Ambulance Fraud

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Medicare pays for different levels of ambulance services, including air transport (fixed-wing and rotary-wing transport). These levels of service are differentiated by the qualifications and training of the crew and the equipment and supplies available on a vehicle that allows for treatment of more complex medical conditions. The rotary wing air ambulance may be necessary because the beneficiary’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles (for example, heavy traffic), preclude such rapid delivery to the nearest appropriate facility by ground ambulance.

Medicare regulations set forth medical necessity and other conditions of payment for any ambulance services. The fundamental medical necessity requirement for ambulance services, including rotary wing (helicopter) ambulance services, is that they are covered “only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.”

In addition to those regulations, CMS has adopted some interpretive rules in the Medicare Carrier Manual (“MCM”). The MCM expressly limits payment for air ambulance service to those instances where “the beneficiary’s medical condition is such that transportation by either basic or advanced life support land ambulance is not appropriate.” Furthermore, the MCM states that payment for air ambulance will be covered by Medicare if “the beneficiary’s medical condition required immediate and rapid ambulance transportation. . . .”

Air ambulance services, as opposed to ambulance services in general, are limited to instances where a patient needs immediate acute-care services at a hospital that is too far away for safe transportation by land. The illustrative list of medical services in the MCM makes it clear that air ambulance services are justified only when the patient needs emergency services that are available solely at a distant destination. The list includes the following:

– Intracranial bleeding – requiring neurosurgical intervention;
– Cardiogenic shock;
– Burns requiring treatment in a Burn Center;
– Conditions requiring treatment in a Hyperbaric Oxygen Unit;
– Multiple severe injuries; or
– Life-threatening trauma.

Providers of ambulance services submit claims for payment to carriers or Medicare contractors. Independent ambulance suppliers bill carriers on CMS Form 1500. Ambulance suppliers are not required to submit additional documentation with Form CMS-1500, but appropriate documentation containing medical necessity and other information must be kept on file and made available for contractor review if requested.

The opportunity to commit Medicare fraud for air ambulance services without detection is great, making it highly vulnerable to abuse. Known methods are:

  1. Billing for services that were not covered because the beneficiary’s condition did not meet coverage requirements or medical appropriateness as the beneficiary did not require immediate and rapid ambulance transportation;
  2. Billing for services that were not covered because the air transport was not to the closest appropriate facility, to the extent air transport was even medically necessary;
  3. Billing for hospital to hospital transport when transportation by ground ambulance would not have endangered the beneficiary’s health and/or the transferring hospital had appropriate facilities/the transferee hospital did not have appropriate facilities;
  4. Medicare kickbacks;
  5. Waiving copayments.