Our Blog

What you need to know

For the past two years, the Department of Justice, through its local U.S. Attorney offices, along with the Department of Health and Human Services’ Office of Inspector General (OIG), has been actively investigating fire-based services for improperly billing Medicare for ALS ambulance transports when a BLS level service should have been billed.  These investigations are ongoing across the country and involve all sizes and types of fire-based services.  I am personally aware of multiple services under investigation that provide fewer than 100 Medicare transports annually.  The issue at hand is that Medicare does not necessarily reimburse at an ALS level despite fire departments responding with ALS equipped and staffed ambulances.  There are somewhat complex Medicare billing guidelines that must be followed to determine whether Medicare should be billed for an ALS or BLS service.  However, it is exceedingly common for fire departments to simply bill Medicare at an ALS rate.  By doing so, the government is claiming that these fire departments are violating the federal False Claims Act by submitting false claims to Medicare for reimbursement.

What you should do

• To determine if you have a potential billing issue and may be subject to federal investigation, you need to know how often you are billing Medicare for ALS and BLS services. As a general rule of thumb, a fire-based service should have an annual Medicare mix of 70% ALS and 30% BLS.  You should contact your billing provider or in-house billing department and determine your ALS-BLS mix.
• If you have a greater than 70% ALS rate, you may have a problem and could become subject to investigation. The government is using data analytics from Medicare to find fire services with a high ALS billing percentage and this is who typically becomes subject to investigation.
• I also recommend hiring an independent 3^rd party to conduct an audit of your Medicare claims. We’ve seen numerous clients who relied on a billing company to submit their claims only to find out the billing company was billing inaccurately. The government expects you to bill correctly and having an independent audit can be critical in defending yourself in an investigation.
• If you determine that you have been over-billing Medicare for ALS transports, you must make immediate arrangements to refund the overpayments. Medicare’s 60-day overpayment rule requires you to do so.  You will be in violation of the False Claims Act if you do not promptly refund the money.
• Finally, the government expects you to have a healthcare compliance program in place in order to avoid improperly billing Medicare. They expect such a compliance program regardless of your size.  In 2003, the OIG outlined exactly what they expect from ambulance providers when it comes to compliance programs.  This guidance and the requirements can be found at the OIG website: https://oig.hhs.gov/fraud/docs/complianceguidance/032403ambulancecpgfr.pdf

Author: Lauren Fairlie