Kusserow on Compliance: Update on Ambulance Service Compliance Issues

As we move to the end of 2014, we are reminded of the continuing problems with some ambulance services who become subjects of investigation for claiming emergency services on behalf of beneficiaries that are not needed. Life Support Corporation and its company owners pleaded guilty of health care fraud in November. They, like many others this last year, were transporting patients who were able to walk and could travel safely by means other than ambulance and who, therefore, were not eligible for ambulance transportation under Medicare requirements. Falsified reports made it appear that the patients needed to be transported by ambulance when they knew that was not the case. In some cases, patients were transported in personal vehicles but Medicare was billed as if ambulance services had been provided. There are many other similar cases that I have reported over the last year and this is just the latest in a series of cases evidencing increased enforcement efforts involving ambulance fraud. In another recent posting, I reported on the increase enforcement efforts involving ambulance fraud and cited the HHS Office of Inspector General (OIG) report on the subject.

Common elements of Ambulance Fraud

  • Falsely claiming services never provided
  • False reports to indicate patients needed to be transported by ambulance
  • Recruiting or paying kickbacks to able beneficiaries to unnecessarily use ambulance services
  • Charging Medicare at a higher rate by mischaracterizing the type of service provided

OIG 2015 Work Plan

The OIG noted in its prior work that there were many inappropriate payments for emergency transports and has once again moved to further address this area, including a report (OEI-09-12-00350) on utilization of Medicare Ambulance Transport that took note of the fact that Medicare Part B payments for ambulance transports is growing at a much faster rate than all other types of payments, and cited from previous reports a number of vulnerabilities to fraud for ambulance transport under Medicare. The 2015 Work Plan is showing continued interest in this area, beyond just investigating and working in the enforcement arena. There are two major reviews relating to ambulance services. The first is titled “Ambulance Services-Questionable Billing, Medical Necessity, and Level of Transport.” This area will be the subject of both audits and evaluations encompassing a number of specific reviews. The OIG will be examining Medicare claims data to:

  • Assess the extent of questionable billing for ambulance services, such as transports that never occurred or potentially were medical unnecessary transports; and
  • Determine whether Medicare payments for ambulance services were made in accordance with Medicare requirements.

The second item in the Work Plan is a project to analyze and synthesize OIG evaluations, audits, investigations, and compliance guidance related to ground ambulance transport services that are paid by Medicare Part B. The objective is to identify vulnerabilities and minimize inappropriate payments for ambulance services. The Plan notes that according to federal regulations, Medicare will only cover “reasonable and necessary” ambulance transports where a beneficiary’s medical condition at the time of the transport is such that using other means of transportation would endanger the beneficiary’s health.

All of this activity spells increased interest in focusing on ambulance fraud and what can be done to prevent such activities in the future.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2014 Strategic Management Services, LLC. Published with permission.