How to Prevent EMS Fraud

Health-care fraud and abuse are playing a prominent role in political theatre. Targeting fraud and abuse is an easy political position; who could possibly argue against prosecuting crooks that take advantage of our health-care system and taxpayers? As would be expected, when the politicians focus on a specific agenda, the bureaucrats follow.

 

The government has unleashed an army to combat health-care fraud–the Office of Inspector General, the Federal Bureau of Investigation, state attorneys general and the Department of Justice have committed significant resources to identify and prosecute health-care fraud.

 

Then there are the disgruntled employees, former employees, competitors and others who are more than willing to aid the government and claim up to 30% of any damages, penalties and fines ultimately collected. In fact, whistleblowers initiate many government investigations of EMS and ambulance services. Increasing awareness and prevention at all levels of an organization proves the best way to avoid prosecution.

What is fraud?

Many of us fail to understand the full meaning and implications of health-care fraud. We believe that fraud requires the intent to steal money not rightly due the perpetrator. In reality, this assumption is naà¯ve. Many investigations, prosecutions, settlements and sentences are the result of errors, omissions, misunderstanding, and lack of knowledge of the rules and regulations governing the filing of health-care claims.

 

Without confusing the issue with the legal definitions, fraud–as it relates to most ambulance investigations–is simply the result of filing a false claim. A false claim is one where the documentation associated with the trip doesn’t substantiate the information submitted on the claim. It doesn’t matter whether the ambulance service provider intended to file an incorrect claim or if the information submitted was due to a failure to understand the rules and regulations.

 

Blatant examples of fraud within the ambulance industry include transporting dialysis patients who can walk to the ambulance and then billing Medicare, filing for patient transports that never occurred, filing claims for services not rendered and filing for upgraded levels of service that weren’t appropriate. Although these cases make headlines and the evening news, the vast majority of investigations deal with finer nuances in the rules. The following are areas that are being closely scrutinized:

  • Filing for Medicare reimbursement for patients who could’ve been transported by means other than ambulance;
  • Filing claims at the ALS level for all 9-1-1 requests just because a paramedic responded;
  • Seeking reimbursement for an emergency response when the transport doesn’t meet the definition of emergency;
  • Seeking reimbursement for transports beyond the closest appropriate facility capable of caring for the patient;
  • Filing claims that conflict with documentation in the patient care report or physician certification statement; and
  • Using incorrect modifiers to identify a non-covered destination as a covered destination.

By far, the predominant focus is on medical necessity (i.e., whether the patient could’ve gone by other means) and billing at the ALS level for assessment when the transport didn’t fulfill the necessary criteria (especially documenting the patient’s condition in dispatch that indicates that an ALS assessment is necessary). Investigations into air medical providers often focus on the issues of medical necessity and transport to the closest appropriate facility.

Relying on false assumptions?

How do we get into trouble when our intentions are good and we want to comply? Frankly, many of us have made false assumptions. These include the following situations:

  • The doctor ordered it, so it must meet the criteria for medical necessity.
  • It’s Medicare’s responsibility to determine whether the claim meets medical necessity. If they pay the claim it’s OK.
  • I have a signed PCS form, so the trip is covered.
  • All 9-1-1 patients deserve and require a paramedic response; therefore, they should be billed and paid at the ALS level.
  • Our billing service is responsible for filing appropriate claims.
  • As a paramedic or EMT, it isn’t my job to determine whether the patient could’ve gone by means other than ambulance.
  • Using incorrect modifiers to identify a non-covered destination as a covered destination.

Believing in any of these assumptions can lead to trouble. If you’ve heard statements similar to these repeated within your organization, you have some work to do. More importantly, you must understand that you’re responsible for what is submitted on claims for reimbursement.

 

Just because Medicare pays a particular claim doesn’t mean it’s accurate. In fact, investigations often come down to calculating the overpayment amount an ambulance service will have to pay back. The Medicare contractor paying the claim isn’t penalized.

 

If your EMS organization relies on a billing service to process claims, understand that the government will extract overpayments, penalties and fines directly from you, the ambulance service provider, regardless of who was at fault for filing the errant claims.

