AMR Connecticut: Who Billed for the Paramedics?

In the American Medical Response Connecticut settlement, American Medical Response of Connecticut, Inc. paid $601,759 to resolve allegations that it billed Medicare and Medicaid for advanced life support while providing basic life support transport. Alongside that payment, AMR agreed to a separate $25,000 civil penalty to Connecticut.

According to the government, local fire departments supplied the paramedic care. For someone who worked those calls or handled the claims, the question is concrete: whose care did AMR bill for?

The U.S. Attorney’s Office for the District of Connecticut announced the settlement on March 29, 2022. It covered claims submitted from January 2014 through December 2019. The governments described different billing problems for Medicare and Connecticut Medicaid, both arising from the same division of work at an emergency scene.

What Happened in a Joint Response?

In the joint responses described by the government, a local fire department supplied advanced life support and AMR supplied the ambulance transport. Both responded to the same emergency, but they performed different services.

The Justice Department explained that local fire departments in several Connecticut towns provided ALS emergency services after a 911 dispatch. AMR also went to the scene to transport the patient to a hospital or other medical facility. The release described AMR’s contribution in those calls as basic life support, or BLS. The governments alleged that AMR often billed both programs for ALS anyway.

That division matters in a business where responding and transporting can belong to different organizations. A community needs crews ready to respond, while Medicare ordinarily pays for the completed, medically necessary transport. As the Medicare Benefit Policy Manual explains, when multiple ambulance providers respond, payment generally goes to the provider that actually transports the patient.

The local response therefore has to become a claim that accurately identifies the service being billed. The patient can receive paramedic care from the fire department and a ride from AMR. Which organization receives payment for that care depends on the billing arrangement and the payer. That is where the Connecticut allegations divide.

Why Medicare and Medicaid Were Different

The Medicare allegation concerned a missing written billing agreement. The Connecticut Medicaid allegation concerned duplicate payment for the paramedic service. Calling both simply overbilling loses the distinction an insider needs to recognize.

Medicare and the Written Billing Agreement

According to the government’s settlement announcement, AMR could properly have billed Medicare for ALS during these joint responses if it had a written billing agreement with the local fire departments. The government said AMR had no such agreement during the relevant period. The issue was how the fire department’s paramedic service became part of AMR’s Medicare bill.

For a billing or compliance employee, we would connect the agreement in effect for a particular response with the fire department’s care record, AMR’s transport record and the submitted claim. Those documents answer different questions. The clinical record identifies the care. The agreement addresses the billing relationship. We need to understand both.

Connecticut Medicaid and the Duplicate Payment

For Connecticut Medicaid, the government alleged that both AMR and the local fire departments billed for ALS in many cases. In the government’s account, Medicaid paid the fire departments for the paramedic services and then paid AMR for those services too.

The alleged duplicate was payment for the paramedic care. That is more specific than saying the patient had an expensive ambulance ride or that multiple responders appeared at the scene. The useful comparison is between the claims each organization submitted for the same response and the payments each received.

We see the absurdity in that account: the fire department supplied the paramedics, yet the program paid for their service again on AMR’s bill. One service, paid twice. Taxpayers carried the second payment.

What Does ALS Mean on an Ambulance Bill?

ALS means advanced life support. The Connecticut announcement describes it as paramedic services at the emergency scene and in the ambulance, requiring a high level of medical monitoring. BLS describes lower-acuity services that an emergency medical technician-basic can provide, including the transport described in this case.

Medicare also recognizes a qualifying ALS assessment as a basis for ALS1 emergency payment. Its Benefit Policy Manual explains that an appropriately dispatched ALS crew may complete an assessment that supports that payment even when the patient ultimately needs no advanced intervention during the ride. The transport must still be medically necessary and meet the other coverage requirements.

The assessment depends on the patient’s reported condition at dispatch being such that only an ALS crew was qualified to assess it. The dispatch information, the assessment performed and the care furnished therefore belong together when we examine the billed level.

What Is Considered Medically Necessary for an Ambulance?

Medicare ambulance medical necessity turns on the patient’s condition at the time of transport. That condition must require both the ambulance ride and the level of service provided, with other transportation unsuitable for the patient’s health.

The Medicare manual ties payment to the medically necessary services actually furnished. The vehicle and the dispatch are parts of the story. The patient’s condition and the service record complete it.

For a joint response, we bring that clinical account together with the division of work between the responders. The care record can explain why paramedics were needed. The billing records show which organization claimed payment for their work.

What the Settlement Resolved

The U.S. Department of Health and Human Services Office of Inspector General and the Connecticut Office of the Attorney General investigated the case. The company also entered a separate consent agreement with the Connecticut Department of Public Health. Under that agreement, AMR agreed to stop the prohibited conduct and pay the separate state civil penalty.

What Evidence Does a Whistleblower Need?

For joint-response billing, the useful evidence connects the care supplied by each responder, the billing agreement, the service level claimed and the payer’s payment. You may know one part of that chain through the work you already do. We work with you to understand how it fits the rest.

A crew member may know which organization supplied the paramedic assessment and which supplied transport. A fire-department billing employee may recognize the claim submitted for that care. An AMR biller may know the service-level code used. Someone responsible for the public-partner relationship may know what the written billing agreement covered and when it took effect.

A separate AMR case shows why someone who knows the patient record may have an important account even without seeing the bill. A court opinion describes an EMT’s allegations that AMR required crews in its New Haven operation to revise or recreate patient care reports with false statements supporting medical necessity. The complaint also alleged that crews lacked access to the billing operation. Those allegations about altered run reports concerned a different case from the joint-response settlement. They show another place where the employee who saw the care and the employee who saw the claim could hold different parts of the account.

Do You Get Money for Reporting Medicaid Fraud?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. If you recognize the difference between the paramedic service supplied and the service billed, our whistleblower experts can assess that knowledge with you and the ambulance fraud whistleblower lawyers we bring in.

You Know Who Supplied the Care

If your crew supplied the paramedics or your billing desk handled the joint-response claims, talk with our whistleblower experts about what you saw. We build the case around the connection between that care, the billing agreements and the payments, and bring in ambulance fraud whistleblower lawyers who understand shared-response claims. We stay beside you as your partners throughout the case.