North East Mobile Health Services: Bed-Confinement Claims and Retained Overpayments

North East Mobile Health Services agreed to pay $825,000 to resolve allegations that it billed Medicare for medically unnecessary ambulance rides and knowingly retained overpayments, the U.S. Attorney’s Office announced. The government’s account followed information from Maine Medical Center personnel into the ambulance company’s bills. If you handled the discharge statement, transported the patient or billed the ride, you may recognize the problem at the center of this case: the patient’s condition and the condition described for payment can be different stories.

What the North East Mobile Health Settlement Covered

North East Mobile Health Services was an ambulance operator based in Scarborough, Maine. The North East Mobile Health settlement concerned non-emergency ambulance transportation of patients discharged from Maine Medical Center from 2007 onward. The government alleged that North East falsely represented patients as bed-confined or otherwise medically needing ambulance transportation, then billed Medicare for those transports. Its allegation about knowingly keeping Medicare overpayments was part of the same resolution.

Maine Medical Center, in Portland, separately agreed to pay $600,000 to resolve allegations concerning the medical-necessity information its personnel supplied. The government’s combined announcement carried a $1,425,000 total under separate agreements. The ambulance company’s settlement addressed its billing and retention of payments. The hospital’s settlement addressed the statements that supported the billing.

The U.S. Attorney’s Office for the District of Maine announced the civil settlements on February 23, 2018. The Office of Inspector General for the U.S. Department of Health and Human Services investigated the case.

How Hospital Statements Reached Medicare Claims

The government alleged that Maine Medical Center personnel gave North East statements containing incomplete or inaccurate information about patients’ need for ambulance transportation. North East then used those statements to bill Medicare. The allegation followed a document across the boundary between the hospital arranging a discharge and the company seeking payment for the ride.

That handoff matters to a health care worker who knows the patient but never sees the ambulance invoice. The hospital statement supplies a clinical account. The crew’s run report describes the transport. The bill asks Medicare to pay on the strength of the supporting information. We examine how those accounts fit together, including what happened when they disagreed.

An ambulance physician certification statement supports the medical-necessity claim, but the patient’s condition still has to justify the ride. The Medicare Benefit Policy Manual says that a physician’s order does not by itself establish that ambulance transportation was medically necessary.

We see the absurdity in allowing a completed form to overrule the patient it describes. If the clinical information is wrong, moving it from a hospital statement to an ambulance bill gives the error a financial consequence. The North East allegations show why our review follows both the information supplied and the claim made with it.

What Does Bed Confinement Status Mean?

Bed confinement means the patient cannot get out of bed without assistance, cannot walk and cannot sit in a chair or wheelchair. The Medicare manual requires all three parts of that description. A note saying someone needs help getting up leaves the walking and sitting questions unanswered.

The manual also distinguishes bed confinement from bed rest and from being unable to walk. For a discharge planner or crew member, the practical detail is what the patient could actually do around the transport: get out of bed, walk, and sit in a chair or wheelchair. The allegation against North East included both false bed-confinement representations and false representations that ambulance transportation was otherwise medically necessary.

What Is Considered Medically Necessary for an Ambulance?

Ambulance transportation is medically necessary when the patient’s condition makes another means of transportation unsafe. The medical need must support both the ambulance ride and the level of service provided.

The manual also says that another vehicle’s availability does not decide medical necessity. If a different means of transportation could carry the patient without endangering their health, its being unavailable does not make the ambulance payable. A discharge plan needs transportation. Medicare needs a medical reason for this transportation.

The same need for clinical support applies to repeated dialysis rides. A recurring appointment supplies a schedule. It cannot supply the clinical justification for the ambulance.

What the Retained-Overpayment Allegation Adds

North East’s settlement also resolved the government’s allegation that the company knowingly retained Medicare overpayments. That concerns money already received and kept, adding a separate payment decision to the allegations about what the company originally billed.

For someone working in healthcare billing, refunds or compliance, the distinction is concrete. The original claim concerns what the company told Medicare about the transport. The retained-payment issue concerns what the company knew about money it had received and what it did with that money afterward. Our review follows the knowledge as well as the payment.

Getting paid was not the end of the alleged problem. Keeping the overpayment was part of it.

A Separate Maine Case Followed the Same Handoff

Capital Ambulance’s September 27, 2019 settlement involved another Maine hospital-to-biller handoff. Capital, the name used by Meridian Mobile Health in Bangor, settled allegations involving non-emergency transportation of patients discharged from Eastern Maine Medical Center.

In that case, the government alleged that hospital personnel supplied certification statements with incomplete or incorrect information about medical necessity, which Capital used to bill Medicare. Capital voluntarily disclosed the conduct.

The useful comparison is the path of the information. In each government’s account, hospital personnel supplied statements about medical necessity and an ambulance company used them in Medicare billing. The person who knew what the statement left out could be working at the hospital, while the person who knew how it became a claim could be working for the ambulance company.

What Evidence Is Needed to Report Fraud?

For these allegations, the useful evidence connects the patient’s condition, the hospital statement, the crew’s account and the Medicare claim. A retained-overpayment concern adds what the company knew after payment. We work through those connections with you, whether your view comes from discharge planning, patient care, billing or a payment review.

The crew’s account has its own importance. The HHS Office of Inspector General’s 2003 ambulance guidance identifies the patient’s status, the reason other transportation was unsuitable, the reason for the service level and who ordered the trip as information an ambulance supplier should record. Those details give us a way to understand what a statement about medical necessity actually rests on.

If your concern involves a run report changed for billing, we examine the original clinical account and the change being requested. If it involves hospital paperwork, we examine the information supplied about the patient and how the ambulance company used it. Your knowledge of that handoff may explain something the final claim cannot show on its own. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know the Patient Behind the Paperwork

If you saw discharge information turn into an ambulance claim that misrepresented the patient, or know why a Medicare overpayment stayed with the company, your knowledge may be the starting point for a qui tam case. We stay beside you as partners, build the case with you, and bring in ambulance fraud whistleblower lawyers who understand medical necessity and retained overpayments. Speak with our whistleblower experts about the ride and the payment.