Last month we wrote an article here on our blog explaining how ambulance companies commit Medicare fraud. It outlined the different schemes that some non-emergency companies pull---and what CMS is doing to try to stop them.
After it went live, we received a ton of feedback from medical professionals around the country. More than 28,000 visitors viewed the post --- and it clearly struck a chord. Many readers (especially EMS workers) mentioned that they had personally witnessed some of the schemes mentioned in the post.
Others pointed out a different but related issue --- that discharge personnel at hospitals and skilled nursing facilities that arrange transportation services for patients are often unknowingly contributing to this type of fraud. We thought it would be a good idea to write a follow-up post looking into some of these claims.
Taken together, the comments below reveal an EMS population frustrated with fraudulent ambulance companies AND hospitals who either don't understand the rules, or who essentially sign blank PCS forms to free up beds.
“It’s the facilities that EVERY day fabricate a PCS form, and don’t blink an eye lying about medical necessity. Where is their accountability?”
"Absolutely! It’s a destructive cycle when the medical staff at an ECF or SNF will write just about anything so that they can just continue calling an ambulance for transport instead of doing the required legwork to get the correct level of care and transportation lined up for their patients. What’s an EMS provider to do when they show up at a facility and a patient obviously does not meet criteria for ambulance transport?”
“Transport as chair car/BLS, inform dispatch of the change, tell the hospital/SNF staff why the patient isn’t BLS appropriate, and reflect that it is chair car coverage in your paperwork. If the company refuses, tell them. Otherwise, it’s Medicare fraud for which you are a mandated reporter and also lose your license if caught.”
“Then go home and look for a new job, because you keep that up and you’ll see your hours shrivel up quickly.”
“It’s time to put the requesting providers under an audit.”
“Do not think that government payors are the only ones looking at fraud. The commercial payors managing Medicare lives all have direct lines to OIG and will soon be coming in with criminal and civil suits with the same gusto if not more when larger providers are controlling market share alongside large commercial payors.”
“I have worked in private EMS since 1981. The biggest problem is the physicians who write PCS papers to help the fraudulent companies. I have had more patients than I can count who walk from their house, down the stairs, out into the street, and want to climb into my ambulance to sit on the cot because they are able. But the doctor who filled out the PCS stated the patient needed ambulance transport due to weakness. Some move better than I do. I’ve told billing, owners, and dispatch. I’ve completed redetermination of care forms, I’ve documented what I see, and still the transportation continues. It falls back, many times, on the doctors. I agree completely there are bad ambulance companies out there but we can’t forget that we do what we are ORDERED to by a doctor. Yes we can pass off the fraudulent run. But then that has repercussions for refusing runs. I would love for the rules to be tightened for both ambulances and doctors.”
Two EMTs arrive at a hospital to pick up a patient to take him to a rehab facility. They observe that the patient seems to be in relatively good condition. They take a look at the Certificate of Medical Necessity form and notice that it's largely empty. They then ask the nurse requesting the transport why the patient requires ambulance transportation (as opposed to a wheelchair van, medical car, or a taxi service).
The nurse then explains that "nothing is particularly wrong with him, but he has no other way to get to there." If further questioned by the EMTs, she claims the patient is afflicted with one of the following conditions:
- patient is unable to walk independently
- patient has an altered mental status
- patient is oxygen-dependent
If the EMTs argue the decision, they face discipline from their superiors. The ambulance company also could be blacklisted by the hospital for having the nerve to question the decisions of the hospital's discharge staff.
A real-life example
One recent news story highlighted what our commenters were saying. In May of last year, nine Florida hospitals paid a combined $7.5 million settlement in response to allegations that they led ambulance companies to bill Medicare for unnecessary rides.
“The ambulance companies, not the hospitals, received payment from Medicare or Medicaid for the rides, but the hospitals benefitted indirectly by quickly removing patients who no longer needed treatment, freeing up space for new patients” explains Lisa Schencker of Modern Healthcare in an article on the settlement.
“Hospitals need to educate their employees and contractors in regard to the documents they sign. They need to make sure they understand the criteria to which they’re certifying every time they sign one of these documents,” said Andrea Treese Berlin, sernior counsel with the Department of Health & Human Services.
The revival of wheelchair van and medical car services
Many hospitals and skilled nursing facilities paid close attention to the Florida story. As a result, in our view, facilities are now being more careful about what sort of discharge transportation they arrange. Slowly but surely, for patients who need some travel assistance but do not meet the requirements for ambulance transportation, facility discharge planners are turning to wheelchair vans and medical cars from medical transportation companies.
Unlike ambulances, this mode of transportation is NOT covered by Medicare, but more often than not, it's the more appropriate solution both for the patient and for our healthcare system.
Meanwhile, the debate on who carries the responsiblity of matching patients with the correct mode of transportation continues. Ambulance companies and EMS workers point to hospitals, while physicians and discharge planners maintain that they shouldn't have to learn the ins and outs of Medicare ambulance regulations.
How can hospitals assure compliance?
Because of various discrepancies and fears of commiting fraud in our industry, many ambulance providers now offer compliance lessons to the hospitals they work with. If you arrange for transportation for patients from a hospital or other healthcare center, ask your transportation provider to hold a Medicare transportation training session at your facility. These can be a great opportunity to open lines of communication, discuss any issues that may have arisen, and assure compliance with all rules and regulations on both ends.
By John Carreyrou --- The Wall Street Journal
By Katie Bo Williams --- healthcaredive.com
By Shantanu Agrawal, M.D., Medical Director for the Center for Program Integrity at the Centers for Medicare & Medicaid Services
By Dr. Peter Budetti, CMS Deputy Administrator and Director of the Center for Program Integrigy
What to do when you discover conduct that may violate federal fraud and abuse laws