Ambulance and EMS Fraud: Billing Schemes and Rewards

understanding ambulance and emergency services fraud and abuse

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What is Ambulance Fraud?

Ambulance fraud is an EMS company billing Medicare or Medicaid for rides that were not medically necessary, not provided, or staffed and coded dishonestly.

It is a violation of the False Claims Act, and a whistleblower who reports it can recover 15% to 30% of what the government collects. If you have seen an ambulance company bill for rides it should not have, call (888) 713-6653 for a free, confidential review of your potential claim.

The federal government, through the Medicare and Medicaid programs, shoulders a large part of the money that is spent providing ambulance services throughout the US every year. These programs provide insurance for millions and make payments to the companies that provide ambulances when insured patients are given emergency care in transit to hospitals.

How much these companies are paid comes down to many different factors. Depending on the type of care provided, who provides the care, and how far the ambulance travels, the amount compensated can change significantly.

EMS are the first responders and provide transportation and medical care in emergency situations like car accidents.

However, the emergency medical services are provided by companies that cultivate relationships with both hospitals and local governments and this is fertile grounds for corruption. These services often enjoy the advantages of exclusive contracts, reliable demand for services and excellent compensation.

This has led some companies, owners, and ambulance operators to attempt to engage in fraudulent practices.

 

What You'll Learn From This Guide
  • What Constitutes Ambulance & Emergency Servicees Fraud
  • The Fact Patterns of Patient & Billing Fraud
  • All about Ambulance Ride Schemes Commonly Used to Defraud
  • How to Report Abuses If You Have Knowledge of Misconduct

 

How is the False Claims Act Used Against Ambulance Fraud?

The False Claims Act (FCA) is a piece of legislation with more than 100 years of history. It was originally passed by Lincoln during the Civil War to prevent fraud against the U.S. Army. It created enhanced penalties and enforcement mechanisms for fraud against the government.

One of the most important of these enforcement mechanisms is the qui tam provision that was passed with the law. This provision allowed anyone with knowledge of fraud to report it and claim a portion of any funds that were recovered.

In the past, ambulance fraud has amounted to millions of dollars, and whistleblowers have been able to claim massive sums.

Fact Patterns of Abuse: Exposed by whistleblowers, the following
actions constitute some the most common ways emergency service providers are cheating taxpayers:

Free Ride Schemes, Upcoding & Falsifying Documents, Illegal Kickbacks, Providing Unnecessary Care to Inflate Reimbursements, and Billing for Unprovided Care.

Section I: Examples of Ambulance Fraud Schemes

emergency ambulance services

Public health programs lose millions of dollars to fraud every year. This fraud takes place across dozens of different services, including hospitals, hospice centers, and pharmacies.

To report a healthcare fraud claim under the False Claims Act the violation needs to be against a Federal or State Healthcare Program. Ambulance companies use a handful of recurring schemes to overbill Medicare and Medicaid:

  • Billing for services that were never provided
  • Billing for non-emergency “free rides”
  • Billing for rides staffed by personnel not licensed to perform medical services
  • Upcoding basic services as if they were advanced life support services
  • Falsifying records to inflate miles driven, time spent or destination
  • Participating in kickback arrangements for referrals
When Does Medicare Cover an Ambulance?

The whole question of ambulance fraud turns on medical necessity. Medicare pays for an ambulance only when the patient's condition at the time of the trip is such that any other form of transport would endanger their health, and the trip is to or from an approved destination. Two levels of service are reimbursed at different rates: Basic Life Support (BLS) for routine medical transport, and Advanced Life Support (ALS) for patients who need cardiac monitoring, IV medications, or other advanced interventions. A ride that did not meet the medical-necessity standard, or a BLS trip billed as ALS, is a false claim.

Medicare usually coversMedicare does NOT cover
Emergency transport when the patient's condition makes other travel unsafeRoutine trips a patient could safely make by car or wheelchair van
Non-emergency transport with a valid Physician Certification Statement showing medical necessityRides billed as medically necessary when the PCS is false or missing
Transport to the nearest appropriate facility able to treat the patientTransport to a farther or non-covered destination billed as covered
The level of service actually needed and provided (BLS or ALS)A basic (BLS) ride upcoded and billed as advanced life support (ALS)

There are many different types of ambulance fraud. You can learn more about pharmaceutical fraud here. The following examples include situations where records have been falsified in order to defraud public health programs. Many of these examples have occurred and ended in prosecutions in recent years.

 

Fraud Involving Billing for Unprovided Services
Billing for services that were never provided


Billing for services that are not provided is one type of ambulance fraud has been detected in the past.

The patient themselves may not be real. More frequently, the patient is real but services they did not receive were recorded as administered.

This type of fraud can be difficult to detect because patients cannot always account for all the services that they receive during an emergency.

They are unlikely to be sure of devices that were used or drugs that were given to them. For that reason, whistleblowers have been instrumental in proving that false records were submitted.

Fraud Involving "Free Rides"
Billing for non-emergency “free rides”


In recent years, some ambulance services have been detected offering free rides in ambulances.

