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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.

  1. Carol Kirchner permalink

    I am have a difficult time dealing with Rural Metro of Greater Seattle.
    They trasported my mother from a hospital after she had had surgery for a broken hip. She had to be transported by ambulance around four days after her surgery to a rehab clinic where she could have theropy in order to walk again. She is eigthy-eigth. The ambulance has billed her three or four times, each time asking for payment of $1095.74 for a trip that was nine miles. They billed three times and did not provide an itemized bill untill recently. Each time i would send back the insurance information, each time they demanded payment and asked for the insurance information. I finally warned them with aleter to their webpage that the information was on its way again and to send me an itemized statement. It came after I told them I had called Medicare and Blue Cross blue Sheild. Now while I wait to hear back from them the collection companies have begun to call and send letters. The bill is very paded, for things not used and it is an amazing bill anyway! $1095.74 to lay there and ride nine miles.
    You can add one more person angry at Rural Metro of Greater Seattle.

    • Lee permalink

      Lucky for you the two EMTs are being paid minimum wage, otherwise, think how big the bill would be!

  2. Marie Bodinier permalink

    I am very angry at Rural Metro of Greater Seattle too, I required a transportation (prescheduled, non-emergency), back and forth ((12 miles total) from my home to an orthopedic clinic for an appointment for my pelvis that I broke at different places 2 days prior to the appointment. It was snowing that day. The ambulance arrived late, with 2 young adults who had no clue how to transport me from my home into the ambulance (I have stairs outside to go from my home to the street), they had me try to sit in a soft bag/chair that they would lift. It was so hurtful, that I screamed, then I eventually told them how to lift me. My neighbor was watching and offered to come with me, since she was very uncomfortable, as I was, with their poor handling of the situation. My neighbor sat in the front seat. She told after the ride, that the driver was texting while driving (remember it was snowing quite heavily that day)…They waited at the clinic and drove me back home. For that non professional service, I got a bill of $1,848 !! what a rip-off! I wrote them a letter explaining my discontent about the poor service and the law infraction. I called their billing department several times but did not get any considerations. They kept telling me that I owe them $1,848 and that they will collect the money regardless of what I consider a poor service and also despite the wrongness of the bill (they billed for a 36 miles trip.., and billed twice for infection control supply…).
    Who is controlling their services and rates? how those types of price can be even applicable? Who can pay such prices?

Trackbacks & Pingbacks

  1. United States Files Complaint Against Medical Transport Corporation « FraudBlawg
  2. U.S. Intervenes in Frohsin & Barger Qui Tam Suit Against National Ambulance Company Rural Metro « FraudBlawg
  3. Nationwide Takedown of Medicare Fraudsters: 107 Doctors, Nurses, and Medical Professionals Charged, 52 Others Suspended by HHS « FraudBlawg
  4. Whistleblower Prompts Rural/Metro Ambulance to Pay $5.4 Million Qui Tam Settlement « FraudBlawg

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