In July 2018, the Officer of the Inspector General (OIG) issued a Report, Medicare Improperly Paid Providers for Nonemergency Ambulance Transports to Destinations Not Covered by Medicare.  The OIG found that Medicare made improper payments of $8.7 million to providers for non-emergency ambulance transports to destinations not covered by Medicare.

What the OIG Reviewed

The OIG reviewed non-emergency ambulance transports (billed using HCPCS codes A0426 and A0428) with dates of service from January 1, 2014, through December 31, 2016 (audit period).

Specific Report Findings

The OIG found that Medicare made improper payments to providers for 31,441 claim lines for which providers billed non-emergency ambulance transports to destinations not covered by Medicare, such as the scene of an accident or acute event (destination code “S”).  For example, the OIG found that one provider used modifier RS to bill for a non-emergency ambulance transport from a beneficiary’s residence to a scene of an accident or acute event. The majority of the claim lines (59%) were for transports to diagnostic or therapeutic sites, other than a physician’s office or a hospital, that did not originate from SNFs.

What are the Medicare Destination Requirements?

Medicare covers ambulance transports to only the following destinations:

• From any point of origin to the nearest hospital (including a critical access hospital) or nearest SNF that is capable of furnishing the required level and type of care for the beneficiary’s illness or injury;
• From a hospital (including a critical access hospital) or SNF to the beneficiary’s home;
• From a SNF to the nearest supplier of medically necessary services that are not available at the SNF where the beneficiary is a resident, including the return trip; or
• From a beneficiary’s home to the nearest facility that furnishes renal dialysis (for a beneficiary who is receiving renal dialysis for treatment of ESRD), including the return trip.

What CMS is Doing in Response to the Report

In accordance with the OIG’s recommendations, CMS has agreed to take the following actions:

1. Instruct Contractors to Recover Identified Overpayments.  CMS said it will direct Medicare contractors to recover the portion of the $8.7 million in improper payments made to providers for claim lines that are within the claim-reopening period.
2. Identify Providers and Notify them of Potential Overpayments.  For the remaining portion of the $8.7 million outside of the Medicare reopening and recovery periods, CMS said it will instruct Medicare contractors to notify providers of potentially improper payments so that those providers can exercise reasonable diligence to investigate and return any identified similar improper payments and identify and track any returned improper payments.
3. Further Review of Noncovered Destinations.  The OIG recommended that CMS direct its contractors to review claim lines for non-emergency ambulance transports to destinations not covered by Medicare. CMS said it will instruct contactors to consider a review for non-covered destinations similar to the current dialysis prior authorization program.  This might effectively mean prepayment review for all non-emergency transports.
4. Nationwide Edits. Finally, CMS said it will work to implement national prepayment edits for non-emergency ambulance transports regarding approved and inappropriate destinations. 

The Take Home for Ambulance Providers

This Report puts all ambulance providers on notice that they should check for potential overpayments related to non-emergency transport destinations.  In fact, the OIG states that the Report “constitutes credible information of potential overpayments"- the term used in the 60 Day Rule that triggers the need to conduct reasonable diligence to determine if an overpayment exists.

CMS will use the OIG’s Report to identify specific providers and notify them of potential overpayments.  It is strongly recommended that all ambulance providers that have billed for non-emergency transports over the past six years audit those claims for potential overpayments related to potentially improper destinations.   This Report was not limited dialysis transports. So, all nonemergency claims should be considered.

If you have questions, or would like the audit team at Page, Wolfberg & Wirth to help identify potential issues for your agency, please contact us at info@pwwemslaw.com or call (877) EMS-LAW1 (877) 367-5291.