUMBER
DATE:
Cover +
456-2878
REMARKS:
Info on Ambalance - the proposed rule is in
Departmental clearance.
IF FAX MACHINE RETRANSMISSION IS NECESSARY PLEASE CALL:
AT:
(Name)
(Phone)
912024562878 P.01
01
JUL-22-1996 09:47 FROM ADMIN BALTO OFFICE
Background
Ambulance services are costly and rapidly escalating.
At $1.7 billion in FY94, they are the most costly
services that Medicare still pays based on reasonable
charges.
For the past 3 years, Medicare payment for ambulance
services have increased 15% per year.
There are two types of ambulances services currently
being delivered, Basic Life Support (BLS) and Advanced
Life Support (ALS), which is a more sophisticated and
costly service.
ALS services are approximately twice as costly as BLS
services.
Because they are paid based on reasonable charges, there
is a wide variation in the actual payment amounts for
ambulance services.
Current Policy and Proposed Change
Medicare is currently operating under a transportation-
based ambulance benefit where the type of vehicle used
determines the level of payment, i.e. if an ALS
vehicle is used, the ALS rate applies.
We are in the process of preparing a proposed regulation
that would move to a medical-condition-based benefit
under which coverage and payment are determined by the
level of care that is medically necessary.
Problem Raised by Local Government Regulation
The ALS/BLS issue is further complicated by the fact
that there are a number of local governments mandating
through ordinances or regulations, ALS ambulance
services as the minimum standard level of ambulance
transport.
This development has put Medicare in the position of
paying at the ALS rate even when ALS services are not
necessary, leading to increased expenditures for both
the Medicare program and its beneficiaries who are
subject to a 20 percent copayment on these services.
912024562878 P.02
01
JUL-22-1996 09:48 FROM ADMIN BALTO OFFICE
TOTAL 2.03
While we do not dispute the value of ALS services when
they are needed, we also do not believe that Medicare
and its beneficiaries should pay at the higher rate in
cases where ALS services are not required.
Rural Exception
o
We recognize that certain rural areas could be adversely
affected because it may not be economical for them to
maintain multiple ambulances, a mix of ALS and BLS.
o
Therefore, in these instances where only ALS services
are available in a rural area, we would provide for an
exception to our proposed policy change.
We are refining the details of what constitutes a rural
area, keeping in mind the rural area definition used in
the Medicare Prospective Payment System for hospitals. We
are also consulting with the Office of Rural Health Policy
on this issue.
Regulation Process and Timing
0
We have been meeting with the American Ambulance
Association and the American College of Emergency
Physicians on this issue on a regular basis.
912024562878 P.03
01
JUL-22-1996 09:48 FROM ADMIN BALTO OFFICE
01/17/96 17:45 FAX 501 463 8591
PAFFORDAMBULANCE
002
P
Pafford Ambulance Service, Inc.
P.O. Box 130
214 Main Street
Hermilage, AR 71647
VIA FAXMILLE 1-202-456-2878
Jennifer Klein
Domestic Policy
The White House
Washington, DC
Dear Jennifer:
Attached please find the American Ambulance Association's interpretation of Section
11461 of the President's plan for Medicare reform under Budget Reconciliation. If our
interpretation is correct, this section of the Fresident's plan would have a significant
impact on ambulance services covered under Medicare. My last conversation with you
was on the eleventh of December, at this time you concluded that the President's plan
did not impact current Medicare law for ambulance services, I would appreciate your
reviewing this matter to resolve the different interpretations.
As we have discussed before, the American Ambulance Association does not object to
ambulance services being put under a fee schedule. However, we believe that fee
schedule language which specifically addresses the areas of coverage and
reimbursement that needs reform should be included. Additionally, we believe that the
process of negotiated rulemaking should be required as this would provide an
opportunity for all affected parties (e.g. ambulance providers, State regulators, and the
emergency physician community) to have direct input into a rulemaking adoption
process. I have attached such language passed by the House of Representatives as an
example of the type of language we believe is important.
