The authors of the study concluded that the increase was due in part to inflation, the transition to a national fee schedule for Medicare ambulance transports and the continued growth in utilization of ambulances services.
Although the total number of Medicare fee-for-service beneficiaries increased just 7% from 2002 to 2011, the study found that the number of beneficiaries who received ambulance transports jumped 34%, increasing from 619 to 830 transports per supplier. The number of ambulance providers varied by state, from a decrease of 25% in Mississippi to an increase of 207% in Virginia. Nationally, the average number of transports per beneficiary increased 26%.
In addition, the number of ambulance suppliers increased 26%, up from 14,087 in 2002 to 17,776 in 2011. The most noteworthy increase was seen in ambulance suppliers that provide BLS nonemergency transports. That number nearly doubled from 2002 to 2011.
Dialysis-related transports increased most significantly, compared with transports to or from other origins and destinations. The number of dialysis-related transports during the study period increased 269%. They represented 9% of the total number of ambulance transports in 2002 and 19% of all transports in 2011. The report indicates that beneficiaries with end-stage renal disease (ESRD) “who received transports accounted for an increasing percentage of all ambulance transports,” even though the percentage of beneficiaries with ESRD who required transports remained relatively consistent from 2002 to 2011. The greatest increase in dialysis-related transports by state occurred in South Carolina. In 2002, 2% of all South Carolina’s transports were dialysis-related. By 2011, dialysis-related transports represented nearly half of the total ambulance transports for that state.
Although transports to and from hospitals represented a larger proportion of all ambulance transports, these increased at a considerably slower rate than did dialysis-related transports–just 55%. The number of transports from a residence to a hospital increased 51%, accounting for approximately half of all transports to a hospital. ALS emergency transports to a hospital increased 69%, while BLS emergency transports to a hospital increased 60% during the same time period.
The authors noted an increase in transports to nonhospital facilities. In particular, there was an 829% increase between 2002 and 2011 in visits by beneficiaries who received transports to community mental health centers.
According to the report, ambulance suppliers billed for greater average transport distances in 2001. The average trip length increased 1.6 miles (from 7.8 to 9.4 miles). Furthermore, suppliers billed for longer-mileage transports. At the same time, Medicare beneficiaries were no more likely to live in a rural location in 2011 than in 2002.
The authors noted that, while transports from 2002 to 2011 increased throughout the United States, utilization changes varied widely by state. Ambulance transportation utilization was the lowest in Utah (8%) and the highest in California (289%). Other states reporting exceptionally high increases included Virginia, South Carolina, Georgia and New Jersey. Ten states had increases of 100% or more.
How the study was conducted
To determine the extent to which the utilization of ambulance transports changed from 2002 to 2011, Medicare Part B claims for ambulance transports from 2002 to 2011 and the Medicare Part A and B claims that were associated with these transports were reviewed. The authors also examined enrollment data for all Medicare fee-for-service beneficiaries. The characteristics of beneficiaries, suppliers and transports were analyzed and the percentage difference between 2002 and 2011 was calculated. Changes in utilization were also calculated by state.
Only transports for which mileage was also billed were reviewed. Transports billed by institution-based ambulance providers were excluded.
The authors did not review the medical records of beneficiaries who received transports. Therefore, no determination was made whether the transports were medically necessary or met coding and documentation requirements for coverage.
The report does not contain recommendations. However, the OIG plans a subsequent analysis of ambulance suppliers that exhibited “characteristics of questionable billing in the first half of 2012, as well as geographic areas with high numbers of these suppliers.”
The speculation among EMS leaders is that, while the report primarily focuses on the potential for fraud and abuse in the area of BLS transports–and more specifically, dialysis transports–all ambulance transport providers should be aware that the additional scrutiny from the OIG may generate increased ambulance audits throughout the industry.
Not everyone sees this as a bad thing. “Although I know this report will be discussed at many levels of the EMS industry, I see it as a positive sign,” says Don Lundy, BS, NREMT-P, president of the National Association of EMTs. “EMS has entered the world of healthcare and that is a good thing. We are becoming an integral part of the process, instead of–dare I say it?–ambulance drivers. With that comes great responsibility from all of us in the ambulance industry to ensure that how we approach our patient care and business practices are, at all times, both ethical and moral.”
The OIG is accepting comments or questions about this report. However, they must be received within 60 days of the September 24 publication date. Refer to report number OEI-09-12-00350 in all correspondence.
The entire report can be downloaded at the Document Repository at www.emsinsider.com.