Appendix A-Additional Risk Areas
1. ‘‘No Transport’’ Calls and Pronouncement of Death
If an ambulance supplier responds to an emergency call, but a patient is not transported due to death, three Medicare rules apply. If an individual is pronounced dead prior to the time the ambulance was requested, there is no payment. If the individual is pronounced dead after the ambulance has been requested, but before any services are rendered, a BLS payment will be made and no mileage will be paid. If the individual is pronounced dead after being loaded into the ambulance, the same payment rules apply as if the beneficiary were alive. Ambulance suppliers should accurately represent the time of death and request payment based on the aforementioned criteria.
2. Multiple Patient Transports
On occasion, it may be necessary for an ambulance to transport multiple patients concurrently. If more than one patient is transported concurrently in one ambulance, the amount billed should be consistent with the multiple transport guidelines established by the payor in that region. Under CMS’s new fee schedule rules for multiple transports, Medicare will pay a percentage of the payment allowance for the base rate applicable to the level of care furnished to the Medicare beneficiary (e.g., if two patients are transported simultaneously, 75 percent of the applicable base rate will be reimbursed for each of the Medicare beneficiaries). Coinsurance and deductible amounts will apply to the prorated amounts.
3. Multiple Ambulances Called to Respond to Emergency Call
On occasion, more than one ambulance supplier responds to an emergency call and is present to transport a beneficiary. These are often referred to as ‘‘dual transports.’’ In such cases, only the transporting ambulance supplier may bill Medicare for the service provided. If payment is desired for services provided to a patient, the non-transporting ambulance company should receive it directly from the transporting supplier based on a negotiated arrangement. These payments should be fair market value for services actually rendered by the non-transporting supplier, and the parties should review these payment arrangements for compliance with the anti-kickback statute. On occasion, when multiple ambulance crews respond to a call, a BLS ambulance may provide the transport, but the level of services provided may be at the ALS level. If a BLS supplier is billing at the ALS level because of services furnished by an additional ALS crew member, appropriate documentation should accompany the claim to indicate to the payor that dual transportation was provided. In any event, only one supplier may submit the claim for payment.
4. Billing Medicare ‘‘Substantially in Excess’’ of Usual Charges
Ambulance suppliers generally may not charge Medicare or Medicaid patients substantially more than they usually charge everyone else. If they do, they are subject to exclusion by the OIG. This exclusion authority is not implicated unless the supplier’s charge for Medicare or Medicaid patients is substantially more than its median non-Medicare/Medicaid charge. In other words, the supplier need not worry unless it is discounting close to half of its non-Medicare/Medicaid business. Ambulance suppliers should review charging practices with respect to Medicare and Medicaid billing to ensure that they are not charging Medicare or Medicaid substantially more than they usually charge other customers for comparable services. It is appropriate for an ambulance supplier to determine its usual charge with reference to its total charges to non-Medicare/Medicaid customers for an ambulance transport (whether or not the charges are structured as base rate plus mileage or otherwise) and then to compare the resulting ‘‘usual charge’’ to its total charge to Medicare (i.e., base rate plus mileage) or Medicaid for comparable transport.
Appendix B—OIG/HHS Information
The OIG’s web site (http://oig.hhs.gov) contains various links describing the following: (1) Authorities and Federal Register Notices, (2) Publications, (3) Reports, (4) Hearing Testimony, (5) Fraud Prevention and Detection, (6) Reading Room, (7) OIG Organization and (8) Employment Opportunities. Such information is frequently updated and is a useful tool for ambulance providers seeking additional OIG resources.
Also listed on the OIG’s web site is the OIG Hotline Number. One method for providers to report potential fraud, waste and abuse is to contact the OIG Hotline number. All HHS and contractor employees have a responsibility to assist in combating fraud, waste, and abuse in all departmental programs. As such, providers are encouraged to report matters involving fraud, waste and mismanagement in any departmental program to the OIG. The OIG maintains a hotline that offers a confidential means for reporting these matters.
