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Review of the ‘Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports’ Report

The Office of Inspector General (OIG) for the Department of Health and Human Services released their report late last year entitled, “Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports.”

This 36-page report reviewed 7.3 million ambulance transports from 15,164 ambulance suppliers (institutional based ambulance providers not included). Patient care reports from the first six months of 2012, Jan. 1through June 30, were reviewed.

The Office of Inspector General’s (OIG) office reviewed these areas of ambulance transports:

  • Transport destinations
  • Transport levels
  • Distance of urban transports
  • Geographic locations where the beneficiaries who received transport resided
  • Other Medicare services that beneficiaries received

The report identified that for the first half of 2012, Center for Medicare and Medicare Services (CMS) paid $24 million for ambulance transports not meeting sufficient payment justification, including issues with medical necessity and transportation to non-covered facilities. The report also indicated that one in five ambulance suppliers had questionable billing practices.

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports

Geography

One of the findings within this report indicated that the questionable billing was geographically situated within four metropolitan areas. These identified areas include Philadelphia, Los Angeles, New York and Houston. These four metropolitan areas with the most questionable transports accounted for more than half of the $207 million in Medicare payments’ questionable transports.

Dialysis

End-stage renal disease (ESRD)—or dialysis—transports remain under strong review from Medicare. Between 2002 and 2011, ESRD transports increased 269%. The report even cited that “one Medicare Administrative Contractor (MAC) estimated that only 10% of beneficiaries with ESRD who receive hemodialysis—one of the two main types of dialysis—require ambulance transports to and from hemodialysis treatment.”

Medical Necessity

Medical necessity of the ambulance transport is a major issue as discussed within the report. It is cited within the Social Security Act that Medicare should honor “ambulance service where the use of other methods of transportation is contraindicated by the individual’s condition, but only to the extent provided in regulations.”1

Documentation is very important to justify why the patient could not be transported safely by any other means. Every patient must have a detailed assessment completed at the scene and those findings must be clearly documented within the patient care report. The information can be obtained from the patient, family members or a bystander. The documentation must also support the level of services that were provided to the patient. As a rule, if the ambulance service is not medically necessary, the ambulance supplier should consider not billing Medicare for the claim, and billing the beneficiary directly for the services provided. This saves time, steadies revenue flow and decreases the threat of delayed payments or audits.

Inappropriate Transports

The OIG also found that CMS paid $30 million for possible inappropriate ambulance transports in which the patient did not receive Medicare services at their destination. Patients are being transported to mental treatment facilities and physician offices, not a covered Medicare service locations.

The OIG has made five recommendations to ensure the correct usage of an ambulance transport:

  1. Determine whether a temporary moratorium on ambulance supplier enrollment in additional geographic areas is warranted
  2. Require ambulance suppliers to include the National Provider Identifier for the certifying physician on transport claims that require certification
  3. Increase monitoring of ambulance billing
  4. Determine the appropriateness of claims billed by ambulance suppliers identified in the report and take appropriate actions
  5. Implement new claims processing edits or improve existing edits to prevent inappropriate payments for ambulance transports

It is up to the ambulance service suppliers to take the time to review the patient care reports and vouch for their completion, quality and overall necessity. As a general practice, ambulance suppliers should continue to review all of their internal processes including patient care, compliance and documentation. This review process should include the implementation of a Quality Assurance / Quality Improvement program that involves all aspects of patient care to assure appropriate compliance.

To read the full report visit http://oig.hhs.gov/oei/reports/oei-09-12-00351.pdf.

REFERENCES

1. Social Security Act Section 1861 (S) (7)