Lynch Ambulance: A Ride Is Not a Medical Reason

In the Lynch Ambulance settlement, FILYN Corporation paid $3.05 million to resolve allegations that it billed federal health care programs for medically unnecessary ambulance transports. The Anaheim company did business as Lynch Ambulance, and the case began with two former employees. For someone who knows what happened during a ride and what the bill later said, that is the important connection: the patient’s condition inside the ambulance and the medical need represented to the government.

The government alleged that Lynch regularly billed Medicare, TRICARE and the Federal Employees Health Benefits Program for the disputed transports from 2001 through 2007. Lynch and two of its principals settled the case in 2013.

What the Government Alleged About Lynch Ambulance

The government’s allegation concerned patients who were not bed-confined or whose ambulance transports otherwise were not medically necessary. The question was whether the patient needed the ambulance that federal programs paid for.

We see the practical issue in the gap between furnishing transportation and justifying an ambulance: taxpayers were allegedly paying for a level of transport the patients did not need. The paperwork has to explain the patient, not merely the fact that a vehicle made a trip.

What Is Considered Medically Necessary for an Ambulance?

Medical necessity for a Medicare ambulance transport turns on whether the patient’s condition makes other transportation unsafe. The patient’s condition at the time of the ride matters, along with the service actually needed. A diagnosis, an order for transport and the dispatch of an ambulance each tell only part of that story.

The Medicare Benefit Policy Manual makes the distinction concrete. It ties coverage to whether another method of transportation could be used without endangering the patient’s health.

Bed confinement is one part of the patient’s condition, rather than the whole coverage decision. Medicare describes it through the patient’s ability to get out of bed without assistance, walk, and sit in a chair or wheelchair.

What the Crew Sees and What the Claim Says

A medical-necessity claim connects the patient’s condition to the ambulance service billed. The crew’s patient care report, also called a run report or trip sheet, records the transport and the clinical account behind it. The bill carries that account into the payment process.

In an unnecessary-transport case, the operational detail matters: how the patient moved, whether the patient could sit, what care was needed en route, and why another form of transportation would endanger the patient’s health. The service level matters too. Medicare ties payment to both the need for the ambulance and the level of service furnished. The equipment in the vehicle does not answer those questions for the patient.

The Department of Health and Human Services’ Office of Inspector General addressed these connections in its ambulance compliance guidance in 2003. It identified dispatch instructions, the patient’s status, the reason other transportation was unsuitable, the reason for the service level and the services provided as information an ambulance supplier should record. Those are details crews and billers handle in the ordinary course of a transport.

A physician certification statement adds another account of the patient’s needs. The signature alone does not establish medical necessity. We look at how the certification fits the condition described by the crew, the care provided and the claim submitted for payment. A signed form cannot do the clinical work of describing what the patient needed that day.

For a crew member, the concern may be a report that no longer describes the patient they transported. For a biller, it may be a direction to change that description so the claim will pay. These are different views of the same mismatch, and each can help explain how a clinical account became a demand for government money. In a separate Tennessee case, a First Call Ambulance Service whistleblower alleged that staff changed run reports to match inaccurate medical-necessity certificates.

Two Former Employees Brought the Lynch Case

Two former Lynch employees filed the qui tam case under the False Claims Act. The United States took over part of the case and negotiated the settlement.

The FBI and inspectors general at Health and Human Services, Defense and the Office of Personnel Management investigated. The Justice Department also reported that Lynch entered a Corporate Integrity Agreement with the Department of Health and Human Services. We find that a remarkable bargain: a payment to settle and an integrity agreement, yet Lynch and its principals admitted no wrongdoing.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In a transport-billing case, the knowledge behind the case may begin with a ride, a document or an instruction that someone outside the operation would never see.

You Know the Patient Behind the Paperwork

If the bill describes a medical need you never saw, or someone changed the report you wrote, talk with our whistleblower experts about the ambulance claims. We work alongside you to build your strongest ambulance fraud case around the patient’s condition, the billing decisions and who knew the difference, bringing in ambulance fraud whistleblower lawyers who understand medical-necessity disputes. You bring your knowledge of the operation, and we stay with you through the case.