These non-emergency rides ferried patients from their homes to hospitals like a taxi service.

In many cases, these rides were offered to seniors who needed to reach an appointment to receive sustained care such as dialysis or chemotherapy.

While these patients did not require medical supervision on the way to the appointments, some did consider it a reassuring perk.

However, these rides were then billed to public programs as if they were emergency rides.

Fraud Involving Non-Licensed Providers
Billing for rides staffed by personnel not licensed to perform medical services)
"The government requires attorney representation for relators to bring suit under the FCA..."


The compensation rates for ambulance rides are based on a number of different factors, including the expertise that is necessary to provide emergency care.

Only certain types of medical professionals are certified to staff an ambulance. Compensation rates are based on the assumption that all the professionals necessary are present when the patient is moved to the hospital.

However, ambulance services have failed to meet that standard in the past. Instead of staffing their ambulances with the required professionals, they hire unqualified staff and pay them less.

When ambulance services fail to hire certified professionals but invoice the government as if they did, it is considered to be a type of fraud.

Fraud Involving Upcoding for Services
Upcoding basic services as if they were advanced life support services
"Emergency service misconduct takes advantage of people when they are most vulnerable..."


Different levels of medical care may be necessary for different patients in ambulances.

The different levels of care are not billed at the same rate.

If a patient requires advanced life support services en route to the hospital (such as emergency blood transfusions or resuscitation), more significant compensation may be approved.

Upcoding basic services to make them appear to be advanced services is a type of fraud that has resulted in charges.

 

Fraud Involving Keeping False Records
Falsifying records to inflate miles driven, time spent or destination
"Blowing the whistle on ems misconduct and abuse - is a shared responsibility..."


The miles that are driven, the amount of time the trip takes and the type of destination are all factors in how much an ambulance service earns from the government for each ride.

All of these details must be accurately recorded.

Falsifying these records to increase the amount that can be billed to Medicare or Medicaid is a form of fraud that has been harshly prosecuted in recent cases.

Fraud Involving Kickbacks
Participating in kickback arrangements for referrals


Ambulance services (depending on contracts with local governments) have some discretion over where they bring patients.

Certain hospitals may be more equipped to handle high volumes of patients, while others may have special centers that are better equipped to handle certain types of emergencies.

Ambulance crews are empowered to make these decisions based on the best interest of the patient, but it is illegal for them to accept kickbacks from the hospitals where they deliver patients.

Incentives can take many forms, including cash payments.

Repetitive Scheduled Non-Emergency Transport (RSNAT) and PCS Falsification

The single biggest ambulance-fraud enforcement area is non-emergency transport, especially recurring trips to and from dialysis. Medicare covers an ambulance only when the patient's condition makes any other transport medically unsafe, and it requires a Physician Certification Statement (PCS) documenting that need. The fraud is routine: companies bill ambulance rides for patients who could safely travel by wheelchair van, and get doctors to sign PCS forms that are not true. CMS now requires prior authorization for repetitive scheduled non-emergency ambulance transport (RSNAT) in many states because the abuse was so widespread. Falsifying the PCS or the trip records is a False Claims Act violation, and a qui tam attorney can file a sealed case on behalf of anyone who has seen it firsthand.

Medicare tried to get ahead of this. In 2014 CMS launched a prior-authorization model for repetitive, scheduled non-emergency ambulance transport, first in South Carolina, New Jersey, and Pennsylvania, then expanded it nationwide. The model saved Medicare about $650 million in four years, a measure of how much waste and fraud was in the system. A federal review found that about one in five ambulance suppliers had questionable Medicare billing, and non-emergency dialysis transport was the single biggest source of it. [5] Suppliers can still bill the first three round trips without prior authorization, which is where some of the abuse continues.

The cases are real and recent. Medical Transport LLC, a Virginia ambulance company, paid $9 million to settle False Claims Act allegations that it billed Medicare for non-emergency transports that were not medically necessary. [4]

Section III: Examples of Ambulance Fraud Cases

Ambulance fraud has received a significant amount of attention from regulators in recent years.

Different schemes, some of them running for years at a time, have been detected by whistleblowers, journalists, and watchdogs.

The following are some of the most significant real-life cases in recent years.

 

 

Notable Ambulance Fraud Cases

Hart to Heart Transportation Services of Maryland

The Hart to Heart Transportation organization, a specialty care transport, ambulance, wheelchair, and paratransit service based out of Maryland, recently settled billing fraud allegations with the US government. [1]

As part of the settlement, they agreed to pay $1.25 million. They were accused of submitting false claims to Medicare to receive compensation for ambulance rides that were not medically necessary.

In addition to other violations, they were accused of sending ambulances for stable patients who simply needed transportation with wheelchair access.

Companies that provide medical transport for Medicare are obligated to use ambulances only when other transportation methods, such as a wheelchair-accessible van, are not viable.

The settlement means that Hart to Heart Transportation Services will not be required to admit liability, but they are responsible for the approved fine.

The false claims were brought to light by a former employee and whistleblower who filed the lawsuit on behalf of the government and became entitled to a portion of the settlement.

