Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports

WHY WE DID THIS STUDY

In 2012, Medicare Part B paid $5.8 billion for ambulance transports, almost double the amount it paid in 2003. Historically, Medicare has been vulnerable to fraud involving ambulance transports. In 2013 and 2014, the Centers for Medicare & Medicaid Services (CMS) imposed temporary moratoria on the enrollment of new ambulance suppliers in two metropolitan areas. Medicare billing for ambulance transports warrants scrutiny, given its rapid growth and its vulnerability to fraud and abuse.

HOW WE DID THIS STUDY

To identify inappropriate payments and questionable billing, we analyzed claims data for 7.3 million ambulance transports during the first half of 2012. We examined transport billing including, but not limited to, transport destinations, transport levels, distance of urban transports, other Medicare services that beneficiaries received, and the geographic locations where the beneficiary who received the transport resided.

WHAT WE FOUND

We identified both improper payments for ambulance transports and questionable billing by ambulance suppliers. We found that Medicare paid $24 million in the first half of 2012 for ambulance transports that did not meet certain program requirements to justify payment. For example, Medicare paid $17 million for transports that were to or from noncovered destinations such as physicians' offices. In addition, Medicare paid $30 million for transports for which the beneficiaries did not receive Medicare services at the pick-up or drop off locations, or anywhere else. These claims may have been inappropriate. We also found that about one in five suppliers had questionable billing. For example, a supplier may have had an unusually high average mileage for the transports that it provided to beneficiaries residing in urban areas. Questionable billing is geographically concentrated, with more than half of all questionable transports provided to beneficiaries residing in four metropolitan areas.

WHAT WE RECOMMEND

Our findings indicate that inappropriate and questionable billing for ambulance transports pose vulnerabilities to Medicare program integrity. In response, CMS should enhance existing fraud and abuse safeguards. Our report made five recommendations. CMS concurred with our recommendations for it to (1) determine whether a temporary moratorium on ambulance supplier enrollment in additional geographic areas is warranted, (2) require ambulance suppliers to include the National Provider Identifier of the certifying physician on transport claims that require certification, (3) increase its monitoring of ambulance billing, and (4) determine the appropriateness of claims billed by ambulance suppliers identified in the report and take appropriate action. CMS partially concurred with our recommendation for it to implement new claims processing edits or improve existing edits to prevent inappropriate payments for ambulance transports. CMS indicated that it will review data on claims identified in this report; CMS should use the results of its review to implement new, or modify existing, claims processing edits needed to prevent inappropriate payments.