In a review conducted by the Office of the Inspector General (OIG) and featured in the Semiannual Report to Congress, the OIG continues to identify the need for the Centers for Medicare and Medicaid Services (CMS) to reevaluate ambulance transports billing practices, specifically, transports of beneficiaries within designated geographical locations. Medicare covers the cost of the ambulance transport when a beneficiary’s medical condition or receipt of a medical service is medically necessary and would endanger the beneficiary’s health. However, Medicare paid $24 million for ambulance transports in 2012 that did not meet program requirements to justify payments; and $17 million for transport of beneficiaries to and from non-covered destinations, such as physician offices, independent laboratories, community mental health clinics to name a few. Medicare also paid out $30 million for transports in which the beneficiary did not receive required Medicare services.
While Medicare has safeguards in place to prevent and detect fraud, waste and abuse, the OIG recommended to the Centers for Medicare and Medicaid Services (CMS) the following to:
Increase monitoring of ambulance billing;
Implement new claims processing edits to prevent inappropriate payments for transports;
Assess the geographical marketplace to determine if a moratorium should be placed on the number of ambulance providers; and
Require ambulance providers to include the National Provider Identifier (NPI) of the physician for transport claims requiring certification to validate the medical necessity of the transport.
