On May 21, 2003, the OIG issued advisory opinion 03-11, addressing the subject of ambulance service subscription/membership programs. This opinion, which is favorable for ambulance services, was obtained through Page, Wolfberg & Wirth, LLC on behalf of one of its clients.
The OIG concluded that an “actuarially sound” ambulance service subscription program does not violate the Federal anti-kickback statute even though the ambulance service waives copayment and deductible amounts for its Medicare Part B subscribers. The OIG concluded that as long as the program meets one of two possible tests, the program would not violate the anti-kickback statute. The tests are
- Whether the total subscription fees collected by the ambulance service reasonably approximate the amount that all subscribers would spend in cost-sharing amounts (i.e., copayments and deductibles); or
- Whether the subscription fees collected by the ambulance service from Medicare Part B beneficiaries would reasonably approximate the cost-sharing amounts that Medicare Part B subscribers would expect to spend over the period covered by the subscription agreement.
Even though Advisory Opinion 03-11 applies only to the ambulance service that requested it, all ambulance services that operate subscription programs should conduct an “actuarial soundness analysis” to evaluate whether their subscription program generates sufficient revenues, under one or both of the tests outlined above, to cover the copayments and deductibles it waives for its subscribers on an annual basis.
The full text of the advisory opinion will be posted at www.pwwemslaw.com on the “Ambulance Service Compliance” page.