Medicare paid out tens of millions for ambulance rides in which beneficiaries did not receive services, according a new government watchdog audit.
The inspector general of Health and Human Services released a report Tuesday that details questionable billing practices from ambulance suppliers, an area that is considered highly vulnerable to fraud. In the first half of 2012, tens of millions of dollars were spent on ambulance transports to destinations that were not covered by Medicare or where no services were rendered.
For Medicare to cover ambulance transports, the beneficiary’s medical condition at the time of the ride must be such that other forms of transportation would endanger his health. Additionally, the person being transported must receive medically necessary Medicare services or must be returning from such a service.
The inspector general discovered Medicare payments of $24 million in the first half of 2012 for ambulance transports that did not meet certain standards to be deemed justified, according to the report. Medicare paid $17 million for transport to locations not covered under Medicare such as between physician offices and an additional $30 million was billed for transport in which a person did not receive Medicare services at the time of the pickup or at the drop off locations.
The problem is concentrated to urban areas, the report states, with more than half of all questionable transport given to beneficiaries living in Philadelphia, Los Angeles, New York, and Houston. These four cities made up 52 percent of the suspect ambulance rides despite accounting for only 18 percent of all transports.
Suppliers located in these cities transported an average of 24 to 69 Medicare beneficiaries in the first half of 2012 and showed billings of $1,264 to $1,525 per patient. All other metropolitan areas were found to transport an average of 18 beneficiaries at a cost of $880 per person.
In 2013 and 2014, the Center for Medicare and Medicaid Services temporarily prohibited new enrollments of ambulance suppliers in Philadelphia and Houston and has since extended this suspension on three separate occasions.
Fraudulent billing practices by ambulance suppliers is a consistent problem, the IG notes.
"Investigators have uncovered a variety of fraud schemes involving ambulance suppliers," the report says. "For example, in May 2015, a Florida supplier paid $1.25 million to settle allegations that it knowingly upcoded transport claims from basic to advanced life support, unnecessarily transported patients, and transported patients unnecessarily to their homes at a level of care meant for emergencies."
In 2014, individuals who worked for a supplier in Philadelphia also received prison sentences for fraudulently billing Medicare $3.6 million by recruiting patients who did not need ambulance transport. These particular individuals were convicted of falsifying documents to justify the transports and providing illegal kickbacks to their patients.
A government watchdog group said that practices like this will continue until real anti-fraud safeguards are implemented.
"Lax safeguards lead to fraudulent behavior and this report demonstrates troubling trends for Medicare," said Curtis Kalin, a spokesman for Citizens Against Government Waste. "Until Medicare develops and implements real and effective preventative anti-fraud measures, this kind of waste will continue. It’s not enough to simply identify waste, fraud, and abuse after the fact. There must be provisions in place to prevent it from occurring in the first place."