What You Need to Know to Help Prevent Ambulance Fraud

The City of Philadelphia and surrounding counties have seen a dramatic increase in the number of ambulance providers.  From 2006 to 2011, Montgomery and Philadelphia counties have had a 73% increase in the number of Medicare credentialed ambulance providers performing services.  Data shows that the State of Pennsylvania has more ambulance providers than both the State of New York and New Jersey combined!  Eighty-four percent of Medicare paid dialysis transports in the State of Pennsylvania originate from one of five (5) Counties in the Philadelphia Region.

The Medicare Ambulance Benefit is very restricted and only allows for payment under limited circumstances.  Physicians who order an ambulance and/or certify the medical necessity for their patients need to be aware of these limitations.   Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health (42 CFR §§ 410.40(d)).  A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment of the ambulance benefit.

It is critical that physicians who complete medical necessity forms for ambulance transports understand their role.  The mere presence of a completed, signed and dated medical necessity form by a physician does not automatically qualify a patient for ambulance transport.  If it is determined that a patient can be safely transported by other means, Medicare will not pay for the trip.

The problem with fraudulent billing of ambulance transports is most evident in the billing for routine transports for dialysis services.  Physicians need to be alert to requests they may receive asking them to certify the need for these ambulance transports.  Unscrupulous ambulance companies have been known to offer kick-backs to physicians who agree to sign Physician Certifications for Ambulance Transports.  These ambulance providers may solicit the beneficiary’s treating physician or physicians who have little or known history with the patient.

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