Navicent Health: The Paramedic Complaint and the Second Investigation

In the Navicent Health ambulance settlement, the hospital agreed to pay $2,549,742 to the United States and Georgia to resolve allegations of billing non-emergency trips as emergencies and charging for medically unnecessary ambulance rides. A former paramedic brought the case over transports between hospitals. Federal investigators separately identified a pattern in trips taking discharged patients elsewhere. For someone who knows what happened on the ambulance or at the discharge desk, the distinction matters: the case combined an insider’s account with a different view of the bills.

The Justice Department’s August 3, 2017 announcement named The Medical Center of Central Georgia, Inc., doing business as The Medical Center, Navicent Health. The civil settlement covered allegations under the False Claims Act and the Georgia False Medicaid Claims Act.

The Hospital Owned the Ambulances

Navicent owned and operated both the hospital and the ambulances. The Office of Inspector General connected that ownership directly to the alleged financial incentive: inflated ambulance payments could benefit the hospital’s own bottom line.

That common ownership puts the discharge and the transport bill inside the same organization. Hospital staff know why a patient is leaving and where the patient is going. Ambulance crews record the patient’s condition and the care provided. Billing turns those accounts into a claim for payment. We look at the connections between those decisions, especially when the service described on the bill differs from the trip the crew remembers.

The alleged premium came from calling non-emergency trips emergencies. The word changed the price.

The Paramedic’s Complaint Concerned Trips Between Hospitals

The former Navicent paramedic’s whistleblower complaint focused on interhospital transports. The Justice Department alleged that Navicent billed non-emergency ambulance trips between hospitals at inflated emergency rates.

The allegation concerns how an actual transport was billed. A crew’s account of the patient and the transfer can be compared with the emergency designation used for payment. That gives the person who handled the ride a view of the transaction that the bill alone cannot supply.

A separate whistleblower complaint against Medstar Ambulance described the same kind of mismatch from the billing side:

The Medstar whistleblower had worked in the billing office. The parallel shows why crew knowledge and billing knowledge can expose the same emergency-upcoding allegation from different points in the business.

Federal Investigators Identified the Discharge Billing Separately

The Department of Health and Human Services Office of Inspector General independently identified Navicent’s hospital-discharge billing for investigation. Its data analysts identified emergency ambulance billing for trips taking discharged patients elsewhere.

The second alleged scheme covered non-emergency trips taking discharged patients to residences, skilled nursing facilities, hospital-based diagnostic clinics and dialysis centers. The government alleged that Navicent billed those rides as emergencies. For many of the transports, it also alleged that using and billing for an ambulance was medically unnecessary altogether.

Those allegations reach different parts of the payment. One concerns an inflated rate for the ride. The other concerns whether the patient needed an ambulance at all. In the government’s account, both problems appeared in the discharge transports.

For dialysis transport, needing treatment does not establish a need for an ambulance. The patient’s condition at transport must justify the ride.

Does Medicare Pay for Non-Emergency Ambulance Transportation?

Yes. Medicare can cover non-emergency ambulance transportation when the patient’s condition and the trip meet its coverage requirements. The Medicare ambulance coverage rule requires medical support for both the ambulance transportation and the level of service provided.

Emergency billing also has an operational test. The Medicare Benefit Policy Manual looks at the nature of the call at dispatch and the local emergency dispatch protocol. When dispatch does not follow that standard, the patient’s condition at the scene determines the appropriate payment level. The dispatch account belongs beside the emergency designation on the bill.

What Is Considered Medically Necessary for an Ambulance?

Medicare’s medical-necessity standard asks whether the patient’s condition made other transportation unsafe and required the ambulance and the service level furnished. The Medicare Benefit Policy Manual ties that assessment to the patient’s condition at the time of transport. An emergency response does not independently establish medical necessity.

Calling the ride an emergency cannot supply the missing medical reason for it. That is the distinction behind Navicent’s discharge allegations: an inflated emergency rate and, for many trips, no medical need for an ambulance at all.

What Is an Ambulance Physician Certification Statement?

An ambulance physician certification statement is a signed and dated statement by the attending physician certifying medical necessity. The certification is required for certain non-emergency transports, and the signed statement alone does not establish that the patient needed an ambulance.

We compare the condition described in the certification with the crew’s account of the ride. A signature cannot make those accounts agree.

The Governments Joined the Case

The United States and Georgia joined the paramedic’s case. The investigators came from HHS-OIG, the U.S. Attorney’s Office for the Middle District of Georgia and the Georgia Medicaid Fraud Control Unit. The settlement resolved the pending case and provided for the former paramedic to receive a share of the settlement payment. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

What Is a Corporate Integrity Agreement?

A Corporate Integrity Agreement requires a healthcare provider to fund and maintain a compliance program overseen by the Office of Inspector General, with reviews by an independent review organization. Navicent already had one. As part of this resolution, its existing agreement was heightened and extended to cover the newly resolved conduct. We expect more from a hospital already operating under an integrity agreement.

What Evidence Is Needed to Report Fraud?

For these ambulance-billing allegations, the useful evidence connects the patient’s condition and the trip with the emergency designation, service level and claim. We work through those connections with the insider who saw one part of the process.

A paramedic may know the original patient-care account. A hospital employee may know what went into the discharge information or certification. A biller may know which emergency designation reached the claim and who directed it. Where a run report was changed for billing, the original account and the later version show where the patient’s story diverged.

You Know the Trip Behind the Bill

If you saw a non-emergency transfer billed as an emergency or a discharge account changed to justify an ambulance, talk with our whistleblower experts about the trip and the claim. We build the case with you and bring in ambulance fraud whistleblower lawyers who understand hospital transport and health care billing. We stay beside you as your account of the work becomes a case for recovering public money.