Relative to the issue of inherent reasonableness, there are grave concerns that if this
provision is eliminated it will remove an important safety net that ambulance providers
have utilized, under unusual circumstances, to correct grossly deficient rates where
they exist.
Please contact me at your earliest convenience so the apparent discrepancies of opinion
can be resolved Thanks again for your help in this matter.
Sincerely,
Jamie Jamie Pafford-Gresham
Vice-President
Pafford Ambulance Service, Inc.
01/17/96
17:45 FAX 501 463 8591
PAFFORDAMBULANCE
003
AP OF CTMADMINISTRATION
200 soe' 5057
JAN-17-1996 17:34
American
Ambulance
Association
VIA FAX
TO:
Board of Directors
Joe Paolella, Government Affairs Committee Chairman
Wendy Ruhlin, Government Relations Representative
David Nevins, Executive Vice President
FROM:
David Werfel
SUBJECT: Administration's Provisions Relating to Part B
DATE:
January 12, 1996
In reviewing $11461 of the Administration's provisions
for Medicare Part E, there are two major changes that will impact
ambulance services, if I am reading the sections correctly.
These two changes, and the reasons for my conclusions,
are as follows:
1. Fee Schedule - Section 11461 (a) amends Section 1833
of the Social Security Act by eliminating the reasonable charge
methodology and plating services described in Section 1832(a) (1)
under a fee schedule. Section 1832a(1) refers to "medical and
other health services". $1861s defines "medical and other health
services". Ambulance is listed at subdivision 7. Therefore,
ambulance services would be placed under a fee schedule.
It is important to note that ambulance services
provided by hospitals reimbursed on a reasonable cost basis would
not be affected by this provision, creating a discrepancy in how
ambulance services are reimbursed by Medicare.
The proposed amendment of 1833a(1) strikes the
"reasonable charge" methodology and replaces it with payment that
is the lower of the actual charge or a fee schedule.
Ambulance services (other than those provided by a Part
A provider) do not meet any of the exceptions in 1833a(1).
Therefore, Part B ambulance services would be allowed the lower
of the actual charge or "applicable fee schedule developed by the
Secretary". of course, DO ambulance fee schedule has, as yet,
Been developed. However, once 10 18, ambulance services would be
on it.
Greenment Medicare Relations: be . T301 Connecticut Ave. NW, Washington, nc 20038 . (202) 258-8390 (915) . 480-5473 FAX 296-6110
Executive Offices 8 2800 Aubura Blvd., Suite C, Excramento, CA 85821-2102 . (918) 473-3827 . FAX
Licer Community Just Tananhaum - HED Collornia Street, 22th Floor Sen Franelsco, a 94108-2000 - (416) 433-1940 FAX (510) . FAIL (45) 199-5460
Law Consultant, David Werral, Eary - One Reive Orive. NY 11722 . (518) - (202)
01/17/96 16:35
TX/RX NO.4692
P.003
01/17/96 17:45 FAX 501 463 8591
PAFFORDAMBULANCE
004
JAN-17-1995 17:35
AMP OF
200
2. Inherent Reasonableness - Subdivision (b) (9) (A) of
the proposed section 11461 strikes paragraphs (8) and (9) of
1842(b). These are the inherent reasonablenets sections.
1842(b)(9) - This section is for the publication of
adjustment to rates for physicians' services. Thus, its being
delated does not affect ambulance services. However,
1842 (b) (6) (A) states that the Secretary shall describe in
Regulations the factors used for determining when inherent
reasonableness adjustments should be made. While 1842 (b) (8) (B)
and (C) specifically reference physicians services, 1842 (b) (B) (A)
does not and has been used as the basis for inherent
reasonableness adjustments for ambulance.
Thus, we would have no methodology in place for
correcting grossly deficient rates.
