Wayne County Ambulance: A Repayment and a Lesson for Other Counties

In the Wayne County Kentucky ambulance settlement, Wayne County Fiscal Court agreed to pay $30,393 over Medicare claims for dialysis rides that the government said lacked a proper physician certification statement. The county disclosed the overpayments itself. For employees handling recurring trips, certification files or billing, the striking part is what came with the repayment: Wayne agreed to teach other county ambulance services what it had learned.

The U.S. Attorney’s Office for the Eastern District of Kentucky announced the resolution on July 26, 2019. Wayne’s part concerned transportation of a Medicare beneficiary to and from dialysis from September 1 through November 30, 2013. The government described an invalid certification statement behind those overpayments.

What Is an Ambulance Physician Certification Statement?

An ambulance physician certification statement is a physician’s written certification that the patient’s condition requires ambulance transportation. Usually called a PCS, it connects the medical reason for the ride to the claim for payment. For scheduled repetitive non-emergency service, the statement comes from the patient’s attending physician.

The certification and the crew’s report do different work. The physician certifies medical necessity. The transport record describes the patient and the service actually furnished. The Medicare Benefit Policy Manual makes the point plainly: a signed order alone does not show the patient needed an ambulance.

Wayne’s settlement concerned the certification supporting its dialysis claims. In the same announcement, Gallatin County Fiscal Court agreed to pay $100,000 to resolve allegations of dialysis transports without medical need and without a physician certification statement, from January 1, 2013 to November 30, 2016. The Department of Health and Human Services Office of Inspector General investigated Gallatin’s case.

Wayne’s smaller repayment covered a shorter period of rides. Gallatin’s allegations reached both the paperwork and whether the patient needed an ambulance at all. For county staff handling health care claims, that is a concrete difference between the cases.

What Are the Requirements for a CMS Physician Certification Statement?

For scheduled repetitive non-emergency ambulance service, Medicare’s coverage rule requires the provider to obtain the physician certification before furnishing the service, with the statement dated no earlier than 60 days before the transport. Both when the physician signed and when the ambulance service obtained the statement matter.

A form sitting in the file today cannot tell the whole story of recurring claims. We examine that history with the person who knows how the paperwork moved between the physician, the ambulance operation and billing.

Who Pays for Transportation to Dialysis?

Medicare can cover qualifying ambulance transportation from home to the nearest dialysis facility and back when the patient’s condition requires an ambulance and the other coverage requirements are met. The need for dialysis and the need for an ambulance are separate questions.

That distinction matters throughout dialysis ambulance billing. A recurring treatment schedule explains the repeated destination. The medical records explain why another form of transportation would endanger the patient. The certification supports that explanation, and the crew’s report describes the actual encounter.

The government announcement noted that dialysis ambulance trips can occur several times a week and represent a significant Medicare expense. Recurrence gives a documentation defect room to follow the patient from claim to claim. For an employee who handles the route or its billing, the connection between a shared certification and repeated claims is the important part of the story.

The Inspector General’s 2015 report, Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports, found a gap that speaks directly to certification: the physicians who certified the medical necessity of questionable transports could not be identified in the claims data. The agency said that missing information limited oversight and recommended including the certifying physician’s identifier on claims requiring certification.

That finding helps explain the value of an insider’s view. A paid claim and the certification behind it are different records. Someone who handled that paperwork can explain how it reached billing, a part of the story the claims data in that study could not supply.

Wayne’s Training Commitment Reached Other Counties

Wayne agreed to provide other county ambulance services with training on what it had learned about medical necessity and physician certification requirements. The government also credited Wayne with fully cooperating in the investigation after voluntarily disclosing the overpayments.

The teaching obligation deserves as much attention as the check. The county that disclosed the certification problem agreed to carry the lesson beyond its own operation. Homework for the county, too.

We care about what happens after the training. Employees hear what the service requires. The healthcare billing records show what it actually used. We want to understand both, including what happened when an employee identified a problem.

What County Ambulance Records Can Reveal

County ambulance records can connect the physician’s certification, the crew’s observations and the claim Medicare paid. Those are different views of the same ride, and an employee may understand one part especially well.

A separate Kentucky case shows why the original patient account matters. The Lee County Fiscal Court resolution covered the county and its former ambulance service director, who agreed to pay $253,930. The government alleged false statements in patient records involving dialysis transportation, despite years of training on the rules.

Lee County admitted submitting false Medicare claims for non-emergency dialysis transports of two patients and acknowledged that it billed without regard for whether the information was true. Earlier settlements in the matter involved a paramedic and the outside billing company Medical Claims Assistance, Inc. It shows how the patient account and the billing decisions can involve different people inside and outside a county service.

We see the absurdity in the government’s account: years of training, followed by allegations of false records. Teaching the rules is one thing. Following them is another.

For a certification concern, we work with you to connect the statement received, the transport dates, the claims and what the people handling them knew. Your account of a missing document, an instruction to bill or a concern raised during training can give those records meaning. You know how the process worked at your service. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know How the Certification Reached Billing

If you handled county ambulance certifications or saw billing continue after a documentation concern, speak with our whistleblower experts about how those claims reached Medicare. We build the case with you, bring in Medicare ambulance fraud whistleblower lawyers who understand certification and recurring transport claims, and stay beside you through the process.