Update on Ambulance Service Compliance Issues

As we approach the end of 2014, we are reminded of continuing problems with certain ambulance services. Often times, ambulance service companies become the subject of investigations due to unnecessary claims for emergency services on behalf of beneficiaries. In November, Life Support Corporation (LSC) and its company owners pleaded guilty to health care fraud charges. They, like many others this past year, violated Medicare eligibility requirements by transporting patients who were able to walk and travel safely by means other than an ambulance. Furthermore, LSC falsified reports making it appear that beneficiaries needed ambulance transportation when LSC had knowledge that this was not true. Lastly, there were even instances where beneficiaries had used personal vehicles for transportation but LSC billed Medicare as if ambulance services had been provided.

Common Elements of Ambulance Fraud

• Falsely claiming for services never provided.
• Submitting false reports indicating patient necessity for ambulance transportation.
• Recruiting or paying kickbacks to allow beneficiaries to unnecessarily use ambulance services.
• Charging Medicare at a higher rate by mischaracterizing the type of service provided.

OIG 2015 Work Plan

In prior work, the OIG determined that there were many inappropriate payments for emergency transports. For the 2015 Work Plan, the OIG has once again further addressed this area, and has issued a report (OEI-09-12-00350) on the utilization of Medicare Ambulance Transport. The report highlights that Medicare Part B payments for ambulance transports are growing at a much faster rate than all other types of payments and also cites a number of Medicare fraud vulnerabilities for ambulance transport services.

The 2015 Work Plan also shows 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 medically unnecessary transports; and
• Determine whether payments for ambulance services were made in accordance with Medicare requirements.

The second item in the 2015 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 OIG’s 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 these steps taken by the OIG indicate an increased interest in ambulance fraud and in preventative measures to decrease fraudulent activity in this area.