Ambulance Billing Fraud

There has been an upsurge of False Claims Act cases involving
non-emergency Ambulance Billing Fraud. In 2016 alone, according to the Centers for Medicare and Medicaid Services (CMS), government insurers paid out more than $350 million as a result of fraudulent billing practices. Here are just a few examples of ambulance companies that in recent years have paid back money to Medicare, Medicaid or Tricare for such conduct: Medical Transport LLC (Virginia Beach, VA); North East Health Services (Scarborough, ME); AmeriCare Ambulance (Tampa, FL); Medstar Ambulance (Leominster, MA.); KMD Healthcare Services (Houston, TX); Murfreesboro Ambulance Service (Tennessee); Trans-Star Ambulance (Kentucky); Navicent Health (Macon, GA); and Rural/Metro Corp. (California).

Why has there been an increase in ambulance billing fraud?

Ambulance companies have the means, opportunity and motive for submitting false bills. There are millions of elderly and non-ambulatory patients who need medical-related transportation. And, government insurers pay a lot of money for their transportation. The base level charge before mileage and add-ons is around $2,500. In 2012 alone, Medicare Part B paid almost $6 billion for ambulance transports. It is relatively easy for unscrupulous ambulance companies to take advance of this large pool of healthcare reimbursements and try to get even more money through false billing.

What does the government require for legitimate billing?

CMS requires that non-emergency ambulance transportation service must be “medically reasonable and necessary.” The patient has to be properly enrolled as a beneficiary in the program. And, the destination must be local and it needs to be an appropriate facility. 

What paperwork is required to support a bill for ambulance services?

Medical records are critical. One of the most important is the physician’s Certificate of Medical Necessity (CMN), also known as a Physician’s Certification Statement (PCS). Part A or Part B billing records are also important. 

Under what circumstances will the government NOT pay for

ambulance services? When patients can walk on their own or use a wheelchair to be transported, are able to safely use other methods of transportation (such as cars, taxis, wheelchair vans or medical cars), can sit up in bed, or otherwise do not meet all qualifying criteria. The government also does not pay for transportation to a physician’s office.

Typically where do ambulance companies transport (or supposedly transport) patients in false billing schemes?

To Hospitals, Critical Access Hospitals (CAHs), Dialysis Centers, Cancer Treatment Centers, Outpatient Testing and Imaging/MRI Facilities, Nursing Homes/Skilled Nursing Facilities, Home Health Agencies, Hospice Facilities, and Rehabilitation Centers.

What is the most common form of ambulance billing fraud?

Billing for “medically unnecessary services.” Meaning, the patient does not need to be transported via a stretcher in an ambulance. A classic example is transporting an ESRD patient to a dialysis center by ambulance when that person is able to get their on their own, for example by taxi.

Are other types of fraudulent billing practices? Billing

for services that were never rendered, in other words, “phantom” or “ghost” patients or transports, is an obvious violation of the False Claims Act. Also, billing for services that should have been provided but were not is not only a serious billing issue but even more importantly may have caused patient harm.

What is “Upcoding?” That means charging for more expensive

services or goods than were actually provided. Common examples in the ambulance context include inflating miles driven or supplies or services provided during the ride (oxygen, drugs, IV infusions, therapy, extra attendants, tests/ECGs). Billing regular trips as “Specialty Care Transports” is another example.

Does false billing also frequently involve the creation

of false medical records? Yes, often medical records are falsified to support medical necessity. The most egregious example would be forging a doctor’s signature on a Physician’s Certification Statement (PCS). Other times true things about the patient’s condition< are intentional omitted or changed or false things are added. In other instances, there may be inadequate documentation of medical necessity in the company’s files.

In addition to billing fraud are there other improper practices one should look out for with ambulance companies?

Yes, the most serious are illegal kickbacks. These can consist of actual cash payments or more indirect things of value like gifts or free goods or services. Kickbacks may be going to to patients, patient recruiters, hospitals and dialysis centers or prescribing doctors. They may involve complex arrangement, like “swapping,” where a hospital rewards an ambulance company for taking low reimbursement patients with higher ones. If you are aware of or suspect Medicare, Medicaid, Tricare or other government insurance billing fraud involving non-emergency ambulance transportation and want to stop it you can. It is also possible you can be financially rewarded for doing so. Your best course of action is to contact an experienced False Claims Act qui tam whistleblower attorney. He or she can provide you with invaluable advice and assistance. You should contact a lawyer as early as possible. This is especially true if you are a current employee of an ambulance company that is committing fraud, or if you otherwise have access to real-time evidence and information that might get lost or destroyed. You should also get legal advice promptly if your job is in jeopardy or you are facing whistleblower retaliation. Taking action quickly may be the difference between having a successful case and one that takes a long time and ends badly.