2
01/17/96 16:35
TX/RX NO.4692
P.004
01/17/96
17:45 FAX 501 463 8591
PAFFORDAMBULANCE
005
JAN-17-1996 17:35
AMR Ut
SENI DIAETOX JUE: , 1- 2-90 , 6-41MR
:= 2
white House Proposal
11D-68
1
(b) EFFECTIVE DATES.-
2
(1) The amendments made by subsection (c) apply to
3
contracts whose periods and at, or after, the and of the
'
third calandar sonth that begins after the date of enactment
of this Act.
(2) The amendments made by subsections (a), (D), (8),
and (e) apply to contracts whose periods begin after the
third calandar month that begins after the date of shartment
of this Act.
20
Subpart C-Provisions Relating to Part B of
11
Medicare
12
see. 11461. REPLACEMENT or REASONABLE CHARGE RETRODULEGY BY FEE
23
SCHEDULES.
14
(a) IN GENERAL.-The matter in sastian 1833(a) (1) (42 U.S.C.
15
22951(a) (1)) preceding clause (A) is amended by striking "the
25
reasonable charges for the survices" and inserting "the lasser of
17
the actual charges for the services and the accunts determined by
18
the applicable fee schedules developed by the Secretary for the
19
particular services".
Proposed New Section 80% of the lesser of the actual charges
for the cervices and The and(or?) the amount
determined by The applicable for schedule
developed by my secheting for The policil is
01/17/96 16:35
TX/RX NO.4692
P.005
01/17/96
17:45 FAX 501 463 8591
PAFFORDAMBULANCE
006
JAN-17-1996 17:35
AMR OF CTHADMINISTRATION
203 562 5357 P.06/13
11D-72
1
(2) by redasignating clauses (11) and (111) as
a
subparagraphs (B) and (c), respectively, and
,
(2) by redesignating subalauses (I), (II), and
d
(III) of subparagraph (A) (as redesignated by
5
subperagraph (D) of this paragraph) as clauses (1),
F
(11), and (111), respectively.
Inhered
7
(9)(2) section 1842(b) (42 U.S.C. 1395u(b)) is amended
by striking paragraphs (8) and (9).
(B) The first sentence of section 2834 (a) (10) (B) (42
stally
10
U.S.S. 1395m(a) (10(3)) is amended by striking everything
11
after "is authorised to" up to the period and inserting the
etits
12
following: "dascribe by regulation the factors to be used
A
in determining the CASSE (of particular items) in which the
14
application of this subsection results in:the determination
15
of as amount that, by reason of its being gressly excessive
16
or grossly deficient, is not inherwatly reasonable, and to
17
provide in these cases for the factors that will be
18
considered in astablishing an amount that is realistic and
19
equitable*.
(10)
Section 1842(b) (10) (42 U.S.C. 1395u(b) (10)) is
overgives 20 21
repealed.
proud
23
(11)
Section 1862(b) (11) (42 U.S.C. 1395u(b) (21)) is
23
amended
24
(A) by striking subparagraphs (B) through (D),
25
(B) by striking "(11)(A)" and inserting "(11)",
26
and
01/17/96 16:35
TX/RX NO.4692
P.006
02/09/96 12:35 FAX 501 463 8591
PAFFORDAMBULANCE
001
Pafford Ambulance Service, Inc.
FAX Transmittal
P.O. Box 130
FAX Number (800)532-7571
214 Main Street
(501)463-8591
Hermitage, AR 71647
Office Number (800)451-8036
TO: Jennifer Klein
FAX Number. 202-456-2878
Date: 2/9/96
Number of Pages
(Including Header Page) 3
From: Jamie Pappoid
Comments: l did not Send a Copy 8 Memo with
my fax this week - (See attached)
d have Received Several phonecalls This week
about the language of the draft.
