Ambulance fraud makes up a significant portion of the estimated $60 billion lost to healthcare fraud every year in the United States; though emergency transport services are an integral part of the healthcare system, the practice of fraudulently billing Medicare in order to receive undue reimbursement is common.
When reviewing claims for reimbursement, Medicare has strict guidelines for the medical necessity of emergency transportation services. In order to qualify for such services, patients must have documentation proving that the services are, in fact, emergent, and no alternative transportation is available at the time of service. As cited in the Centers for Medicare and Medicaid Services (CMS) Manual, “In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services.”
In order to circumvent these standards, fraudulent ambulance providers will often employ unlawful techniques in order to receive reimbursement to which they would otherwise not be entitled; these practices include:
- Upcoding; the practice of claiming a higher severity of injury or illness to bill for emergency services at a higher rate
- Billing for services that were not provided
- Submitting claims for non-emergent transportation, such as rides to routine doctor appointments
- Offering discounted transport rates to participating facilities in exchange for referrals
- Engaging in kickback schemes, which involve providing or receiving illicit funds in return for fraudulent services
In efforts to reduce waste of government healthcare funding, CMS has frequently established temporary moratoria in high-risk areas that prevent private ambulance companies from eligibility for reimbursement. Though it is estimated that these provisions have reduced the frequency of such fraudulent activity, it still very much exists. Ambulance fraud is easily veiled given the typical circumstances of care; this puts potential whistleblowers in a unique position, as the majority of schemes are brought forward by internal sources.
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