Baptist Health Jacksonville: The Hospital Signed, the Ambulance Company Billed

In the Baptist Health Jacksonville ambulance settlement, Baptist agreed in 2015 to pay $2.89 million to resolve allegations that its hospitals certified medically unnecessary non-emergency ambulance transports. The hospital supplied the certificate. The ambulance company submitted the bill. For a discharge planner, clinician or billing employee who saw the patient described differently on those documents, that division of work is the heart of the case.

The Justice Department’s May 8, 2015 announcement described a $7.5 million package involving nine Jacksonville hospitals and an ambulance company. The health care programs involved were Medicare, TRICARE, Medicaid and the Federal Employees Health Benefits Program, which the Office of Personnel Management manages.

The Certificate Put Medical Need on Paper

The government alleged that, from January 1, 2009, through April 2014, the hospitals supplied Certificates of Medical Necessity stating that patients needed basic life support, non-emergency ambulance transportation when the transports were medically unnecessary. Baptist owned and operated four Jacksonville hospitals, according to the announcement.

A hospital’s ambulance medical-necessity certification supplies information used to support the transport claim. The hospital staff member describes the patient’s need, and the ambulance company uses that description in seeking payment. That handoff puts the person who knows the patient and the business billing for the ride on different sides of the paperwork.

The whistleblower’s amended complaint in the Liberty branch of the Jacksonville cases alleged an economic purpose for false hospital certificates:

We expect a certificate to explain the patient’s medical need. Here, it allegedly shifted the hospital’s transportation bill onto taxpayers. The signature was doing financial work.

What Is Considered Medically Necessary for an Ambulance?

Medical necessity for an ambulance depends on whether the patient’s condition makes another means of transportation unsafe. The condition must support both the ambulance ride and the level of service provided. A signature cannot supply the clinical need.

The Medicare Benefit Policy Manual says that when another means of transportation could be used without endangering the patient’s health, ambulance payment is unavailable even if that alternative transportation is not actually available. A hospital can have a real transportation problem without the patient having a medical need for an ambulance.

The same distinction matters on repeated dialysis transports: a signed statement still has to be supported by the patient’s condition at the time of the ride. For the Jacksonville hospitals, the government’s allegation concerned what their certificates said about the need for the non-emergency transports. That is the clinical question a hospital insider can recognize before seeing the final claim.

Century’s Billing Allegations Were Separate

Century Ambulance Service agreed to pay $1.25 million in the same announcement over allegations that it knowingly upcoded basic life support claims to advanced life support, transported patients unnecessarily and unnecessarily transported patients home as emergencies. Those were the ambulance company’s alleged acts. Baptist’s settlement concerned the hospital certificates supporting non-emergency rides.

Whether the patient needed an ambulance, which level of service was justified and whether the trip warranted emergency billing are separate questions. A hospital certificate addresses the medical need. A crew’s patient care report describes the transport and care. The service billed has to connect to those accounts.

The whistleblower’s Liberty complaint separately alleged that the ambulance company altered crew reports to obtain reimbursement that otherwise would have been unavailable or lower. That is the falsified run-report allegation, involving the ambulance company’s account of the ride.

A Separate Florida Case Over Emergency Billing

Courtesy Transport Services resolved a similar emergency-rate allegation in a separate Northeast Florida matter. In a July 20, 2016 settlement with the HHS Office of Inspector General, Courtesy agreed to pay $362,188 over allegations that it billed emergency transportation to skilled nursing facilities and patient residences when it should have billed the lower non-emergency rate.

Courtesy’s case illustrates the pricing issue in Century’s allegations: the emergency designation can change the bill for a ride home. Baptist’s case reaches a different point in the same payment chain, the hospital’s statement that an ambulance was needed in the first place.

Why the Court Papers Say Southern Baptist Hospital of Florida

Southern Baptist Hospital of Florida Inc. is the entity the Justice Department called Baptist Health in its settlement announcement. Shands Jacksonville Medical Center Inc. likewise appears in the announcement as UF Health Jacksonville.

The Jacksonville proceedings included two related qui tam cases brought by the same former ambulance employee. Both named the same hospital defendants. One named Century as the ambulance defendant, and the other named Liberty.

The government joined the cases, settling with the hospitals and Century while pursuing Liberty separately. Liberty later reached its own settlement, announced in July 2018.

The Other Hospitals in the Jacksonville Settlement

Memorial Hospital, Specialty Hospital, Lake City Medical Center and Orange Park Medical Center collectively agreed to pay $2.37 million. UF Health Jacksonville agreed to pay $1 million. The Justice Department described the same certificate-of-medical-necessity allegations for the hospitals, while assigning them separate settlement amounts.

What Evidence Does a Whistleblower Need?

For a hospital-certification case, the useful evidence connects the patient’s condition, the certificate, the transport and the claim. We examine those connections with you, including what the people preparing and using the documents knew. Your view of the handoff can explain a discrepancy that a payment record alone leaves invisible.

A certificate and a run report describe different parts of that same journey. When their accounts disagree, the person who saw the patient or prepared the original document may know why.

In its September 2015 report, Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports, the Inspector General identified a specific oversight problem: claims data did not identify the physicians who certified questionable transports. That limited the oversight agencies’ ability to connect claims to the people certifying them. The finding explains why knowledge inside the hospital can add something the billing data alone does not show.

The Federal Bureau of Investigation, the Florida Medicaid Fraud Control Unit and the Defense Health Agency Program Integrity Office were among the agencies that investigated the Jacksonville case. We follow those connections with the insider who can explain them.

What Is the Reward for Uncovering Fraud?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In the Jacksonville announcement, the Justice Department said the former ambulance employee who initiated the case would collect more than $1.2 million from the settlements.

The practical point for a hospital insider is that the case reached the certificates supplied by hospital staff as well as the ambulance company’s billing. Knowing how the patient became a description on a form can matter as much as knowing how that form reached a claim.

You Know the Patient Behind the Certificate

If you saw a hospital certificate describe a need the patient did not have, talk with our whistleblower experts about the transport and the claim. We build the case with you, bring in healthcare whistleblower lawyers who understand hospital certifications and ambulance billing, and stay beside you through the pursuit of a recovery.