Ambulance Transport Fraud

What is ambulance transport fraud?

Ambulance transport fraud involves any scheme to get Medicare or Medicaid reimbursement for ambulance transports or services that were not medically appropriate or were otherwise ineligible for reimbursement. Ambulance transportation providers that commit Medicare or Medicaid fraud may face liability under the qui tam provisions of the False Claims Act.

There have been several successful qui tam whistleblower cases brought by relators (whistleblowers) under the False Claims Act against the providers of ambulance services. Under some circumstances, the Medicare and Medicaid programs cover ambulance transportation. However, Medicare and Medicaid pay for ambulance services only under specific, limited conditions. In a number of cases, hospitals and ambulance companies have cheated the system and obtained Medicare or Medicaid reimbursement for ambulance transportation of patients who do not need an ambulance and do not qualify for reimbursement. In other cases, providers have obtained higher reimbursement for ambulance services than the Medicare or Medicaid programs allow.

Medicare will pay for the ambulance transport of a Medicare patient only when the ambulance transport is “medically necessary,” i.e., only if the ambulance services “are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated.” 42 C.F.R. § 410.40(d)(1). Medicare considers an ambulance transport to be “medically necessary” only if the use of other means of transportation would endanger the patient’s health, whether or not such other transportation is actually available. Medicare Carrier Manual (“MCM”) § 2120.2(A). In addition, Medicare covers ambulance services only if they are reasonable in the treatment of the illness or injury involved. MCM § 2120.2(B). If patients are “ambulatory” or if less expensive means of transportation could be used, the Medicare and Medicaid programs may deny coverage for the ambulance transport.

One example of the way in which some ambulance providers have violated the False Claims Act has been in connection with the transportation of patients receiving routine kidney dialysis. Ordinarily, in order to travel to or from their regularly scheduled dialysis sessions, patients who are ambulatory (i.e., they can walk around) can use taxicabs or other forms of transportations that are only a small fraction of the costs of an ambulance transport. The Medicare Carrier Manual states that a “beneficiary receiving maintenance dialysis on an outpatient basis is not ordinarily ill enough to require ambulance transportation for dialysis treatment.” MCM § 2120.3(J). Yet, providers might arrange to have these patients regularly transported to and from their dialysis appointments in ambulances, at unnecessary expense to the taxpayer.

Ambulance companies may also defraud the Government by entering into unlawful kickback “swapping arrangements” with hospitals and other healthcare facilities to provide discounted ambulance services in exchange for referrals for ambulance transports. For example, in 2006, American Medical Response (AMR), one of the largest ambulance providers in the United States, paid over $9 million to settle a qui tam False Claims Act lawsuit alleging that AMR entered into unlawful swapping arrangements with hospitals in Texas. More recently, AMR paid $2.7 million in 2011 to resolve a qui tam False Claims Act case alleging that AMR had inflated its claims for transport.

VSG’s Qui Tam Attorneys are Experienced in Handling Ambulance Fraud Cases

In one of VSG’s cases, the ambulance company would routinely send ambulances to transport dialysis patients to their regularly-scheduled appointments. An ambulance showed up at the home of one patient while he was driving a tractor; the patient got off his tractor and walked over to the ambulance, which then took him to a dialysis appointment! In another case, a whistleblower successfully sued a hospital chain that was providing ambulance services to its patients through a related company, and then inflating the costs of the ambulance services on the hospital’s annual Medicare cost reports.