EMS Providers Can Face Civil or Criminal Penalties for Billing Medicare When a Ride to the Hospital Isn’t Medically Necessary. Are Your Billing Practices Putting You at Risk for Federal Prosecution?
Not all mobile ambulance transportation services are eligible for reimbursement under Medicare’s billing regulations. In fact, mobile ambulance transportation services are not reimbursable unless the transportation qualifies as “medically necessary” according to the Centers for Medicare and Medicaid Services (CMS).
Maintaining compliance with the Medicare billing regulations is among the most challenging aspects of operating a business in the health care industry. In addition to the general billing regulations that apply to all providers, emergency medical service (EMS) companies are also subject to a number of unique requirements. This includes not only the “medically-necessary” transportation service requirement noted above, but various other conditions for reimbursement eligibility as well.
When Are Mobile Ambulance Transportation Services Not Eligible for Medicare Reimbursement?
Despite providing lifesaving services to patients with traumatic injuries and severe illnesses, EMS providers are subject to intense scrutiny with regard to when and why they bill Medicare. Sadly, this has the effect not only of exposing EMS companies to substantial liability (and potentially exposing their owners and executives to federal incarceration), but also of placing these companies in a state of uncertainty as to whether they can afford to provide transportation services under varying circumstances.
The following are just four examples of scenarios in which mobile ambulance transportation services are not eligible for Medicare reimbursement and in which improperly billing Medicare can lead to federal charges:
1. The Transportation Is Deemed Not “Medically Necessary”
As noted above, in order to be eligible for Medicare reimbursement, mobile ambulance transportation services must be medically necessary. But, (i) in this context, medical necessity is determined based upon the Medicare program guidelines, and (ii) emergency medical technicians (EMTs) will not necessarily be qualified to assess whether a situation calls for emergency medical treatment. As a result, it is not at all uncommon for Medicare to deny EMS providers’ reimbursement claims based upon an after-the-fact and non-fact-specific assessment of the need for ambulance transportation.
There are exceptions to the rule of medical necessity that will protect EMS providers in some cases. But even here, providers need to be prepared to respond to auditors’ and investigators’ second-guessing. Proof of medical necessity is not required if:
- The patient is non-ambulatory;
- The patient needs vital medical services during transportation; 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. The Patient Does Not Ultimately Receive Treatment That Is Eligible for Medicare Reimbursement
A second critical requirement for Medicare reimbursement of mobile ambulance transportation services is that the patient must be in need of transportation for Medicare-eligible treatment. If the patient appears to need reimbursable treatment based upon EMTs’ initial on-site assessment but a physician subsequently determines that such treatment is unnecessary, then the transportation services will not be eligible for reimbursement.
3. The Facility to Which the Patient Is Transported Does Not Meet Medicare’s Eligibility Requirements
In addition to ensuring that patients are eligible for Medicare-reimbursed medical services, EMS providers must also ensure that they are transporting patients to Medicare-compliant facilities. If a facility is non-compliant or if a particular treating physician has been excluded from Medicare participation, these are both factors that can disqualify mobile ambulance transportation services from Medicare reimbursement.
4. The EMS Provider or Ambulance Is Not Medicare-Compliant
Finally, let’s assume that your EMTs correctly discerned the need for emergency (and Medicare-eligible) treatment, and let’s assume that the treatment was rendered at a Medicare-compliant facility. But, let’s also assume that something about your business or the ambulance used to provide the transportation is deficient under Medicare’s coverage guidelines for mobile ambulance services. In this scenario, even technical noncompliance unrelated to the transportation itself can potentially be enough to disqualify the transportation from reimbursement.
What Does It Mean If Mobile Ambulance Transportation Services Are Not Eligible for Medicare Reimbursement?
If transportation services rendered are determined to be ineligible for Medicare reimbursement, what does this mean for the EMS provider? Ultimately, it means that the cost of services must be paid by the patient directly (or, if the services are covered, by the patient’s private health insurer). If the services were billed to Medicare, it also means that the provider could be at risk for legal action under the False Claims Act (FCA).
The False Claims Act is a federal statute that prohibits the submission of false and fraudulent claims to Medicare. Any reimbursement request that violates the Medicare billing guidelines is considered to be “false or fraudulent” under the FCA. Since the FCA includes provisions for civil and criminal penalties, EMS providers can face penalties even for unintentional violations (under the FCA’s civil enforcement provisions). If there is evidence to suggest that the reimbursement request was intentional, then the request can potentially lead to criminal charges.
While a single mistake is unlikely to lead to substantial penalties, it is very likely to trigger an audit or investigation. A Medicare audit or investigation can look back at several years of an EMS provider’s billing records. Are you confident that this was your company’s first mistake? Even if you are, there is too much at risk for you to allow the audit or investigation to take place without legal intervention.
Experienced and Aggressive Legal Representation for EMS Medicare Audits and Investigations
In order to effectively intervene in a Medicare audit or investigation, you need experienced and aggressive legal representation. Dr. Nick Oberheiden is a health care fraud defense attorney who has successfully represented EMS providers in federal matters across the country. If your company is being targeted for its Medicare billing practices, Dr. Oberheiden can help – but only if you get in touch.
To schedule an appointment with Dr. Oberheiden, please call us at (888) 356-4634 or contact us online. Your initial consultation is free and confidential, and we will arrange for you to speak with Dr. Oberheiden as soon as possible.
Dr. Nick Oberheiden has successfully represented healthcare executives and physicians – as well as businesses in the areas of toxicology, pharmacy, home health and hospice centers, DME, hospitals, surgery centers, neuro-monitoring, and blood and DNA testing centers – in healthcare compliance and defense.