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Under Medicare guidelines, the program will pay for emergency and non-emergency transports, when such services are medically necessary. The guidance on getting such covered transports is well documented by CMS, and can be found here. Notwithstanding the written policies, unscrupulous providers of transportation services will always find ways to circumvent polices, data analytics, and create environments to make stealing from the Medicare program easy. Of note are those patients who reside in skilled nursing facilities (SNF) and are transported by BLS (which implies a patient transport via a stretcher), but the patient can be transported via other means, such as wheelchair van. There are a few states where CMS has implemented a preauthorization process, which the OIG has indicated has had dramatic reductions in payments. This preauthorization process, however, has not been rolled out nationally, so the issues will continue to exist.
Patients who require non-emergency, routine transports from the SNF to something like radiation therapy or dialysis, are probably the most common varieties of BLS transportation that you will find occurring. Under the Medicare Part A benefit, the SNF is paid a rate that would include the costs of transportation needed to provide care to the patient. In effect, if the patient needed to be transported for one of the services via wheelchair, that service would have to be paid for by the SNF. In a correct billing environment, the transportation company would have a contract in place with the SNF outlining the fees associated with the transportation of the patient. The transportation company takes the patient, via wheelchair, to their appointment, bills the SNF, and the SNF pays the bill. What does that do for the SNF? That effects their bottom line. If the SNF can get the patient costs pushed onto Medicare, the SNF can save on the costs of that transport. How does that happen? The SNF employs medical staff to provide care and treatment of SNF patients. The SNF maintains the purse strings.
Here is a potential scenario: the operator of the SNF directs the medical staff to prepare a certificate of medical necessity; a required document to establish that the patient is unable to be transported via any other means other than stretcher. That document is a key record that establishes that there are one or more issues that would make wheelchair or other means hazardous to the patient. By having this document, the SNF is able to push the patient to the BLS transportation. The SNF saves the cost of transportation and the BLS transportation company gets paid by Medicare for the transportation. What are some other collateral results? Maybe the operator of the SNF pays the medical staff for certifying the medical necessity. Maybe the BLS transportation company pays a kickback to the SNF. Maybe the BLS transportation company provides very favorable rates to the SNF in return for the patient referrals.
I investigated a BLS transportation company that had created unbelievably favorable rates to SNFs in return for referring patients that “needed” BLS transportation. Some of those favorable rates included reduced mileage rates, absorption of costs for oxygen usage, free van usage for group trips, and a host of other discounted rates. The BLS transportation company did not have a “9-1-1 or equivalent” agreement with any of the SNFs, yet still submitted numerous claims for “emergency” calls. During my investigation I was unable to establish the kickback agreement, per se, but was absolutely able to show that there was questionable medical necessity for the BLS transports. This was done by looking beyond the medical necessity document, which I was skeptical of from the beginning. Was the patient going to physical therapy, occupational therapy, or taking family trips outside of the SNF? A deep dive of patient records from the SNF worked to establish the pattern of falsehoods.
There is very stiff competition for BLS transports. The unscrupulous companies will always look for what they can use as the edge to get the business. In my career, I found that it was not about the quality level of service, response time, mechanical soundness of the ambulances, or any of the things that we as consumers would look for in any other type of service we pay for. Like all other things that involve fraud, and in Medicare fraud, it is all about greed.
Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.