Ambulance Fraud

Under Medicare “Part B” – Supplementary Medical Insurance for the Aged and Disabled – Medicare covers medically necessary ambulance services.  Ambulance services are deemed medically necessary “if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.” 42 CFR 410.40. Although “bed-confinement” is itself neither sufficient nor required as evidence of medical necessity, it is a “factor to be considered.” A Medicare beneficiary is bed-confined if three requirements are met: “(i) the beneficiary is unable to get up from bed without assistance; (ii) the beneficiary is unable to ambulate; (iii) the beneficiary is unable to sit in a chair or wheelchair.”

Medicare imposes an additional requirement for non-emergency, scheduled, repetitive ambulance services, such as dialysis transport: in addition to itself determining that medical necessity requirements are met, the ambulance service provider must, before providing service, obtain a written order from the patient’s physician certifying the medical necessity of ambulance transport. 42 CFR 410.40(d). Such order is valid for 60 days.

Effective April 1, 2002, CMS established a fee schedule for ambulance services, replacing the previous “reasonable charge” billing procedure. See 42 CFR 414.601. The fee schedule defines several different levels of ambulance service.  Payment is made on the basis of services actually performed – rather than on the type of call or vehicle involved.  For example, Basic Life Support (BSL) is defined as “transportation by ground ambulance vehicle and medically necessary supplies and services, plus the provision of BLS ambulance services.” Accordingly, ambulance providers are required to maintain all records demonstrating the medical necessity of transport services billed to Medicare or Medicaid, as well as the actual provision of a level of service requiring an ambulance.

Frohsin & Barger has identified and uncovered the following types of fraud related to ambulance transport:

• False billing for ambulance service to patients who are not bed bound or otherwise in need of transport by ambulance;
• False records reflecting fictitious patient conditions intended to justify unnecessary ambulance service;
• False records indicating health services – such as oxygen – that were not provided;
• False billing for individual transport when transport was in fact provided on a group basis;
• False billing for ambulance services that were never provided;
• Paying Illegal kickbacks to nursing homes and assisted living facilities in exchange for referrals of dialysis patients.

To report ambulance fraud, contact Frohsin & Barger.