Fraudulent Ambulance Billing To Medicare

Tuesday, October 29, 2013 | By Scott | No Comments

Here is a brief description of the type of ambulance fraud we have been seeing.

Medicare will pay for emergency and non-emergency ambulance services only when a beneficiary’s medical condition at the time of transport is such that other means of transportation, such as taxi, private car, wheelchair van or other type of vehicle is contraindicated (i.e. would endanger the beneficiary’s medical condition).  Medicare does not cover any means of transport other than transport by ambulance.

Non-emergency transportation by ambulance is appropriate and covered only when a patient is bed-confined and his/her condition is such that transportation by ambulance is medically required.  Medicare defines bed confinement as: unable to get up from bed without assistance; unable to ambulate;  and, be unable to sit in a chair or wheelchair.

Much of the income for many ambulance companies is generated by providing non-emergency ambulance transport to Medicare recipients to medical centers, such as dialysis clinics.

The companies transport patients who could walk or be transported by other means (i.e., taxi or paratransit van), falsely representing to Medicare that these patients medically required transportation by ambulance.  For example, patients are directed to get onto a stretcher or were placed onto a stretcher by ambulance company employees, when the patients were able to walk or to be moved by wheelchair.  Alternatively, some patients simply walk to and from the ambulance.  This also permits the ambulance company to transport 2-5 patients at once in the ambulance, rather than just one patient on a stretcher. 

The ambulance company then bills Medicare for the transport of these patients by ambulance, claiming it was a medical necessity.  The majority of dialysis patients need to attend dialysis treatments three times per week, thereby allowing the ambulance company to bill extensively for these patients.  For a round-trip transport, Medicare can pay between $400-800 per person depending on the area of the country and the patient’s needs. 

Kickbacks may be involved in this process:

  1. KBs from ambulance company to dialysis clinic employees who recruit, solicit or identify potential patients for the ambulance company.  Dialysis clinic employees, esp. admissions staff, often see the patients walking, etc. from the ambulance and know which ones are complicit in the fraud.
  2. KBS to physicians who will sign a certificate claiming that a patient requires transport due to a medical necessity.
  3. KBs to the patients themselves who are supposed to receive ambulance transport and do not need it.  Patients are often paid “signing bonuses” for agreeing to be transported by an ambulance company, or from switching from one company to the next.  There is considerable competition between ambulance companies for these patients.

Damages from these cases can range from the six figures up to $5-10 million depending on the size of the company.

 

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