Government spending on healthcare and the cost of healthcare in general has risen dramatically in the past few decades. With costs continuously escalating, the federal government has more incentive than ever before to root out the fraud and corruption in the healthcare sector that costs taxpayers billions of dollars each year.
For an ambulance transport claim to be properly paid by Medicare, the transport must be “medically necessary” as that term is defined by federal law. Federal law sets forth two criteria that must be satisfied to meet Medicare’s “medically necessary” requirement for ambulance transports:
Any transport that fails to meet Medicare’s medically necessary criterion is not a covered benefit and is therefore not eligible for reimbursement. An ambulance company that knowingly or with willful disregard submits a claim for payment for an ambulance transport that fails to meet Medicare coverage criterion has submitted a false claim in violation of the False Claims Act.
Types of Ambulance Fraud
One of the most common fraudulent billing schemes perpetrated by ambulance companies is billing for medically unnecessary dialysis transports. Patients undergoing dialysis typically require treatment several times per week, making these “frequent flyers” lucrative customers.
Other common instances of ambulance fraud include:
Many ambulance companies have paid steep penalties for cheating Medicare. In 2015, after a multiple-year investigation, the United States announced settlements with the following defendants: Baptist Health, who owns and operates four hospitals in Jacksonville (settlement of $2.89 million); Memorial Hospital, Specialty Hospital, Lake City Medical Center, and Orange Park Medical Center (collective settlement of $2.37 million); UF Health Jacksonville (settlement of $1 million); and Century Ambulance Service (settlement of $1.25 million). In reaching this settlement, the parties resolved allegations that, from January 1, 2009, until April 2014, the hospitals provided Certificates of Medical Necessity that attested to the need for basic life support, non-emergency ambulance transports even when these transports were not medically necessary. With respect to Century Ambulance, the parties resolved allegations, for the same time period, that Century Ambulance knowingly up-coded claims from Basic to Advanced life support, unnecessarily transported patients, and unnecessarily transported patients to their homes in an “emergent” fashion.
Similarly, in 2006, American Medical Response paid $9 million, with a reward of approximately $1.6 million being paid to the whistleblower. In 2004, Adventist Health reached a settlement of $20 million for ambulance fraud. In that case, a whistleblower received a reward of approximately $2.4 million. In 2002, American Medical Response also paid $20 million for ambulance fraud, with the whistleblower receiving approximately $3.8 million.