First Call Ambulance: ALS Billing and the Alleged Rewrite of the Trip

First Call Ambulance Service, LLC agreed to pay $500,000 in the First Call Ambulance settlement to resolve allegations that it billed for advanced life support that patients did not need or did not receive. For the crew member who saw the patient and the biller who saw the claim, the alleged gap is concrete: basic life support on the trip, advanced life support on the bill.

The U.S. Attorney’s Office for the Middle District of Tennessee announced the settlement on May 29, 2014. The United States and Tennessee alleged upcoding on transports covered by federal healthcare programs and TennCare, Tennessee’s joint state and federal Medicaid program. A whistleblower’s qui tam complaint started the case.

What the Government Alleged About ALS Billing

The government alleged that First Call billed a higher level of care than patients needed, or a higher level than crews actually provided. Those allegations concern different parts of a transport: the patient’s need and the service delivered. In some cases, the government said, basic life support was both the necessary service and the only service furnished.

The payment difference explains the incentive. The Justice Department’s announcement says federal health insurance programs pay less for basic life support than advanced life support. An advanced life support bill therefore asks the payer for more money on the strength of a claim about the patient’s care.

The whistleblower’s complaint alleged a company policy that put the billing decision ahead of the individual trip:

We see the problem in the word all. Under the policy alleged in the complaint, the route between hospitals supplied the billing answer before anyone considered what that patient needed. The crew’s clinical judgment had to fit a category the company had already chosen.

The same split appeared in the government’s Medstar Ambulance settlement allegations: billing for services above what patients’ conditions required and above what crews provided. Looking at the patient’s condition and the care delivered exposes different ways the same higher code can overstate a trip.

What Does ALS Mean on an Ambulance Bill?

ALS means advanced life support. Medicare’s advanced life support level one category, ALS1, covers ground ambulance transport with medically necessary supplies and services and either a qualifying ALS assessment or an advanced intervention. The assessment matters because it can support payment even when the patient ultimately needs no advanced intervention.

Under the Medicare Benefit Policy Manual’s assessment rule, the emergency service must be appropriately dispatched, the advanced life support crew must complete the assessment, and the transport must meet medical-necessity and other coverage requirements. The patient’s reported condition at dispatch must call for an assessment that only an advanced life support crew is qualified to perform.

That puts dispatch information beside the run report. What was reported when the call came in, why an advanced life support crew was needed to assess it, and what the crew actually did all bear on the billed service.

The Medicare Claims Processing Manual also ties payment to the medically necessary service provided rather than the vehicle used. A fleet equipped for advanced care does not set the service level for every patient it carries. The bill has to describe the trip.

What Is an Example of Improper Documentation on a Patient Care Report?

Changing a report from a patient walking into the ambulance to a patient confined to bed is the example alleged in the First Call whistleblower’s complaint. The alleged change replaced an observation from the trip with a different account for billing.

The complaint also alleged that quality assurance returned reports that contradicted medical-necessity certificates, or changed the reports itself to match those certificates even when the certificates were plainly incorrect. That account places the alleged rewriting of patient care reports between the crew’s observations and the bill.

The whistleblower also alleged that management rejected entries saying an ambulance was not medically necessary and told the whistleblower to find a reason in the patient’s history. A past episode of congestive heart failure was the complaint’s example of a diagnosis management allegedly wanted written down as justification. That is a different question from the patient’s condition during the ride.

The complaint described quality assurance returning reports with information that would prevent payment and instructing the EMT to omit that information in the future. In that account, the pressure affected what crews would record on later trips as well as the report already under review.

We see a reversal of what quality assurance should accomplish. In the whistleblower’s account, the certificate became the story to preserve, and the firsthand observation became the thing to change.

Medicare’s coverage rules require the patient’s condition to support both ambulance transport and the level of service. A signed physician certification statement alone does not establish medical necessity. We examine the clinical account alongside the certification, including who asked for changes and what those changes did to the claim.

The complaint’s account of dialysis transport gives those documents a recurring setting: patients traveled to treatment and back. The patient’s condition on the particular trip remains the clinical question. A standing paperwork routine can obscure the very observations needed to answer it.

What the Settlement Covered

The United States and Tennessee joined part of the whistleblower’s case for settlement and declined to join other allegations. The Justice Department said federal and state investigations corroborated conduct originally alleged in the complaint. Its announcement describes the resolved advanced life support billing allegations.

What Is a Corporate Integrity Agreement?

A corporate integrity agreement requires a company to undertake specified compliance measures. Alongside the payment, First Call entered an agreement with the Department of Health and Human Services requiring measures intended to reduce future violations of the False Claims Act and other health care rules.

The Later First Call Skilled Nursing Facility Billing Settlement

On April 5, 2022, First Call Ambulance, LLC of Old Hickory, Tennessee entered a separate $164,418 settlement with the HHS Office of Inspector General. The inspector general’s office alleged Medicare Part B claims for ambulance transportation already covered by skilled nursing facility payments under Medicare Part A.

What Is Included in SNF Consolidated Billing?

Certain ambulance transports during a covered skilled nursing facility stay are included in the facility’s bundled Part A payment. In the later First Call matter, the inspector general’s office alleged that transports to and from skilled nursing facilities were billed separately to Part B despite already being covered by that bundle.

The earlier allegations concerned the level of care needed or delivered. The later allegations concerned which payment already covered the trip.

Where the Crew’s Account Meets the Claim

The complaint describes crew observations, quality-assurance decisions and billing instructions at different points in the same workflow. An EMT may know what the patient could do. A billing employee may know why the account changed before the claim went out. We connect that knowledge to the service billed and the decisions behind it.

The Justice Department said the whistleblower who brought the First Call case would receive a share of the settlement proceeds. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Saw the Trip Before It Became a Bill

If you know how an advanced life support claim was chosen or why a crew’s report was changed, talk with our whistleblower experts about what you saw. We stay beside you through the whole case, connect the clinical records to the claims, and bring in ambulance fraud whistleblower lawyers who understand service-level billing and facility payments.