Maine Medical Center: The $600,000 Ambulance-Certification Settlement

In the Maine Medical Center ambulance settlement, the Portland hospital agreed to pay $600,000 to resolve allegations that its personnel supplied incomplete or inaccurate medical-necessity information that North East Mobile Health Services used to bill Medicare. For someone working in discharge or certification, that is the point of this case: the information supplied at the hospital mattered after the patient left.

The U.S. Attorney’s Office for the District of Maine announced the settlements on February 23, 2018. North East, based in Scarborough, agreed to pay $825,000, putting the hospital’s payment close to the ambulance biller’s. The announced total was $1,425,000, with separate agreements for the ambulance provider and the hospital that supplied the disputed information.

What the Government Alleged About the Hospital’s Statements

The government alleged that Maine Medical Center personnel gave North East statements containing incomplete or inaccurate information about whether patients needed ambulance transportation. North East then used those statements to bill Medicare.

On North East’s side, the government alleged improper Medicare billing for non-emergency transportation of patients discharged from Maine Medical Center from 2007 onward. It said North East falsely described patients as bed-confined or otherwise medically in need of an ambulance. North East’s settlement also resolved allegations that it knowingly retained Medicare overpayments.

We see an expensive fiction in treating discharge paperwork as an administrative afterthought. In the government’s account, that paperwork supplied the medical justification for spending public health care money. More than a form. The hospital employee who knows what went into the statement can see a part of the claim that sits outside the ambulance billing office. The Office of Inspector General for the U.S. Department of Health and Human Services investigated the case.

What Is an Ambulance Physician Certification Statement?

An ambulance physician certification statement is a signed and dated statement from the patient’s attending physician certifying medical necessity. Medicare’s rules for ambulance certifications require more than a completed form: the statement alone does not establish that the patient needed the ride.

The hospital’s medical record and the ambulance crew’s account supply the clinical evidence behind the statement. That is why the Maine allegation concerns the information hospital personnel provided and the use North East made of it. A signature cannot make an inaccurate description of a patient’s condition accurate.

What Is Considered Medically Necessary for an Ambulance?

An ambulance is medically necessary under Medicare’s coverage rule when the patient’s condition makes other transportation medically inadvisable and requires both the ambulance and the level of service provided. The question concerns the patient’s condition at the time of the trip.

For a hospital discharge, the useful comparison is between what the statement says the patient needs and what the medical and transport records describe. A statement about mobility should fit the patient’s ability to get out of bed, walk or sit.

What Does Bed Confinement Status Mean?

Bed confinement for Medicare ambulance coverage means the patient cannot get out of bed without assistance, cannot walk, and cannot sit in a chair or wheelchair. The Medicare Benefit Policy Manual also makes clear that bed confinement alone does not establish medical necessity.

That distinction matters to North East’s alleged billing. The government described patients falsely claimed to be bed-confined or otherwise medically in need of ambulance transportation. Both parts lead back to the patient’s actual condition. A bed-confinement label cannot replace that clinical account.

Hospital Knowledge That a Billing Extract Can Miss

The underlying certification can identify who supplied the medical assertion in a way that claims data alone may not. In its September 2015 report on Medicare ambulance transports, the Office of Inspector General found that the physicians who certified the medical necessity of questionable transports could not be identified in the claims data. The finding explains the value of the actual form and the medical records behind it: a payment extract can leave the person making the medical assertion out of view.

In the Maine Medical Center case, the government attributed the disputed information to hospital personnel. For a hospital insider, the useful knowledge concerns how that information reached the statement: what the patient record said, who supplied the description, and what went to the ambulance company. We work with that account to connect the hospital’s part of the process to the claim it supported. In the Capital Ambulance case, the government alleged that Eastern Maine Medical Center personnel supplied incomplete or incorrect certification information that Capital used to bill Medicare.

What Evidence Is Needed to Report Fraud?

For a hospital-certification case, we work with you to connect the medical record, the statement supplied to the ambulance company, the crew’s transport report and the Medicare claim. Those records let us compare what the patient needed with what Medicare was told.

When the Crew’s Report Is Changed to Fit the Form

A whistleblower complaint against First Call Ambulance Service, which transported patients to dialysis, alleged a particularly revealing response to conflicting documents. The whistleblower said quality assurance staff changed crew reports to match certificates of medical necessity, even when the certificates were wrong:

That allegation shows why changes to a crew’s report matter alongside the hospital’s form. Making the documents agree can conceal the disagreement an employee originally saw. We want to understand what changed and why, with the patient’s condition at the center of the comparison.

You Know What the Hospital Supplied

If you work or worked in hospital discharge, certification or billing and saw medical-necessity statements that did not match the patient, speak with our whistleblower experts about the healthcare claims they supported. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We build your strongest case with you, bring in ambulance fraud whistleblower lawyers who understand hospital certifications and Medicare billing, and remain your partners throughout the case.