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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:
- The use of other methods of transportation is contraindicated by the individual’s condition and
- The individual’s medical condition must warrant the level of service purportedly provided and billed.
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:
- Billing Medicare for medically unnecessary transports, such as routine transports of dialysis patients and patients requiring radiology services, such as radiation treatment for cancer.
- Upcoding the level of ambulance transport that was provided. For example, upcoding a non-emergency Basic Life Support transport to a non-emergency Advanced Life Support transport, which is reimbursed at a substantially higher rate by Medicare.
- Charging for supplies or services that were not actually rendered, such as oxygen and cardiac monitoring.
- Entering into unlawful contractual relations with facilities that provide large volumes of ambulance transport referrals, such as hospitals or nursing homes. In these "swapping arrangements," ambulance companies provide low- or below-cost ambulance transports in exchange for referrals of emergency and non-emergency discharge ambulance transports billable to Medicare Part B, which is a violation of the Anti-Kickback Statute.
Recently, several ambulance companies have paid steep penalties for cheating Medicare. 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.
Experienced Qui Tam Whistleblower Representation
Kenney & McCafferty attorneys have substantial experience in bringing claims against ambulance transport companies under the False Claims Act, which remain under seal at this time.
If you have knowledge of any of the above schemes involving ambulance fraud, you can become a whistleblower by filing a qui tam lawsuit. As a whistleblower, you can help stop fraud against the government and even receive a percentage of the amount recovered as a whistleblower reward for your service to the taxpayers.
Kenney & McCafferty is a public interest law firm whose dedicated qui tam attorneys have been assisting whistleblowers in their qui tam actions for over fifteen years. Our experience enables us to work closely with the U.S. Department of Justice and state attorney general offices to rectify cases of fraud reported by whistleblowers while simultaneously working to protect the client’s rights under the applicable provisions of the False Claims Act.
Kenney & McCafferty attorneys will consult with you about your case, without obligation. All communications with Kenney & McCafferty attorneys during these consultation services are confidential and protected by the attorney-client privilege.
If you have knowledge of a fraud or false claim against the government, please contact our qui tam lawyers today.