Flagler County: Emergency Rates for Rides Home

The Flagler County PST ambulance settlement resolved emergency-rate Medicare billing allegations for $86,251, covering claims from 2009 through 2015. The Office of Inspector General of the Department of Health and Human Services alleged that trips to skilled nursing facilities and patient residences should have been billed at the lower non-emergency rate. The alleged overbilling put the higher charge on Medicare and the taxpayers who fund it.

Emergency Rates on Trips to Nursing Facilities and Homes

The Board of County Commissioners of Flagler County, Florida, and PST Services, Inc. entered the settlement on June 13, 2016. The HHS-OIG announcement identifies PST as the county’s biller and alleges that they billed Medicare, or caused Medicare to be billed, at emergency rates when lower non-emergency rates applied.

We see the absurdity in that allegation: an emergency price for a ride home. The trip record and the billing decision belong beside each other: where the patient went, what the response required and what Medicare was asked to pay.

Ambulance billing has more than one way to raise the service payment. Billing basic life support as advanced life support changes the clinical service level claimed. Billing a non-emergency trip as an emergency changes the response category. Basic life support and advanced life support level one each have emergency and non-emergency rates. Flagler’s settlement concerned the latter distinction.

The First Billing Period Included PST

The Inspector General alleged that Flagler County and PST billed Medicare, or caused Medicare to be billed, at emergency rates from September 1, 2009, through May 30, 2011. Both organizations appear in this part of the allegation. PST’s role as an outside biller is part of the case, alongside the county whose ambulance services were being billed.

That is why we look at the handoff between the transport operation and the billing office. A run report carries the crew’s account of the patient and the service. The submitted claim carries the code requesting payment. Understanding a billing allegation means connecting those records to the people who supplied, changed or transmitted the information.

The Second Billing Period Did Not Include PST

The Inspector General alleged that Flagler County billed Medicare, or caused Medicare to be billed, at emergency rates from June 1, 2011, through March 28, 2015, with no involvement of PST. The later allegation belongs to the county alone.

The allegation continued into the later period. The biller’s involvement did not. For someone who handled the county’s claims, the question is who made the coding decisions during the period they know firsthand.

Why Dispatch and Destination Belong Beside the Code

An emergency designation has a payment meaning tied to the response. The Medicare Benefit Policy Manual explains how the nature of the call at dispatch and the local emergency dispatch protocol determine whether an emergency response is appropriate.

An immediate response means beginning the necessary response steps as quickly as possible. Dispatch classification therefore carries information about what the caller reported and how the ambulance service responded.

The destination supplies another part of the picture. An emergency-rate claim ending at a nursing facility or a patient’s home can point toward a discharge trip that warrants closer examination. The dispatch record, crew observations and service billed are what let us examine that signal. We want to know why the emergency rate appears on that particular trip.

The Inspector General’s Consolidated Data Analysis Center helped achieve the Flagler settlement. A separate 2019 Inspector General audit of hospital-to-nursing-facility transports found emergency-level claims for what the reviewed claims showed were ordinarily scheduled discharges. That is a concrete reason to examine the destination alongside the emergency code.

Does Medicare Pay for Non-Emergency Ambulance Transportation?

Medicare pays for qualifying non-emergency ambulance transportation when the patient’s condition requires the ambulance and the service meets the coverage requirements. The patient must need both ambulance transportation and the level of service billed.

For a crew member, the patient’s condition during the trip is the concrete part: what made another means of transportation unsafe, and what care the patient needed. For a biller, the task is to translate the supported service into the claim.

A physician certification statement can support the patient’s need for ambulance transportation alongside the medical record, as the Medicare coverage regulation explains. We examine those documents together with the crew’s account of the actual ride.

The Emergency-Rate Pattern Beyond Flagler

Flagler’s case sits beside other settlements over the same emergency-rate allegation. In November 2015, Shawano Ambulance Service entered a $108,086 settlement, a larger sum than Flagler’s, over emergency-rate claims for trips to skilled nursing facilities and patient residences. The Wisconsin settlement announcement described services that should have been billed at the lower non-emergency rate.

The useful comparison is the payment decision. In both settlements, the Inspector General alleged that a transport had been assigned the higher emergency rate. The county setting in Flagler and the ambulance-company setting in Wisconsin put different organizations behind the same kind of claim. A healthcare billing insider who recognizes that coding decision has something more specific to discuss than a general suspicion that ambulance bills are too high.

The County, the Biller and the Claim

County ambulance operations face a health care funding problem: keeping an ambulance ready costs money even when no patient needs a ride. Medicare pays no separate standby amount for maintaining a staffed vehicle through a quiet shift. The service has to finance that readiness through its paying work and other support, including local revenue and contracts.

We see why the distinction matters to a finance office: readiness is a continuing cost, while the emergency rate belongs to a qualifying response. The bill has to reflect the service that supports the payment. The need to fund the next shift cannot supply the facts for the last claim.

Different employees can explain different parts of that connection. A dispatcher knows the information behind the response. An EMT or paramedic knows the patient’s condition and the care documented. A biller knows the service code sent to Medicare. Someone managing the billing relationship may know which organization handled the claims during a particular period.

If the concern extends to changes in the patient care report, the original observations and later wording become part of the examination. We look at whether the documentation supports the payment requested and who was involved in turning that documentation into a bill. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know How the Trip Became a Bill

If you handled county ambulance claims or saw emergency coding carried into bills that the trip records did not support, speak with one of our Whistleblower Experts. We work beside you to build your strongest ambulance billing whistleblower case around the decisions you can explain, bring in ambulance billing whistleblower lawyers who understand dispatch and payment, and stay with you through the case.