Feds crack down on Medicare ambulance fraud

Teams of federal officials have been fighting ambulance fraud where one fraudulent ambulance operator would shut down only to have another, sometimes headed by a friend or family member, replace it, reports JEMS.

Since 2014, authorities have fought these fraudulent systems by not allowing new ambulance firms in the Philadelphia region to be paid by Medicare and requiring repetitive nonemergency trips to have receive prior authorization.

In southeastern Pennsylvania, Medicare's annual spending on basic ambulance services dropped to $12.7 million last year from $55.4 million in 2010.

"We're never going to claim victory, but we think we did a good job of rooting out a lot of these fraudulent companies," said Nick DiGiulio, special agent in charge of the Philadelphia regional office of the U.S. Department of Human Services' (HHS) Office of Inspector General.

Since 2014, 83 ambulance firms, more than a quarter in the area, have closed. In the past five years, there have been 30 criminal convictions with a total restitution order of $22 million.

The fraud, he DiGiulio, centered on Medicare beneficiaries who needed kidney dialysis three times a week. Transportation of a single dialysis patient by ambulance costs $67,000 a year, said Ron Kerr, assistant special agent in charge of HHS's Office of Inspector General here and these patients have become the biggest money makers for criminals.

Before Medicare's preauthorization rules took effect, ambulance companies only had to bill Medicare and pretend they had physician certification that the rides were medically necessary. Companies would bid against each other for the chance to be the patients' transportation provider. Some were paying patients as much as $500 a month for the right to bill Medicare, which pays $360 to $380 per round trip, including mileage, for each of those three weekly trips.

Shantanu Agrawal, director of CMS's Center for Program Integrity, said there is no way to know how much of the estimated $89 billion in improper Medicare and Medicaid payments last year was due to fraud.

CMS has begun to provide investigators to access the billing information but the prior authorization program needs improvement, as some of patients that meet the criteria for non-emergency transportation are being denied.