Medicare’s Strict Billing Rules for Mobile Ambulance Services Create Significant Risks for EMS Providers
Emergency medical services (EMS) providers serve a critical role in our health care system. However, like all health care providers that bill Medicare for their services, they are subject to strict billing rules and regulations, and failure to adhere to these rules and regulations – as interpreted by the Centers for Medicare and Medicaid Services (CMS) – can lead to charges for federal fraud.
One of the greatest areas of risk for EMS providers is mobile ambulance transportation. While it may seem prudent to err on the side of caution and take patients to the hospital whenever it appears that medical treatment may be necessary beyond that which can be provided by emergency medical technicians (EMTs), unfortunately – and somewhat paradoxically – this approach can get EMS providers into trouble with CMS.
Not only can improperly billing Medicare for mobile ambulance transportation services result in the claim being denied, but it can also lead to charges under the False Claims Act and the federal health care fraud statute for attempting to “defraud” Medicare.
4 Medicare Eligibility Requirements for Mobile Ambulance Transportation Services
In order to be eligible for Medicare reimbursement, mobile ambulance transportation services must satisfy four specific billing requirements:
- Mobile ambulance transportation was medically necessary (or an exception applied);
- The patient needed transportation in order to receive medical treatment that was eligible for Medicare reimbursement (or to return from receiving such treatment);
- The facility to which the patient was transported is Medicare-compliant; and,
- The EMS provider satisfies all CMS requirements for mobile ambulance services.
As you can see, as am EMS provider, it is not always (or even necessarily even often) a straightforward process to determine whether a mobile ambulance ride will qualify for Medicare reimbursement. Let’s look at each of these four requirements in more detail:
1. Medically Necessity (Subject to Exception)
As a general rule, in order to be eligible for Medicare reimbursement, mobile ambulance transportation services must be medically necessary as determined by CMS. This means that use of an ambulance is the only safe way to transport a patient. Typically, this requires that: (i) the patient potentially be at serious risk of medical danger, and (ii) no safe alternative means of transportation are available.
However, there are a few exceptions to the requirement of medical necessity. Under the current Medicare billing guidelines, a patient can receive mobile ambulance transportation in the absence of medical necessity if:
- The patient is unable to walk, sit in a wheelchair, or get out of bed without assistance;
- The patient needs vital medical services during transportation (i.e. administration of intravenous (IV) medications); or,
- The patient lives in a skilled nursing facility and is subject to a doctor’s order for health care services that require transportation to another location.
2. Medicare-Eligible Treatment
Not only must the patient be in need of medical treatment; but, in order for mobile ambulance transportation services to be eligible for reimbursement, the needed treatment must be Medicare-eligible as well. While most forms of emergency treatment qualify for Medicare reimbursement, types of services that are not eligible for Medicare include:
- Long-term care (also called custodial care)
- Most dental care
- Eye exams related to prescribing glasses
- Cosmetic surgery
- Hearing aids and exams for fitting them
- Routine foot care
Of course, EMTs are not doctors, and ambulances are not designed or equipped to fully diagnose patients’ medical needs. As a result, it is entirely possible (and not at all uncommon) for an EMT to incorrectly assess a patient’s needs – particularly if the patient provides inaccurate or incomplete information about his or her condition.
3. Medicare-Eligible Facility
Next, the facility to which the patient is transported must be fully compliant with all Medicare coverage guidelines. As a result, even if mobile ambulance transportation is medically necessary, and even if the patient needs Medicare-eligible treatment, the transportation services still will not be eligible for reimbursement if the services are rendered at a non-compliant facility. Of course, the Medicare eligibility requirements for medical facilities are extraordinarily complex; and, even when an independent EMS provider has a working relationship with a hospital or other facility, that provider still may not be privy to whether the facility is (and remains) Medicare-compliant.
4. CMS-Compliant Mobile Ambulance
Finally, in addition to each of the above requirements, EMS providers must ensure that their ambulances are Medicare-compliant as well. If an ambulance is considered to be deficient in any respect, then any transportation services provided with the ambulance will be ineligible for Medicare reimbursement.
When billing Medicare for mobile ambulance transportation services, an EMS provider must certify as to the satisfaction of each of these four requirements. Submitting an inaccurate, or “false” certification is considered Medicare fraud, and it can lead to severe civil or criminal penalties. These penalties can include:
- Recoupments, denial of pending claims, and pre-payment review of future claims
- Fines and treble (triple) damages
- Loss of Medicare eligibility
- Federal imprisonment
Ensuring Compliance and Defending Against Allegations of Mobile Ambulance Fraud
The best way for EMS providers to avoid mobile ambulance fraud allegations is to implement and maintain comprehensive compliance programs. From contracting with medical facilities to upfitting compliant ambulances and training EMTs on Medicare’s guidelines for medical necessity, there are numerous steps that EMS providers must take in order to mitigate their risk of federal Medicare fraud investigations.
Of course, if your business is already under investigation, then you need to shift your focus to preventing the investigation from resulting in federal charges. This involves intervening in the investigation, conducting an internal audit, proactively addressing any compliance issues, and working with federal prosecutors to achieve a favorable resolution.
Speak with a Medicare Fraud Defense Lawyer at Oberheiden, P.C.
At Oberheiden, P.C. we provide comprehensive compliance and defense representation for EMS providers in all Medicare-related matters. If you have questions or need help and would like to speak with an attorney, you can call (888) 519-4897 or contact us online for a free and confidential consultation.