Lee County Ambulance Service: Dialysis Claims, False Records and the County’s Admission

In the Lee County Kentucky ambulance settlement, the county and its former ambulance director agreed to pay $253,930 to resolve False Claims Act allegations over unnecessary dialysis transports and false medical records, the Justice Department announced on April 4, 2019. Lee County admitted submitting false claims and creating or causing false records about patients’ conditions. For someone who knows the patients, runs the routes or handles the bills, the question is how the patient’s condition became a claim Medicare would pay.

What Lee County Admitted About Dialysis Claims

Lee County admitted false Medicare claims for non-emergency transports of two patients to and from dialysis. Their transports, from January 1, 2013, through June 15, 2016, resulted in over one thousand false reimbursement claims, according to the Justice Department’s account of the agreement. A small patient roster. A long stream of bills.

The county also admitted making, or causing others to make and use, false records about the patients’ medical conditions. It acknowledged submitting claims with reckless disregard for whether the information was true or false, and agreed that its conduct damaged the United States. That admission reaches both the demand for payment and the medical account used to support it.

We expect a public ambulance service to protect public health care dollars. Here, the county admitted using false patient records to claim them.

The United States brought the civil lawsuit. The Department of Health and Human Services Office of Inspector General and the Kentucky Attorney General’s Medicaid Fraud and Abuse Control Unit investigated it.

How False Medical Records Supported the Claims

The government alleged that Lee County Ambulance and its former director made false statements about the patients’ medical conditions to secure Medicare reimbursement. The Office of Inspector General’s description puts the patient beside the bill:

A false description can supply the supposed medical need that the patient’s actual condition does not support. The broader problem of falsified ambulance run reports starts at that handoff. The run report records the patient’s condition, services furnished and reasons another means of transportation was unsafe. In its 2003 ambulance compliance guidance, the Office of Inspector General told suppliers to record those facts and warned personnel against filling gaps or contradictions with assumptions. For an insider, the useful comparison is between the patient encountered, the account written about that encounter and the account used for billing.

The Former Director, the Operations Captain and the Outside Biller

The government alleged that Lee County Ambulance submitted the unnecessary-transport claims at its former director’s direction. It also alleged that the county and director disregarded Medicare’s transport rules despite receiving years of training on them.

The Captain of Operations, a paramedic, and Medical Claims Assistance, Inc., the county’s third-party billing company, had already reached separate settlements. Those agreements resolved allegations that they caused Lee County to submit false claims. The combined agreements recovered over $515,000 for the United States in connection with false claims to Medicare and Medicaid.

This healthcare fraud case reached across the public ambulance operation: the county, the director, operations and outsourced billing. A billing employee may know what information arrived from the service and what was submitted for payment. A crew member may know what happened before that information reached the billing company. We connect those accounts because the patient record and the payment decision can sit in different hands.

What Is Considered Medically Necessary for an Ambulance?

An ambulance is medically necessary for Medicare coverage when the patient’s condition makes other transportation unsafe and requires the level of service billed. Medicare’s coverage rule requires support for both the ambulance transport and the service level. The Lee County allegations concerned patients transported to dialysis without the required medical need.

The Medicare Benefit Policy Manual makes a further distinction that matters on recurring routes: Medicare still requires a medical reason for an ambulance even when the patient has no other ride available. A patient may need help reaching treatment, but the ambulance claim still has to rest on the patient’s medical condition. Scheduling the ride answers how the patient will get there. The medical record has to explain why the patient needs an ambulance.

Who Pays for Transportation to Dialysis?

For patients with end-stage renal disease, Medicare can cover qualifying ambulance transportation from home to the nearest dialysis facility and back when the patient meets the ambulance medical-necessity requirements. The need for dialysis treatment alone does not establish the need for an ambulance. Repeated dialysis rides make that distinction consequential because the same patient can generate recurring claims.

What Is an Ambulance Physician Certification Statement?

A physician certification statement is a signed, dated statement from the attending physician certifying medical necessity. For scheduled, repetitive non-emergency ambulance service, the certification must be obtained before transport. Medicare’s rule says a signed certification alone does not establish medical necessity. The supporting clinical information still matters.

Other Ambulance Settlements Connect Records and Billing

Gallatin County and Wayne County also resolved ambulance overpayments involving dialysis transports without the required medical need and physician certification statements. The Justice Department announced their resolutions in July 2019. Wayne County disclosed its overpayments itself. Both counties agreed to train ambulance employees on Medicare coverage requirements, and Wayne County agreed to train other county ambulance services as well.

The training comparison is telling. Those resolutions included a commitment to teach the coverage rules. In Lee County, the government alleged that the county and former director had already received years of training and disregarded the rules anyway. For someone inside a county service, what management knew about coverage and what it directed staff to bill belong in the same account.

The certification can also come from outside the ambulance operation. In a separate Jacksonville case, the government alleged that hospitals supplied medical-necessity certificates for non-emergency transports that patients did not medically need. Hospitals and Century Ambulance Service reached separate settlements. That comparison shows why the person supplying the medical account and the company submitting the bill both matter to understanding an ambulance claim.

What Evidence Does a Whistleblower Need?

For a case involving unnecessary dialysis transports and false records, the useful evidence connects the patient’s condition, the medical account and the claims submitted for payment. We work with the insider who can explain a particular part of that sequence: a crew member’s observations, an operations instruction, a certification, or the information sent to an outside biller.

Lee County also shows why training and billing decisions belong together. We examine what the service had been told about medical necessity, who directed the disputed claims and how the supporting records described the patients. Your knowledge of how the operation actually worked can give those documents meaning that the finished claim alone cannot supply. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know How the County’s Claims Were Made

If you worked the dialysis routes, supervised the service or handled its claims, speak to one of our Whistleblower Experts about how the county’s dialysis claims got paid. We build your strongest ambulance fraud whistleblower case with you around the clinical facts and the decisions inside the operation, and bring in ambulance fraud whistleblower lawyers who understand public providers and outsourced billing. You have a partner from the first conversation through the pursuit of the recovery.