Tonieann EMS and Rosenberg EMS

Anthony Chukwudi Nwosah was the owner of Tonieann EMS and Rosenberg EMS, two emergency medical service companies that provide ambulances in Texas. Anthony was involved in more than $3 million dollars worth of false claims that were made to Medicare. He collected more than $1 million personally while participating in the fraud. [2]

The large-scale fraud involved multiple schemes including…

  • Filing ambulance claims for patients who were transported by vans
  • Instructing EMTs to make false statements about vital signs, symptoms, and mileage
  • Falsifying records to create rides that never happened and EMTs who did not work for him

Anthony pleaded guilty in 2018 and faced up to a $250,000 fine and 10 years in federal prison. There were no reports that whistleblowers were involved in the case, so the recovered money was returned directly to the government.

East Texas Medical Center Regional Healthcare System, Inc.

Seven defendants affiliated East Texas Medical Center Regional Healthcare System, Inc., East Texas Medical Center Regional Health Services, Inc. and ambulance company, Paramedics Plus agreed to pay the government more than $21 million as part of one of the largest ambulance fraud cases ever resolved. [3]

The defendants were accused of participating in a massive kickback scheme. They were accused of providing coercing municipalities into signing lucrative contracts in exchange for benefits that included large political donations.

In addition to the operators of the ambulance services, several government officials and counties were implicated.

The initial accusations were brought by a whistleblower. The US government intervened to seriously expand the scope of the investigation, leading to a significantly larger settlement that was in excess of $20 million.

The whistleblower was granted nearly $5 million for his role in bringing about the settlement.

Section IV: How to Claim Compensation for Reporting Ambulance Fraud

If you are aware of ambulance fraud as...

  • An employee of an emergency services company
  • A medical professional who patients from ambulances
  • A patient who believes your records are being falsified
  • A bookkeeper
  • A person with knowledge of a past or ongoing scheme

You may be able to file on behalf of the government and claim a reward from recovered money. The programs that provide medical care to millions rely on whistleblowers like you to have the courage to speak up.

Blowing the whistle may entitle the relator to millions of dollars in compensation when the case is concluded.

It can be difficult to determine if the behavior is, in fact, fraudulent. If you suspect misconduct, discuss it with a lawyer before you choose to act.

Whistleblower attorneys are the best way to get help in navigating a complex situation case like this.

They will be able to advise on the merits of a case, whether it is worth moving forward, and how much one may be able to claim as a whistleblower.

If you suspect misconduct or fraud, you should contact a lawyer as quickly as possible. Be prepared to review the details of the case and discuss it honestly during an initial consultation.

Effective evidence may include examples of altered records, written orders to alter records or written policies that require that untrue information be submitted to Medicare or Medicaid.

Ambulance Fraud FAQ

Q: What is ambulance fraud?

A:    Billing Medicare or Medicaid for ambulance rides that were not medically necessary, never provided, upcoded from basic to advanced life support, staffed by unqualified personnel, or padded with false mileage. Kickbacks for hospital referrals also count. Each is a False Claims Act violation.

Q: Is a non-emergency ambulance ride fraud?

A:    It can be. Medicare pays for an ambulance only when other transportation would endanger the patient. Routine rides, such as taking a stable dialysis patient to an appointment, billed as if they were medically necessary emergency transport are a common form of ambulance fraud.

Q: What is ambulance upcoding?

A:    Billing a basic life support (BLS) transport as advanced life support (ALS), which Medicare reimburses at a higher rate. Coding a ride for a level of care the patient did not need or receive is fraud.

Q: Who reports ambulance fraud and gets paid?

A:    EMTs, dispatchers, billers, and hospital staff bring most of these cases. A whistleblower recovers 15% to 30% of what the government collects. In one of the largest ambulance cases, a $21 million settlement, the whistleblower was awarded nearly $5 million.

Q: Will I be protected from retaliation?

A:    Yes. The case is filed under seal, so your employer does not learn of it while the government investigates, and the False Claims Act makes retaliation illegal, allowing a fired whistleblower to recover reinstatement, double back pay, and costs.

Talk to an Ambulance Fraud Whistleblower Attorney

EMS services across the country are a vital urgent care life line for people in need of out-of-hospital treatments and emergency health care. How ambulance companies commit fraud in order to inflate government reimbursements share a number of common fact patterns. An awareness of the schemes used by emergency transport companies to cheat government programs is key to reporting and stopping the abuse.

From billing fraud, kickback schemes, falsifying information, to providing services not required among other tactics - ambulance medicare fraud is not a victimless abuse.

It diverts funds from where they are sorely needed in the healthcare center and leads to patients not receiving the treatment they deserve when they need it most. Using the False Claims Act, whistleblowers are critical to reporting perpetrators and helping the government fight to stop it.

Call (888) 713-6653 for a free, confidential review of your potential ambulance fraud claim. You Win or It's Free.

We work with the EMTs, dispatchers, billers, and hospital staff who saw an ambulance company bill for rides it should not have.

 

 

References

 

 

 

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