Contacting the OIG Hotline
By Phone: 1–800–HHS–TIPS (1–800–447– 8477).
By Fax: 1–800–223–8164.
By E-Mail: [email protected]
By TTY: 1–800–377–4950.
By Mail: Office of Inspector General, Department of Health and Human Services, Attn: HOTLINE, 330 Independence Ave., SW., Washington, DC 20201.
When contacting the hotline, please provide the following information to the best of your ability: —Type of Complaint: Medicare Part A
Medicare Part B
Indian Health Service
Other (please specify)
—HHS department or program being affected by your allegation of fraud, waste, abuse/ mismanagement: Centers for Medicare and Medicaid Services (formerly Health Care Financing Administration) Indian Health Service Other (please specify)
—Please provide the following information (however, if you would like your referral to be submitted anonymously, please indicate such in your correspondence or phone call): Your Name Your Street Address Your City/County Your State Your Zip Code Your E-mail Address
—Subject/Person/Business/Department that allegation is against: Name of Subject Title of Subject Subject’s Street Address Subject’s City/County Subject’s State Subject’s Zip Code
—Please provide a brief summary of your allegation and the relevant facts.
Appendix C—Carrier Contact Information
A complete list of contact information (address, phone number, e-mail address) for Medicare Part A Fiscal Intermediaries, Medicare Part B Carriers, Regional Home Health Intermediaries, and Durable Medical Equipment Regional Carriers can be found on the CMS Web site at http://cms.hhs.gov/ contacts/incardir.asp.
Contact information (address, phone number, e-mail address) for each state Medicaid director can be found on the CMS Web site at http://cms.hhs.gov/medicaid/ mcontact.asp. In addition to a list of state Medicaid directors, the Web site includes contact information for each state survey agency and the CMS Regional Offices.
3. Ambulance Fee Schedule
Information related to the development of the ambulance fee schedule is located at
Appendix D—Internet Resources
1. Centers for Medicare and Medicaid Services
The CMS Web site (http://cms.hhs.gov/) includes information on a wide array of topics, including Medicare’s National Coverage Database, National Coverage Policies, Laws and Regulations and State Waiver and Demonstration Programs. In addition, this Web site contains information related to Medicaid including a General Medicaid Overview, State and Federal Health Program Contacts, State Medicaid Manual, State Medicaid Plans, State Waivers and Demonstration Programs, Letters to State Officials, and CMS Publications.
2. CMS Medicare Training
This CMS Web site (http://www.cms.hhs.gov/home/medicare.asp) provides computer-based training related to CMS’s purpose and history, the three types
of Medicare coverage, the roles agencies and contractors play, and the claims handling process.
3. Government Printing Office (GPO)
The GPO Web site (http:// www.access.gpo.gov) provides access to federal statutes and regulations pertaining to federal health care programs.
4. The U.S. House of Representatives Internet Library
The U.S. House of Representatives Internet Library Web site (http://uscode.house.gov/ usc.htm) provides access to the United States Code, which contains laws pertaining to federal health care programs.
1. To date, the OIG has issued compliance program guidance for the following nine industry sectors: (1) Hospitals; (2) clinical laboratories; (3) home health agencies; (4) durable medical equipment suppliers; (5) third-party medical billing companies; (6) hospices; (7) Medicare+Choice organizations offering coordinated care plans; (8) nursing facilities; and (9) individual and small group physician practices. The guidances listed here and referenced in this document are available on the OIG Web site at http:// oig.hhs.gov in the Fraud Prevention and Detection section.
2. The CMS’s final ambulance fee schedule rule was published in the Federal Register on February 27, 2002 (67 FR 9100) and went into effect on April 1, 2002.
3. The term ‘‘universe’’ is used in this CPG to mean the generally accepted definition of the term for purposes of performing a statistical analysis. Specifically, the term ‘‘universe’’ means the total number of sampling units from which the sample was selected.