What should you do?

Ideally, your EMS organization will implement and use a comprehensive compliance plan to monitor and ensure that claims are documented and filed appropriately. This plan should include the following key elements.

 

Training: Train dispatchers, field personnel, supervisors and billing personnel on the relevant rules and regulations. The following questions should be addressed: When is an ambulance trip medically necessary? What information must be obtained in dispatch to appropriately file a claim as an emergency or for an ALS assessment? How should the field crews document the patients’ conditions, and when and how should they document that the patient doesn’t need an ambulance?

 

Documentation monitoring: Include reviewing information and the PCR relevant for billing in your quality improvement processes. PCRs should be consistently monitored for accuracy and to ensure that important data elements are complete.

 

Internal monitoring: Complete internal prepayment and post payment claims reviews on a regular basis and require that your billing service also conduct reviews. The randomly seleced claims should be examined with other source documentation from the field and dispatch to validate that the information on the claim was clearly supported in the documentation associated with the transport.

 

External monitoring: Ensure annual reviews are conducted by an external entity to assess the accuracy of the claims, overpayment amounts, errors and other variances from the rules and regulations.

 

Reinforce findings: Communicate with staff when problems are identified and, when necessary, update your training programs.

 

Involve the work force: Reaffirm and communicate with staff your organization’s commitment to compliance and the filing of appropriate claims for reimbursement. Let everyone know that you not only want but also expect employees to immediately bring forward any issues that they think may not be appropriate or comply with the letter and intent of the rules and regulations.

 

Compliance with federal rules and regulations for ambulance service billing is an organization-wide endeavor. It will take everyone to do the job right.

No one is immune

Federal and state governments have focused on ambulance services operated by cities, private companies and hospitals. Fraud cases have been instituted against organizations that do their own billing and those that use outside billing services. No one is immune.

 

Many of the cases have been resolved with “two comma” judgments–damages, penalties and fines totaling more than a million dollars. If your municipality, owner or hospital can’t afford to pay a multi-million dollar settlement, it behooves you to do everything possible to ensure absolute compliance with the rules and regulations.

 

The best advice is to use common sense and be conservative. If you don’t know whether a patient could’ve safely been transported by means other than an ambulance, don’t bill. If you’re unsure whether the transport meets the requirements for a higher level of service (i.e., emergency or ALS), bill at the lower service level.

 

The financial risk of not doing things right is immense (See sidebar, “A Cautionary Tale”). For example, one city is currently attempting to settle a fraud case arising from approximately $500,000 in overpayments over four years for nearly $2.5 million, and they think they will be lucky.

 

Fraud investigations originate from false claims. Make sure your claims are clean and that there are no intentional or accidental actions that could be classified as fraud.

 
 

A Cautionary Tale

 

On Oct. 13, the U.S. Department of Justice announced that an ambulance company owner in Texas was sentenced to 15 years in federal prison and ordered to pay more than $1.3 million in restitution for running a health-care fraud scheme. Muhammed Nasiru Usman, the owner and operator of Royal Ambulance Service and First Choice EMS, was convicted in May of this year on 14 counts, including health-care fraud and money laundering. Two co-defendants, Shaun Outen and David McNac–both director-level employees–pleaded guilty prior to trial. They were awaiting sentencing at press time.

 

The two ambulance services routinely transferred patients on a non-emergency basis to and from dialysis treatments three times per week, according to a press release from U.S. Attorney James Jacks. The U.S. government presented evidence that the three defendants “conspired to defraud Medicare and Medicaid by submitting fraudulent claims related to the transportation of dialysis patients.

 

As part of the conspiracy, the defendants told Royal and First Choice employees to omit facts when documenting their transports “¦ such as whether the patients walked to the ambulance, in order to qualify the transports for reimbursement.” According to the DOJ, records showed that many patients rode to their appointments while sitting in the captain’s chair in the back of the ambulance.

 

In total, more than $3.5 million in fraudulent claims were submitted to Medicare and Medicaid, and $1.3 million was paid.

 

No posts to display