Posted and filed under Coding, Compliance, Fraud, FWA, Medical Record Auditing.

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Previously, I wrote a couple of blogs about the continued fraud in the ambulance transport industry.  It continues to be a hot topic, and a fraud variant that has some nuances.  I have been an emergency medical technician (EMT) for about 30 years and understand the emergency services landscape well.  In the world of Medicare Basic Life Support (BLS) services, there are a few different types of transportation: emergency, routine/ non-emergency, and non-routine/non-emergency.

It is important to understand what each of these means:

Emergency

Under CMS guidelines, this type of service requires that the EMS service demonstrate that there was an “immediate response” to the request for medical assistance.  This is a very vague description.  I could write a book on this definition alone.  It really does encompass a much broader review of the facts and circumstances of the call to determine if the call is truly an “emergency.”  CMS provides some examples of what would constitute an “emergency,” but it obviously does not encompass every potential situation.  Emergency transports do not require a certificate of medical necessity to justify the transport.

Routine, non-emergency

This is a bit more straightforward as a definition.  Instances where a patient needs stretcher transport for routine services (such as dialysis), but are unable to be transported by other means, fall into this category. Patients being placed in this category require a certificate of medical necessity by the ordering provider that outlines the reasons why stretcher transportation is the only available method of movement.

Non-routine, non-emergency

This definition is where I believe the fraud is the most prevalent, because these types of transports are coded as “emergency” even when they are not.  An example of this would be the resident of a skilled nursing facility (SNF) who needs to be treated at the emergency department for the replacement of a gastric tube (G-Tube), has the flu or some other medical condition that requires more medical care than can be facilitated at the SNF.  The patient is not in a “life or limb” situation, may have had the condition for several days, and/or need additional evaluation outside the SNF.  Since the destination is the emergency department of a hospital, an unscrupulous ambulance provider will treat such instances as “emergency” using the fact that the patient is being transported to an emergency department as the justification for submitting the higher-level emergency code.

Recently, we have been reviewing a lot of ambulance claims for a client.  That review is targeting claims submitted as emergency calls and matching the claims to the BLS documentation from the EMT crew.  I have found that the upcoding was higher than I initially thought it would be.  In almost every single case that I reviewed, the patient was really a non-routine, non-emergency transport to the emergency department for an evaluation.  There were few, if any, actual instances of a true emergency.   Much of the language from the EMT crew was canned, leaving to wonder if there was direction provided as to what and how to document the call.

This struck a nerve, as many EMTs are put in a position where if they do not follow the directives provided to them by their management, the potential to be terminated is real.  I investigated a BLS provider while at the OIG, and right on the wall where the BLS documentation was to be filed, were actual line by line instructions on how to document a non-routine, non-emergency transport, so it can be billed as an emergency call.  During the execution of a search warrant, there were numerous EMTs that were interviewed who all stated that they were threatened with being terminated if they did not follow the instructions provided.

One thing about EMTs that work for private transport companies is they are grossly underpaid, work immense numbers of hours, and rely heavily on the ability to work overtime.  They are unfortunately pawns in the fraud scheme, and have the fear of termination hanging over them if the instructions are not followed.

The difficulty in these investigations is that on their face, and diagnosis based, it might appear that the transport is an “emergency.”  A keen eye to review the documentation for high-volume calls originating out of a SNF, where the transportation company is a private company (vs a municipal service) is an area to target and review.

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.