The Medicare program represents the biggest pot of gold or perpetual payday for those who seek ways to tap its almost endless coffers. And while fraud has many faces, one area where attempts have been made to grab the gold is the ambulance transport industry. Most providers are honest and ethical but exceptions exist, as we shall see below.
Medicare Part B provides for reimbursement of “medically necessary ambulance services”, under certain strict provisions. For instance, payment requires that a beneficiary’s medical condition precludes the use of other means of transportation. The law further states that bed-confinement is neither required nor sufficient as evidence of the need for an ambulance, but “it is a factor to be considered”.
The law seeks further to ensure the necessity of the service by sometimes requiring the patient’s physician to certify the necessity. The certificate usually had a 60-day shelf life. This requirement is used more for non-emergency and repetitive usage such as transport for check-ups and other medically necessary physician visits.
Just how much does ambulance transport fraud cost taxpayers and the government?
It is hard to say, but a case in 2008 shows the damage wrought by one corrupt provider.
Greybor Medical Transportation, a Los Angeles-based ambulance company admitted it was using its ambulances to cheat Medicare. The owners of Greybor agreed to repay Medicare $6 million for billing its ambulance services for costs that had never been eligible under Medicare.
Interestingly, the company faced similar charges in 2005 and ended up paying the government a $50,000 fine as well as a reimbursement of $2.4 million.
And they’re not alone. Two similar charges were leveled against other big medical transport companies in recent years. American Medical Response (AMR) paid $9 million for a similar scheme using its ambulances to cheat Medicare.
They were brought to justice with the help of a False Claims Act whistleblower who received a reward of $1.6 million for his efforts.
In a major 2004 case, Adventist Health agreed to a settlement of $20 million for ambulance fraud. In that case, a whistleblower received a reward of $2.4 million.
In 2002, American Medical Response also paid $20 million for ambulance fraud, with the whistleblower receiving $3.8 million. Believe it or not, cases have been tried where even taxis tried to bill Medicare for ambulance services.
Although each case differs, certain patterns emerge in the ways or items which ambulance companies use. As examples, federal prosecutors see a lot of the following billings:
- Billing for ambulance service to patients who are not bed bound or otherwise in need of transport by ambulance.
- Fictitious reasons and records used by patients to justify using an ambulance.
- Submitting records for health services, such as oxygen or other specialized equipment, that were either not needed or not provided.
- Billing for individual transport when the service provided was for a group.
Greybor has been given an expensive lesson. Under the False Claims Act, the government was able to make the owners repay treble the amount of the fraud. In addition, the perpetrators received an 18-month jail term.
The government knows this is a well-used type of Medicare fraud and is on the lookout across the country for similar tricks and schemes.
Report Ambulance Fraud/Medicare fraud here.
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