Please Review let me Know of we Need
to H Concerned
Thanks-
ps talked to Julie today - Said Jamie yall had been lrying to
catch T 11N Me Derstand - sorry- you are Pesearchim this wown
02/09/96 12:35 FAX 501 463 8591
PAFFORDAMBULANCE
002
JAN-17-1996 17:34
American
Ambulance
Association
VIA PAX
TO:
Board of Directors
Joe Paolella, Government Affairs Committee Chairman
Wendy Rublin, Government Relations Representative
David Nevins, Executive Vice President
FROM:
David Werfel
SUBJECT: Administration's Provisions Relating to Part B
DATE:
January 12, 1996
In reviewing $11462 of the Administration's provisions
for Medicare Part B, there are two major changes that will impact
ambulance services, if I am reading the sections correctly.
These two changes, and the reasons for my conclusions,
are as follows:
1. Fee Schedule - Section 11461 (a) amends Section 1833
of the Social Security Act by eliminating the reasonable charge
methodology and placing services described in Section 1832(a) (1)
under a fee schedule. Section 1832a(1) refers to "medical and
other health services". $18615 defines "medical and other health
services". Ambulance is listed at subdivision 7. Therefore,
ambulance services would be placed under a fee schedule.
It is important to note that ambulance services
provided by hospitals reimbursed on a reasonable cost basis would
not be affected by this provision, creating a discrepancy in how
ambulance services are reimbursed by Medicare.
The proposed amendment of 1833a (1) strikes the
"reasonable charge" methodology and replaces it with payment that
is the lower of the actual charge or a fee schedule.
Ambulance services (other than those provided by a Part
A provider) do not meet any of the exceptions in 1833a(1).
Therefore, Part B ambulance services would be allowed the lower
of the actual charge or "applicable fee schedule developed by the
Secretary". of course, no ambulance fee schedule has, as yet,
been developed. However, once 11 18, ambulance services would be
on it_
Government Medicare Relations: Inc. 1331 Connections Ava. NW, Washington, ac 20038 . (203) 298-8390 . - 205-8118
Executive Offices . 2800 Auburn Blvd.. Suite c Sacramento, CA 85821-2102 . (918) 625-227 . FAX
Labor Law Tanenbeum . 830 Callfornia Street, 20th Floor - Sen Francisco, CA 94188-2689 . (415) 433-1840 (525) . FAX (415)
Consultant, Consultant Ja# Devid Werral, Enq . One Rabre Orive. NY 11788 a (516) SENS . FAX FAX (202)
01/17/96 16:35
TX/RX NO. 4692
P.003
02/09/96 12:35 FAX 501 463 8591
PAFFORDAMBULANCE
4
003
JAN-17-1996 17:35
AMP. OF CTHRDMINISTRATION
203 562 535? P.04/13
2. Inherent Reasonableness - Subdivision (b) (9) (A) of
the proposed section 11461 strikes paragraphs (8) and (9) of
1842(b). These are the inherent raasonableness sections.
1842(b) (9) - This section is for the publication of
adjustment to rates for physicians' services. Thus, its being
deleted does not affect ambulance services. However,
1842 (b) (8) (A) states that the Secretary shall describe in
Regulations the factors used for determining when inherent
reasonablaness adjustments should be made. While 1842(b) (8) (B)
and (C) specifically reference physicians services, 1842(b) (a) (A)
does not and has been used as the basis for inherent
reasonableness adjustments for ambulance.
Thus, we would have no methodology in place for
correcting grossly deficient rates.
2
01/17/96 16.35
TV /DV NO ACORD
n 004
—
PAFFORD-GRESHAM PAFFORD AMBULANCE-CORPORATE OFFI Fax: 800-532-7571 Voice: 800-451-8036 To: JENNIFER KLEIN
Page 1 of 3 Wednesday, February 07, 1996 4:11:59 PM
Date: Sunday, February 04, 1996
Time: 3:32:01 PM
3 Pages
To:
JENNIFER KLEIN
From: JAMIE PAFFORD-GRESHAM
PAFFORD AMBULANCE-CORPORATE OFFI
Fax:
(202) 456-2878
Fax: 800-532-7571
Voice: +1 (202) 456-2599
Voice: 800-451-8036
Comments:
PLEASE REVIEW THIS WHEN YOU GET A CHANCE.
