By Rebecca Mayo, J.D.
A prior OIG review found that Medicare improperly paid $17.4 million during the first half of calendar year (CY) 2012 for nonemergency ambulance transports. These improper payments were to providers that indicated the nonemergency ambulance transports were to destinations not covered by Medicare. OIG conducted another review, this time for CYs 2014 through 2016, and found that Medicare made improper payments of $8.7 million to providers for these same types of noncovered transports (OIG Report, No. A-09-17-03018, July 2018).
Covered transports. Medicare covers ambulance transports to the nearest appropriate facility, as well as the return transport, for a beneficiary to obtain necessary diagnostician or therapeutic services. The transport must be to receive a medically necessary Medicare service or to return from such a service. To receive Medicare payment for an ambulance transport, the provider must submit a claim and indicate the transport level, the origin, the destination, and the total miles for the one-way transport.
Improper payments. Between January 1, 2014, and December 31,2016, Medicare contractors paid providers $3.2 billion for approximately 18.9 million claim lines for nonemergency ambulance transports. OIG identified 31,441 claim lines, totaling $5,463,851 that were paid by Medicare for nonemergency ambulance transports to destinations not covered by Medicare. It also identified 31,201 claim lines, totaling $3,170,089, that were paid by Medicare for ground mileage associated with nonemergency ambulance transports to destinations not covered by Medicare.
Improper destinations. The majority of claims for nonemergency ambulance transports to improper destinations were for transports to diagnostic or therapeutic sites other than a physician’s office or a hospital that did not originate from skilled nursing facilities (SNFs). One provider billed for a nonemergency ambulance transport from a beneficiary’s residence to a scene of an accident or acute event, which is not covered by Medicare.
OIG recommendations. OIG recommended that CMS direct the Medicare contractors to recover the portion of the $8,633,940 in improper payments made to providers for claims lines that are within the 4-year claim-reopening period. It recommended that for the remaining portion that is outside of that recovery period, Medicare contractors notify providers of the potentially improper payments so that those providers can exercise reasonable diligence to investigate and return any identified similar improper payments in the future. Further, Medicare contractors should review claim lines for nonemergency ambulance transports to destinations not covered by Medicare after the OIG audit period and recover any improper payments identified. Finally, Medicare contractors should be required to implement nation-wide prepayment edits to ensure that payments to providers for nonemergency ambulance transports comply with federal requirements.
CMS response. CMS concurred with the OIG recommendations and noted that it is currently conducting prior authorization reviews and will instruct Medicare contractors to consider a similar review for transports to destinations not covered by Medicare after the audit period. CMS also noted that it has implemented a prior authorization model for repetitive, scheduled non-emergent ambulance transports in nine states and has seen a decrease in expenditures on these claims and a savings of approximately $340 million.
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