Compliance Program Guidance for Ambulance Suppliers
The OIG recognizes that the ambulance industry is comprised of entities of enormous variation: some ambulance companies are large, many are small; some are for-profit, many are not-for-profit; some are affiliated with hospitals, many are independent; and some are operated by municipalities or counties, while others are commercially owned. Consequently, this guidance is not intended to be a one-size-fits-all guide. Rather, like the previous CPGs, this guidance is intended as a helpful tool for those entities that are considering establishing a voluntary compliance program and for those that have already done so and are seeking to analyze, improve or expand existing programs. As with the OIG’s previous guidance, the guidelines discussed in this CPG are not mandatory, nor is the CPG an all-inclusive document containing all the components of a compliance program. Other OIG outreach efforts, as well as other federal agency efforts to promote compliance, can and should also be used in developing a compliance program tailored to an entity’s particular structure and operations.
This guidance focuses on compliance measures related to services furnished primarily under the Medicare program and, to a limited extent, other federal health care programs. (See, e.g., section IV for a brief discussion of Medicaid ambulance coverage.) Suppliers are free to address private payor claims and services in their compliance programs.
As in other sectors of the health care industry, most ambulance suppliers are honest suppliers trying to deliver quality services. However, like other health care industry sectors, the ambulance industry has seen its share of fraudulent and abusive practices. The OIG has reported and pursued a number of different fraudulent and abusive practices in the ambulance transport field. Examples include:
- Improper transport of individuals with other acceptable means of transportation;
- Medically unnecessary trips;
- Trips claimed but not rendered;
- Misrepresentation of the transport destination to make it appear as if the transport was covered;
- False documentation;
- Billing for each patient transported in a group as if he/she was transported separately;
- Upcoding from basic life support to advanced life support services; and
- Payment of kickbacks.
To help reduce the incidence and prevalence of fraudulent or abusive conduct, an ambulance supplier should consider the recommendations in this guidance.
This final CPG has been modified from the draft CPG to take into further consideration CMS’s adoption of a new fee schedule for payment of ambulance services. The CMS’s ambulance fee schedule is the product of a negotiated rulemaking process and will replace (over a five-year transition period) the retrospective, reasonable cost reimbursement system for providers, and the reasonable charge system for suppliers of ambulance services. As the government and the industry gain more experience under the new fee schedule, the OIG may update or supplement this CPG to address newly identified risk areas, as appropriate.