Metropolitan Ambulance: Allegedly Forged Letters to Keep Medicare’s Money

Metropolitan Ambulance paid $2.85 million with Metro North Ambulance and Big Apple Ambulance to resolve allegations that they used false medical-necessity letters to fight Medicare refund demands. The settlement concerned the appeal letters; according to the Justice Department, Medicare’s underlying audit had questioned tens of millions of dollars in ambulance bills. For someone who handled billing or appeal files, the question is who supplied the supposed medical support after Medicare asked for its money back.

The Justice Department’s June 4, 2010 announcement identifies Metropolitan Ambulance & First Aid Corp. as SEZ Metro Corp. and Metro North Ambulance Corp. as SEZ North Corp. Big Apple Ambulance Service Inc. was formerly United Ambulance. Those names connect the operating companies to the settlement an employee may remember under a different name.

What Medicare Asked the Companies to Return

According to the Justice Department, Medicare audited the companies’ past billing and concluded that the disputed trips did not meet its medical-necessity standard. Medicare demanded repayment and gave the companies informal and formal opportunities to appeal.

The disputed trips were non-emergency transports. As the Justice Department described the coverage rule in this case, the companies could bill Medicare only when the patient could not travel another way, such as by car or wheelchair van.

An ambulance business must keep crews and vehicles ready, but Medicare ordinarily pays for a medically necessary completed transport. The Medicare Benefit Policy Manual ties coverage to the patient’s condition at the time of the trip. That puts the account of the patient at the center of both the original bill and a later defense of that bill.

The government’s allegation was that the companies could not otherwise demonstrate the medical need and turned to false supporting letters. We see the absurdity in asking Medicare to trust the medical evidence while allegedly faking its source.

What Is Considered Medically Necessary for an Ambulance?

An ambulance is medically necessary when the patient’s condition makes other transportation unsafe and requires both the ambulance and the level of service provided. The patient’s diagnosis or a physician’s order alone does not answer that question.

For staff working with ambulance physician certification statements, the distinction matters. A certification supplies medical support for the transport, but the coverage regulation says a signed statement alone does not demonstrate medical necessity. Its account has to stand alongside the patient’s medical records and the transport itself.

That is why the source of a necessity letter matters. The person presented as explaining the patient’s condition must actually be the source of that account.

Hundreds of Letters Offered as Independent Medical Support

The government alleged that the companies used hundreds of letters that were forged or falsely presented as coming from an independent health care provider. The Justice Department’s account of the suit described the alleged roles precisely:

A statement offered as independent support could carry the ambulance company’s interest in keeping the payment instead. For an employee who worked on the appeals, that places the requests for letters, the people supplying them and the submitted versions beside the original transport records. We want to understand how the company’s account of the patient reached the appeal file, and who knew where it came from.

The Companies’ President and the Former Chief Financial Officer

The companies’ common president was an individual defendant in the False Claims Act case. The government alleged that he caused the use of the disputed letters in the appeals.

The whistleblower was a different person: a former chief financial officer of one of the companies. The former CFO brought the qui tam case, and the United States later joined it. The Department of Health and Human Services Office of Inspector General and the FBI worked with the Justice Department on the investigation and resolution.

The case started on the finance side of the business. A refund demand puts past revenue back at issue, and a finance insider may understand how the company responded. Here, the government’s allegations connected that response to the medical evidence offered in the appeals.

What the Appeal File Can Reveal

An appeal file can connect the original patient account with the later explanation used to defend a payment. In this case, that comparison includes the medical-necessity letters and the people presented as their independent sources.

The Inspector General’s 2003 guidance for ambulance suppliers identifies the details that give the original transport account substance: dispatch instructions, the patient’s condition, why other transportation was unsafe, who ordered the trip, the service provided, trip times, mileage, and pickup and destination information. Those details let us compare a later medical explanation with what the crew actually recorded.

Changes to the crew’s patient care report can affect the account that supports a claim. The guidance also tells ambulance personnel not to fill gaps or contradictions in trip sheets and medical records with assumptions. When an appeal letter supplies the missing explanation, its author and basis deserve the same attention as its conclusion.

We examine those connections with the person who understands the workflow. A crew member may recognize a changed description of the patient. Someone in billing or appeals may know who requested the supporting letter, what it originally said and what was eventually submitted. A healthcare provider whose judgment the letter claims to express may know whether that account is theirs at all.

The useful knowledge is specific: a particular trip, a particular document and the decision that connected it to payment. The Metropolitan allegations show why the review cannot end with the original claim.

When Old Trips Get New Paperwork

A separate government complaint against Hart to Heart Transportation Services alleged demands for medical-necessity paperwork during an investigation, after the trips had already been paid. That case also included allegations of unnecessary dialysis ambulance transportation.

The government described the requests to hospital employees in concrete terms:

The comparison is the pressure on the supporting account after payment comes under scrutiny. Metropolitan’s case concerned allegedly forged or falsely independent appeal letters. The Hart to Heart complaint described requests to create or revise certifications for completed trips. A facility employee receiving that request can see a part of the billing history that the original ambulance crew may never see.

The Whistleblower’s Share of the Recovery

The former CFO’s announced whistleblower reward was 22% of the settlement. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. For an insider who knows how an appeal document was created, the value of that knowledge lies in connecting the document to the money the company sought to keep.

You Know Who Supplied the Letter

If you handled an ambulance appeal and know the medical support was manufactured, tell our whistleblower experts how it reached the appeal file. We work with you to build the case around the original records, the people directing the response and the Medicare money at stake, and bring in Medicare fraud whistleblower lawyers who understand ambulance billing and refund disputes. We stay beside you throughout the case.