THANK YOU FOR YOUR HELP.
JAMIE
From: JAMIE PAFFORD-GRESHAM PAFFORD AMBULANCE-CORPORATE OFFI Fax: 800-532-7571 Voice: 800-451-8036 To: JENNIFER KLEIN
Page 2 of 3 Wednesday, February 07, 1996 4:12:47 PM
PAFFORD AMBULANCE SERVICE, INC.
PO BOX 130
HERMITAGE, AR 71647
1-800-451-8036
VIA FACSIMILE 1-202-456-2878
February 5, 1996
Jennifer Klein
Domestic Policy
The White House
Washington, DC
Dear Jennifer,
The following is a letter I faxed to you on the 15th of January. Please review it
and see if you might could enlighten me on what might be going on. We hear
such conflicting stories.
I am anxious to hear from you when you get a moment. My home number is
1-501-463-2807, I am under the weather, but needed to follow up on a few
things, feel free to call me.
Sincerely,
Jamie Pafford-Gresham
PS Tell Juli Demeo we finally got some snow down here, but it was with 6 inches
of ice!! We "southerners' don't know how to operate in the snow and ice! It was
a nice treat.
R'S : FREEZE
reas. charge methodology
would apply to ambulances
other reforms should be
addressed in rulemaking
process - used to pay in acc. w/
type of vehicle / proposedvule
to look at determining
payments based on type of
care delivered
input on how fee schedule
set
can't have
negotiated submariting on
Fees - but opp. for public
comment
removes inherent
reasonableness process -
no local adjustment
doesn't effect hospital band
son ambulance services -
but that already exists
AS reas, char ye methodology
From: JAMIE PAFFORD-GRESHAM PAFFORD AMBULANCE-CORPORATE OFFI Fax: 800-532-7571 Voice: 800-451-8036 To: JENNIFER KLEIN
Page 3 of 3 Wednesday, February 07, 1996 4:13:08 PM
PAFFORD AMBULANCE SERVICE, INC.
PO BOX 130
HERMITAGE, AR 71647
1-800451-8036
VIA FACSIMILE 1-202-456-2878
Jennifer Klein
Domestic Policy
The White House
Washington, DC
Dear Jennifer:
Attached please find the American Ambulance Association's interpretation of Section
11461 of the President's plan for Medicare reform under Budget Reconciliation. If our
interpretation is correct, this section of the President's plan would have a significant
impact on ambulance services covered under Medicare. My last conversation with you
was on the eleventh of December, at this time you concluded that the President's plan
did not impact current Medicare law for ambulance services, I would appreciate your
reviewing this matter to resolve the different interpretations.
As we have discussed before, the American Ambulance Association does not object to
ambulance services being put under a fee schedule. However, we believe that fee
schedule language which specifically addresses the areas of coverage and
reimbursement that needs reform should be included. Additionally, we believe that the
process of negotiated rulemaking should be required as this would provide an
opportunity for all affected parties (e.g. ambulance providers, State regulators, and the
emergency physician community) to have direct input into a rulemaking adoption
process. I have attached such language passed by the House of Representatives as an
example of the type of language we believe is important.
Relative to the issue of inherent reasonableness, there are grave concerns that if this
provision is eliminated it will remove an important safety net that ambulance providers
have utilized, under unusual circumstances, to correct grossly deficient rates where
they exist.
Please contact me at your earliest convenience so the apparent discrepancies of opinion
can be resolved. Thanks again for your help in this matter.
Sincerely,
Jamie Pafford-Gresham
Vice-President
Pafford Ambulance Service, Inc.