Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

The Office of Evaluations and Inspections (OEI) at the OIG does some great work when it comes to reviews of program related weaknesses.  They recently posted a review wherein they found that between 2014-2016, Medicare paid nearly $2 million in improper payments for emergency ambulance transports.  Of course, in reading this study, it furthered my position that fraud will always be there, and regardless of the criminal, civil, and administrative sanctions placed on providers in the community, the deterrence is just not there.

Typically, for a private ambulance provider to be able to bill for an emergency call, a variety of factors must exist.  The least of which is that the place where the patient is going is an emergency room (hence the use of the term, “emergency call.”)  I was an emergency medical technician (EMT) for 30 years, worked for several 9-1-1 systems, as well as non-emergency transport companies. It’s fair to say I understand how ambulance transportation works.  I had an investigation on an ambulance transportation company, who had skilled nursing facilities (SNF) as its primary customers. Most of the transportations that came out of the SNFs were considered routine, non-emergency transports.  What does that mean to the public?  These were the three times per week transports, via stretcher (because the patient was unable to sit, stand or walk, per the CMS regulations), to a dialysis or radiation/chemotherapy appointment.

Other transports that are non-emergency would be characterized as non-routine, non-emergency transports (but still requiring the inability to sit, stand or walk to meet the criteria).  In this one particular investigation, the EMT crews were directed to document the ambulance call report (ACR, sometimes known as a patient call report, or PCR) for the routine, non-emergency thrice weekly transports to reflect that the patient was unable to sit, stand or walk to the stretcher, thus triggering a part of the CMS requirement for payment.  The problem was that the EMT crew, in documenting the PCR/ACR, would indicate that the patient was found “sitting in a wheelchair,” “walking in the hallway,” “doing exercises in physical therapy,” and a host of other descriptions; yet, the patient was “transferred to the stretcher due to their inability to sit, stand or walk.”

In other instances, I reviewed hundreds of ARC/PCR sheets for “emergency” transports, where patients were direct admissions to the hospital, transfers from one emergency room to another (for convenience of the patient), or in for routine evaluations in an emergency department for normal medical ailments that the SNF could not address.  What I think got me the most frustrated was that in reviewing the PCR/ACR, the EMT crews would document “responded immediately”, (another factor for identifying an emergency call), yet never checked the boxes for the use of emergency equipment, or better yet, the drive time would be 30-40 minutes.

After reading this, you might be asking “why would the EMT create a false document?”  For most private transportation companies, an EMT in the metropolitan NYC area earns about $20 an hour to start.  They work an unbelievable number of hours, because the overtime is there, and the money is needed.  If given the directive that this is what will keep them employed, provide them with an opportunity for overtime, and all the other potential positives (like not getting fired), what would it matter to the EMT?  In the case in question, a search warrant was executed on the main office of the offending company, and right on the wall for all to see, was a memo written by the owner of the company directing the employees how to document an “emergency call.”

CMS took some effort to stem the fraud in ambulance billing, by incorporating preauthorization for non-emergency transports, and expanding that policy to several states.  Hopefully, CMS will take some of the OEI recommendations to heart and close what appears to be a loop that can be closed. All it will take is some data edits in place based upon place of service codes that CMS already employs to identify the origin and destination of the patient.  This will be particularly important as the ET3 model begins to take shape.

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.