DOJ aggressively investigates ALS transport billing

Submitting false EMS transport claims to Medicare for reimbursement is a violation of the False Claims Act


This article originally appeared in the May 3, 2018 issue of the Paramedic Chief Leadership Briefing.

What you need to know: For the past two years, the Department of Justice, through its local U.S. Attorney offices, along with the Department of Health and Human Services’ Office of Inspector General, has been actively investigating fire-based services for improperly billing Medicare for ALS ambulance transports when a BLS level service should have been billed.

These investigations are ongoing across the country and involve all sizes and types of fire-based services. I am personally aware of multiple services under investigation that provide fewer than 100 Medicare patient transports annually.

The issue at hand is that Medicare does not necessarily reimburse at an ALS level despite fire departments responding with ALS-equipped and -staffed ambulances. Medicare billing guidelines must be followed to determine whether Medicare should be billed for an ALS or BLS transport.

However, it is exceedingly common for fire departments to simply bill Medicare at an ALS rate. By doing so, the government is claiming that these fire departments are violating the federal False Claims Act by submitting false claims to Medicare for reimbursement.

Action steps: Work with your billing provider or in-house billing department, as well as an independent third party auditor, to do the following:  

  • Determine your ALS-BLS ratio to see if you have a potential billing issue and may be subject to federal investigation. Calculate how often you are billing Medicare for ALS and BLS services. As a rule of thumb, a fire-based service should have an annual Medicare mix of 70 percent ALS and 30 percent BLS.

  • Understand how the government is using Medicare data analytics to find fire services with a high ALS billing percentage. If you have an ALS rate greater than 70 percent, you may have a problem and could become subject to investigation.

  • Hire an independent third-party to audit Medicare claims. I’ve seen numerous clients who relied on a billing company to submit their claims only to find out the billing company was billing inaccurately. The government expects you to bill correctly and having an independent audit can be critical in defending yourself in an investigation.

  • Make immediate arrangements to refund the overpayments if your audit determines that you have been over-billing Medicare for ALS transports. Medicare’s 60-day overpayment rule requires repayment or you will be in violation of the False Claims Act.

  • Ensure you have a healthcare compliance program in place to avoid improperly billing Medicare. In 2003, the OIG outlined expectations from ambulance providers, regardless of their size, for compliance programs. Find this guidance and the requirements on the OIG website.

About the author

Kevin Fairlie is a healthcare attorney who specializes in representing fire departments, EMS corporations and agencies. Fairlie is the former general counsel for a large multi-state EMS agency and has held numerous EMS leadership positions including serving as CEO. He is the founding member of EMS Compliance, LLC and Fairlie Law, LLC, which is a national healthcare and EMS law firm.

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