Infographic: Understanding and Preventing Fraud in the Ambulance Billing Services



According to the Centers for Medicaid and Medicare Services (CMS), $350 million in ambulance services is lost or fraud is committed by a host of people, every year!

In 2012 alone, Medicare payments for ground ambulance transports covered under Part B totalled $5.8 billion, up from $2.9 billion in 2003.

Medicare beneficiaries received a total of 14.9 million transports in 2012. In total, more than $3.5 million in fraudulent claims were submitted to Medicare and Medicaid, and $1.3 million was paid.

Did you know?

In January 2014, owners of a supplier in Tennessee received prison sentences for fraudulently billing Medicare and Medicaid $1.2 million for transports to and from dialysis facilities.

One Medicare Administrative Contractor (MAC) estimated that only 10 percent of beneficiaries with ESRD who receive hemodialysis— one of the two main types of dialysis—require ambulance transports to and from hemodialysis treatment!

In June 2014, employees of a supplier operating in Philadelphia and other areas of Pennsylvania received prison sentences for fraudulently billing Medicare $3.6 million for transports that did not meet coverage requirements.

The supplier recruited patients who could walk and did not require transport by ambulance, and was also convicted of falsifying documents to support the transports and paying the patients illegal kickbacks.

In May 2015, a Florida supplier paid $1.25 million to settle allegations that it knowingly upcoded transport claims from basic to advanced life support, unnecessarily transported patients , and transported patients unnecessarily to their homes at a level of care meant for emergencies.

Fraud happens when

  • Medicare beneficiaries are recruited for travel even though they can walk and therefore don’t qualify for ambulance benefits
  • Creating false reports to make make it appear that other forms of travel are contraindicated
  • Paying illegal kickbacks
  • Overbilling Medicare by misrepresenting services provided
What Medicare Covers What Medicare Doesn’t Cover
Transports that occur during a beneficiary’s Part A stay at an inpatient hospital, skilled nursing facility (SNF), or hospice are generally covered as part of the stay. Medicare would not cover a transport to a hospital if the beneficiary was not treated at the hospital. Medicare Part B generally does not make separate payments for transports that occur during Part A stays.
If the transport meets coverage requirements, Medicare also reimburses suppliers for miles traveled with the beneficiary on board Medicare does not cover other means of transport such as wheelchair vans or taxicabs
Medicare covers seven different levels of ambulance transport of which vary in terms of qualifications of the ambulance crew and level of medical care provided & in an emergency Ambulance crew that do not meet the specifications of the certification as required by CMS, and does not meet the “Medical necessity”  rule, Medicare does not cover especially if in an non emergency situation

Who profit from Fraud in ambulance billing services?

Ambulance transport is a lucrative business, especially transporting a typical dialysis patient,  Medicare can be billed $60,000 per patient alone!

Although hospitals don’t directly profit from the ambulance rides as ambulance companies bill Medicare themselves for rides they provide, but some hospitals did benefit indirectly by speeding up their admissions and discharges—a key contributor to hospital profitability dubbed “throughput.”

Everyone thus makes a profit – Doctors, nurses, even top hospital administrators in eight cities in seven states were arrested in connection with separate scams totalling $430 million — nearly a half billion dollars in pilfering. All kinds of fraud are alleged, much of it involving false billing for services that were unnecessary, or never even rendered.

The Result :

Precious taxpayer resources are siphoned off, healthcare costs are indirectly affected and driven up, and the Medicare program loses strength  and the most crucial and hard hitting of all  –it victimizes the most vulnerable section of society – the elderly, disabled and impoverished Americans

Ninety one alleged fraudsters were targeted in cities that include Los Angeles; Miami; Dallas; Houston; Tampa; Baton Rouge; Chicago; and Brooklyn, N.Y & more than $49 million in ambulance transportation fraud alone were siphoned off besides the millions more in other frauds.

Since its inception in March 2007, the federal strike force has charged more than 1,480 defendants who collectively have falsely billed the Medicare program for more than $4.8 billion.

Ways to Stop Fraud in Ambulance Billing services? /Preventive Measures to Fraud in Ambulance Billing Services?

Review Claim policies and procedures:  By training the staff – dispatchers, field personnel, supervisors and billing personnel on the relevant rules and regulations, a lot can be achieved. Besides, employees should be aware that under the federal False Claims Act (as well as similar laws enacted in most states), they may be entitled to a reward should their reports of fraud result in a recovery for the government. Thus, instill in your workers and billers dedication and vigilance that can help stem fraud. Compliance with federal rules and regulations for ambulance service billing is a necessity

Certification: Ambulance suppliers should include the National Provider Identifier of the certifying physician on transport claims that require certification without which Medicare will not accept the bills

Monitor: Increase monitoring of the process of coding and billing, even if outsourced. Put into force a comprehensive plan that can monitor and ensure that claims are documented and filed appropriately.  Test randomly selected claims with other source documentation from the field and dispatch so that the information on the claim is thus validated with supporting documentation associated with the transport like ‘run sheets’ photos, etc.

Audit: Ensure annual reviews & audits are conducted especially by an external entity. This helps to assess the accuracy of the claims, any over payment amounts which immediately need to be flagged, billing or coding errors, and other variances from the rules and regulations.

 But, the most commonsense way to check fraud in ambulance billing service is: When in doubt don’t bill, especially if you don’t know whether a patient could have been transported by means other than an ambulance. And secondly, bill at the lower service level, (ie BSL) when unsure if the transport meets the requirements for a higher level of service (i.e., emergency or ALS). Better not to lose out completely if denied the claim which can impact negatively the Revenue Cycle Management process

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