4. The OIG encourages that providers/ suppliers police themselves, correct underlying problems, and work with the government to resolve any problematic practices. The OIG’s Provider Self-Disclosure Protocol, published in the Federal Register on October 30, 1998 (63 FR 58399), sets forth the steps, including a detailed audit methodology, that may be undertaken if suppliers wish to work openly and cooperatively with the OIG. The Provider Self-Disclosure Protocol is open to all health care providers and other entities and is intended to facilitate the resolution of matters that, in the provider’s reasonable assessment, may potentially violate federal criminal, civil, or administrative laws. The Provider Self-Disclosure Protocol is not intended to resolve simple mistakes or overpayment problems. The OIG’s Self-Disclosure Protocol can be found on the OIG Web site at http://oig.hhs.gov.
5. Ambulance suppliers should read the OIG’s September 1999 Special Advisory Bulletin, entitled ‘‘The Effect of Exclusion From Participation in the Federal Health Care Programs,’’ published in the Federal Register on October 7, 1999 (64 FR 58851), which is located at http://oig.hhs.gov/authorities/frnotices.html, for more information regarding excluded individuals and entities and the effect of employing or contracting with such individuals or entities.
6. OEI–09–95–00412, available on the OIG’s Web site at http://oig.hhs.gov/oei.
7. CMS Program Memorandum B–00–09 describes different options for ambulance suppliers having difficulty obtaining PCSs. (See 42 CFR 410.40(d)(3)(iii) and (iv).) A PCS is not required, for beneficiaries who are not under the direct care of a physician, whether the beneficiary resides at home or in a facility. Id. Section 410.40(d)(3)(ii).
8. 42 CFR 410.42(d).
9. On December 28, 2000, the Department of Health and Human Services (HHS) released its final rule implementing the privacy provisions of the Health Insurance Portability and Accountability Act of 1996. The rule became effective in April 2001, and regulates access, use, and disclosure of personally identifiable health information by covered entities (health providers, plans, and clearinghouses). Guidance on an ambulance supplier’s compliance with the HHS Privacy Regulations is beyond the scope of this CPG; however, it will be the responsibility of ambulance suppliers to comply. Most health plans and providers must comply with the rule by April 14, 2003. In the meantime, many organizations are considering and analyzing the privacy issues.
10. Loaded miles refers to the number of miles that the patient is physically on board the ambulance.
11. HCFA Program Memorandum Transmittal AB–00–118, issued on November 30, 2000.
12. In addition to Medicare and Medicaid, the federal health care programs include, but are not limited to, TRICARE, Veterans Health Care, Public Health Service programs, and the Indian Health Services.
13. The procedures for applying for an advisory opinion are set forth at 42 CFR part 1008. and on the OIG Web page at http:// www.oig.hhs.gov/fraud/ advisoryopinions.html#3. All OIG advisory opinions are published on the OIG web page. A number of published opinions involving ambulance arrangements provide useful guidance for ambulance suppliers. These include OIG Advisory Opinions Nos. 97–6, 98–3, 98–7, 98–13, 99–1, 99–2, 99–5, 00–7, 00–9, 00–11, 01–10, 01–11, 01–12, 01–18, 02–2, 02–3, 02–8, and 02–15. Other advisory opinions not specifically involving ambulance arrangements may also provide useful guidance.
14. See 65 FR 24400; April 26, 2000.
16. See Special Fraud Alert: Routine Waiver of Copayments or Deductibles Under Medicare Part B (59 FR 65372, 65374 (1994)), located on the OIG Web page at http:// www.oig.hhs.gov/fraud/fraudalerts.html#1.
17. The OIG may exclude from participation in the federal health care programs any provider that submits or causes to be submitted bills or requests for payment (based on charges or costs) under Medicare or Medicaid that are substantially in excess of such providers’ usual charges or costs, unless the Secretary finds good cause for such bills or requests. (See section 1128(b)(6) of the Act (42 U.S.C. 1320a–7(b)(6)).)
Dated: February 14, 2003.
Inspector General.[FR Doc. 03–6866 Filed 3–21–03; 8:45 am] BILLING CODE 4152–01–P