Medicare Made Improper and Potentially Improper Payments for Emergency Ambulance Transports to Destinations Other Than Hospitals or Skilled Nursing Facilities

Medicare payments to providers for emergency ambulance transports did not comply or potentially did not comply with Federal requirements. Specifically, Medicare made improper and potentially improper payments totaling $1.9'million: (1)'improper payments of $975,154 for transports to destinations that were not covered by Medicare for either emergency or nonemergency ambulance transports, including the identified ground mileage associated with the transports, and (2) potentially improper payments of $928,092 for transports that may not have met Medicare coverage requirements or might have been paid by Medicare as nonemergency ambulance transports. During our audit period (calendar years 2014 through 2016), the Centers for Medicare & Medicaid Services (CMS) did not require the Medicare contractors to implement nation-wide prepayment edits that would either deny payments or mandate prepayment review for emergency ambulance transports to destinations other than hospitals or skilled nursing facilities.

We recommended that CMS direct the Medicare contractors to (1) recover the portion of the $975,154 in improper payments for emergency ambulance transports to destinations not covered by Medicare that are within the 4-year claim-reopening period and (2) review claim lines that are within that period for emergency ambulance transports that might have been covered by Medicare for nonemergency ambulance transports and recover any improper payments identified, which could represent $928,092. We also made recommendations related to (1) returning any identified improper payments for the remaining portion of the $1.9 million, which is outside of the reopening period, and (2)'reviewing claim lines for emergency ambulance transports to destinations not covered by Medicare after our audit period and recovering any improper payments identified. Finally, we made two procedural recommendations.

CMS concurred with our recommendations. However, regarding our draft report's recommendation that CMS make any necessary regulatory changes to implement our second procedural recommendation, CMS stated it did not concur at this time because the regulatory recommendation was dependent on its findings from the Medicare contractors' review of a sample of claim lines conducted in keeping with our second recommendation. We revised our report to remove the recommendation related to making regulatory changes.