Kusserow on Compliance: Questionable billing for ambulance transportation

The rapidly growing ambulance service program now costs Medicare Part B $6 billion per year, however fraud and abuse has been growing right alongside the program. The Office of Inspector General (OIG) issued a report identifying both improper payments for ambulance transports and questionable billing by ambulance suppliers. The OIG’s findings restate previously identified problems with ambulance transportation, including that Medicare continues to pay for ambulance transports that did not meet program requirements to justify payment. There is hardly a day that goes by without a new reported enforcement action involving ambulance fraud. The problem was so severe that CMS imposed temporary moratoria in 2013 and 2014 on the enrollment of new ambulance suppliers in two major metropolitan areas.

History

The OIG analysis followed up on another report on the subject two years ago. In that report, the agency reviewed the program through the year 1996 and found that two-thirds of ambulance transports did not result in hospital or nursing home admissions or emergency room care. In 2002, 25 percent of the reviewed cases did not meet Medicare program requirements, resulting in hundreds of millions in overpayments. Additionally, 27 percent of total transports to independent dialysis facilities did not meet coverage requirements. The overall conclusion from the prior report reflects the same findings of the recent report, that is, that Medicare Part B payments for ambulance transports have grown at a much faster rate than all Medicare Part B payments with fraud and abuse growing rapidly as well.

Recent report

The OIG provided several examples of the identified problems and found that Medicare paid $17 million for transports that were to or from non-covered destinations, such as physicians’ offices, and another $30 million for transports when beneficiaries did not receive Medicare services at the pick-up or drop off locations, or anywhere else. Claims for services under these circumstances appear to have been inappropriate. Further, the OIG found that about one in five suppliers had questionable billing, which was identified when suppliers had an unusually high average mileage for the transports of beneficiaries residing in urban areas. There is also continuing evidence of questionable billing that is geographically concentrated, as more than half of all questionable transports were provided to beneficiaries that reside in four metropolitan areas.

In arriving at the findings, the OIG analyzed claims data for 7.3 million ambulance transports, including but not limited to, reviewing transport destinations, transport levels, distance of urban transports, other Medicare services that beneficiaries received, and the geographic locations where the beneficiary who received the transport resided. The findings indicate that inappropriate and questionable billing for ambulance transports pose vulnerabilities to Medicare program integrity and call for CMS to enhance existing fraud and abuse safeguards. Specifically, the OIG called for increased scrutiny of ambulance services due to the evidence of its vulnerability to fraud and abuse.

OIG recommendations

  • CMS should determine whether a temporary moratorium on ambulance supplier enrollment in additional geographic areas is warranted.
  • Ambulance suppliers should be required to include the National Provider Identifier (NPI) of the certifying physician on transport claims that require certification.
  • There should be an increased monitoring of ambulance billing.
  • CMS should determine appropriateness of claims billed by ambulance suppliers identified in the OIG report and take appropriate action.

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.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.