Deeper Than the Headlines: Ambulance Services

A couple weeks ago, Medstar Ambulance Inc. settled False Claims Act allegations with the government for $12.7 million. The allegations were first brought to the attention of the government through a former billing office employee who filed a qui tam (i.e., whistleblower) lawsuit under the False Claims Act.

The complaint filed in court alleged many different ways in which Medstar submitted false claims associated with ambulance services. Among these were the following:

1. Mischaracterizing the ambulance services as requiring advanced life support (ALS) for the purpose of billing Medicare a higher amount for reimbursement but which did not require ALS

   The complaint described one of these scenarios for a patient identified as “patient 11”:

   “One ambulance run for which the Plaintiff-Relator has documents concerned "Patient 11" of Sterling Massachusetts. Patient 11, According to the MedStar Ambulance Inc. Patient Care Report, was transported for a follow up on calf surgery. He was transported by MedStar Ambulance, Inc. on 1.25.11 from Beth Israel Deaconess Hospital in Boston to Whittier Rehabilitation Hospital in Westborough Massachusetts. According to the report narrative, Patient 11 remained on the stretcher for the consult and was taken back to Whittier without incident. Billing was through Blue Cross Medicare and the billing certification on the form 1500 was signed by Nick Melehov on 2.3.2011. As such, Medicare paid for this ambulance service as well as the service by MedStar Ambulance Inc. taking Patient 11 from Whittier to Beth Israel. The diagnosis listed on the form 1500 was 136. 9 infections unspecified and 786.09 shortness of breath. The ambulance run from Beth Israel was billed as advanced life support non-emergency base rate A0426 which amounted to $800 plus an additional $330 for mileage.”

2. Billing Medicare for ambulance transportation services when an ambulance was not medically necessary for the patient

   One of the examples shared is patient 10:

   "Patient 10, 68, was transported by ambulance by the Defendant MedStar Ambulance, Inc. from Sterling Village in Sterling Ma. to Umass Memorial Medical Center for his dialysis treatment. He was then transported back to Sterling Village by ambulance by the same Defendant. Patient care records show that the patient was not bedridden, was able to ambulate and did not require a stretcher. There was no medical necessity for an ambulance. Also attached are documents showing ambulance runs and fraudulent billing for "Patient 10" for dialysis appointments 02/16/2013 through 03/4/20.”

3. Billing Medicare for ambulance services provided for transportation of patients for non-Medicare covered services, for example from a nursing home to a doctor's office for a regular doctor's appointment. Patient 8 was an example of this:

   “Patient 8, 88, was transported by ambulance by the Defendant MedStar Ambulance, Inc. from the Whittier Rehab Hospital to the Framingham Union Hospital on 8.26.11 for a routine echocardiogram. The patient was then transported back to Whittier by ambulance by the same defendant. The Patient Care Records show that the patient was not bedridden and did not require a stretcher. Patient 8 was covered by Medicare under Medicare PPO Blue and Medicare was billed over $757 for these runs.”

4. Double-billing both Medigap and ambulance patients at the same time for the same services. For example, in the case of Medicare B patients, the Defendants would bill Medicare some amounts not covered by Medicare. The Defendants would bill the residual amounts both to Medigap and the patient. In many cases, both the patients and Medigap would pay the residual amount but MedStar would purposefully not reimburse the overpaid amount unless the patient specifically called and requested reimbursements.
5. Altering the actual pickup and destination, fraudulently making the service billable to Medicare, when it wasn’t. For example, pickups from physicians' offices with destination modifier (P) on the paperwork, are not covered by Medicare so the destination modifier would be changed to Hospital (H) which is a covered service.
6. Fraudulently billing Medicare for "intercept" services (so called) which fell under contracts with municipalities and for which the municipalities were supposed to bill Medicare. This resulted in higher ambulance service costs to Medicare.

Of course, the methods by which false claims can be submitted are varied and numerous, but the above allegations are some examples that your own compliance program could try to address through policies and procedures, auditing and investigations when necessary.

Also remember, ambulance service providers are one of the provider types for which the OIG has published specific compliance guidance. Read more here.

In addition, the OIG published a special report in September of 2015 on their investigative efforts regarding improper payment of Medicare ambulance services. Read more here.

Though the foundational principles and seven elements of an effective compliance are the same from provider type to provider type, reading these referenced documents as well as court records from lawsuits such as this Medstar case can give your compliance program specific areas upon which it can focus when it comes to ambulance services.