Despite the best efforts being made by the government to ensure that all citizens are adequately covered by insurance, the truth is that many are still not. As a result, emergency medical services such as ambulance companies are misused by individuals who are not suffering from an immediate and health- or life-threatening illness or injury and are trying to take advantage of what they consider a “free service.”
Of course, anyone who has been injured or becomes dangerously ill should never hesitate to call 911 and initiate a response by emergency medical personnel and an ambulance service. Fast and effective emergency treatment and transport to a medical facility can make all the difference in the world. But someone who doesn’t feel well and wants a free ride to the hospital should think twice about making that call. Here’s why:
When an ambulance responds to transport a patient to the hospital for a minor medical complaint that ambulance cannot respond to a different patient suffering from an actual medical emergency. The time wasted transporting the non-emergency conditions can mean the difference between life and death for the patient suffering from the true medical emergency.
In the case of Medicaid recipients, patients should not have to resort to ambulances for basic transportation. Medicaid is federally funded to provide non-emergency medical transportation (NEMT) to program participants. Medicaid will provide transportation free of charge if the recipient claims there are no other forms of transportation available.
Claims submitted for ambulance transport services should be routinely reviewed to not only ensure valid transport services to medical facilities, but also to validate associated claims for services related to those transport services.
Common instances of ambulance fraud may include:
- Billing for medically unnecessary ambulance transport
Submitting a claim for a transport that was not life-threatening or otherwise routine (e.g. scheduled radiation treatment for cancer patients)
- Ambulance transport “upcoding”
Falsely changing the severity of the medical necessity of a transport from “non-emergency” to “emergency” to receive a higher payment
- Billing for services not rendered during transport
Fabricating services and/or supplies to increase billing
- Participating in unlawful agreements/scams with health care facilities
Such as providing ambulance transport at a lower cost in order to receive more “emergency” referrals
Medicare ambulance claims, just like everything involved with Medicare, must meet certain requirements to be considered valid ambulance transport claims. The main factor is the transport must be considered “medically necessary” under Federal law. To do this, two specific criteria must be met:
- The use of other transportation methods is contraindicated by the condition of the individual requiring care
- The individual’s medical condition must require the level and type of service reported to have been provided and billed
If transport is not medically necessary it will not be covered by Medicare. The CMS has an entire chapter about Ambulance Services in the Medicare Benefit Policy Manual which states very clearly:
In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services.
As you can see, often the difference between a legitimate claim and an illegitimate one is how the claim is coded – intentionally or unintentionally. Here at Medstar, we take fraud and billing errors very seriously and work hard to ensure that all of our claims meet the strictest appropriate compliance requirements.
Here are five steps we take to make sure that everything we do is accurate and correct:
- Everyone on our billing staff is a Certified Ambulance Coder, with an up-to-date knowledge of current compliance requirements
- We conduct internal billing monitoring and auditing
- We conduct ongoing training and education on billing standards and procedures
- We have annual external audits and training
- We conduct our own weekly internal audits
If you’d like to know more about or billing policies and practices, please contact our billing department.
