Medicare fraud- potentially fraudulent billing practices, wh

[Ace844]

Medicare fraud- potentially fraudulent billing practices, what do you do?

Hello Everyone,

A good friend of mine is involved with a HHS (federal level), medicare fraud investigation against an Ambulance co. It got me to wondering about the following.

Have any of you ever reported the company/employer which you work for for this?

What was your/their experience like?

Do you know anyone who has?

Any thoughts, opinions, or advice for my friend on this?

It seems pretty common place and I've seen it alot over the years, have you also noticed this 'blase'' attitude from other healthcare providers, as well as your employer??

I hear alot from nurses...just take them home, we don't care...

Comments, advice, suggestions, etc....??

ACE844

"Thank you. before I begin, I'd like everyone to notice that my report is in

a professional, clear plastic binder...When a report looks this good, you know

it'll get an A. That's a tip kids. Write it down. -- Calvin"

[Ace844]

No one has any comments....Guess this never happens.... :roll: :shock:

ACE844

[whit72]

Confused?

He came forward against a ambulance provider?

Medicare came to him stating his run forms were fraudulant?

[Ace844]

Confused?

He came forward against a ambulance provider?

Medicare came to him stating his run forms were fraudulant?

he came forward against a ambulance co who was commiting fraud. he didnt hear from them for like 3 yrs..and now outta the blue, gets a call.....

[whit72]

I understand.

ACE wrote:

I hear alot from nurses...just take them home, we don't care...

That is definitely the attitude. I believe now you must have what they call a medicare necessity on every transfer. Stating exactly why the pt needs ambulance transportation. Does that curb fraud? I doubt it. Usually the hospitals just exacerbate the history of the pt. so they are allowed to receive transportation.

I give your friend a lot of credit.

I am sure if medicare is investigating the ambulance provider for fraud. They were probably cementing their case as far as evidence and witness's. Causing the delay. I believe these cases are probably slam dunks, you wouldn't have to look to hard to uncover fraud in some of these places. Hopefully he wont even have to testify. They maybe just getting their ducks in order in case of trial, contacting possible witness's an such.

I would think they have some pretty strong evidence against this provider. I cant see a federal agency basing a whole investigation on one persons testimony. He probably precipitated the investigation, but I'm sure they have loads of evidence to go along with it now.

Good luck

let us know how he makes out.

[Ridryder 911]

As well and good as that friend's intention was I bet he just ended his EMS career. Even though I totally agree with his principles and what he did. He will be branded (yes, his name will get out) as a trouble maker among EMS administrators and once he is terminated (of curse non-related incidence) finding another EMT position will be hard.

Yes, I agree there is a lot of abuse. Especially, like the scenario described with returns or dismissals. I know we eat a lot of the bills because they do not "meet" criteria, but my administrator feels it is better to eat them than piss of the medical community. We are now placing our wheel chair van unit on more calls, and using a local van more. Actually, informing the patient "this may not be covered, by your insurance and medicare which you are legally bound to do, has deferred many.

Good luck to your friend,

R/r 911

[whit72]

I am not sure if once the medical neccesity form is filled out by the nurse or MD, does that transfer the obligation to the hospital rather then the ambulance provider. My meaning: is the burden of proof now on the hospital to explain why the pt needed ambulance transportation or would it still fall back to the ambulance provider?

[Ridryder 911]

Actually both.. if the service billed and the PCR describes a non-valid reason. Just because the physician signs a form does not excuse the EMS. The physician can be held liable for signing the document, or falsifying the need, which I have seen is a simple warning, until there is a pattern set. But when there is charges billed it is a total different thing.

That is why coding and billing reviewers are essential in EMS. They are supposed to weed out or be able to enforce proper documentation to "justify" or an EMS will have to eat the bill.

Our policy, is to assess the patient, inform the physician or ask the need for required stretcher. See if there can be an alternative transportation. Then, if all else fails inform the patient/family they might be responsible for a $800.00 bill, and have them sign insurance/medicare acknowledgement form that have been informed. That is all one can do...

R/r 911

[whit72]

Interesting thanks for the information. I wasnt sure how that would be handled.

[Ace844]

I understand.

ACE wrote:

I hear alot from nurses...just take them home, we don't care...

That is definitely the attitude. I believe now you must have what they call a medicare necessity on every transfer.Stating exactly why the pt needs ambulance transportation.

This has been the practice for many years, and this individual tells me that the big issues started while he was 'truthfully' documenting his assessment findings, and 'not filling out the med necessities'. IIRC, the old 'medicare' forms had a statement on the which essentially said the 'entire form is only to be filled out and signed by a 'RN, MD, PA, NP or dischrage planner'. The new forms have been changed to exclude this statement.

This individual refused to fill them out and or 'change his standard of documentation'. The company didn't regard this as acceptable 'believeing' that this individual should judt 'shut up and do what he's told, like everyone else'. Furthermore he became aware that they were 'changing the mileage, and other things on providers run forms'. As well that some of the mednecs were blank but 'signed' (meaning the nurse wouldn't fill it out or take the time to do so for any number of reasons) which he turned in with his paperwork; and believes that some of these were being 'used' for other calls as necessary.

This person decided that their morals wouldn't allow him to deal with this and that he'd try to do the right thing and report it... Personally in my own experience, much like 'Rid's' and I'm sure many others who haven't posted their experiences here. It seems that this is a very common and accpeted practice, but got me to thinking about both the moralities of the situation, and what ones 'liability-responsability' as an EMS provider is??? Also, the groups thoughts and opinions on this issue....

Does that curb fraud? I doubt it. Usually the hospitals just exacerbate the history of the pt. so they are allowed to receive transportation.

Also, as I'm sure you've seen as well, they just leave the form 'blank' and or sign it. Some of the RN's and facilities as well as ER's I have even had them say to me; "They didn't have cab fare....It's late and nite time....I know, but I'm sure you can find away to make it so they don't pay, let the govt pay....Well they came in by Ambulance so they go home by Ambulance...."!!!! I guess I was kind of wondering as well what your experiences were as a group and how you 'did the right thing', or even if you ever tried to address this issue in your service...

I give your friend a lot of credit.

Me too, if it ever comes out they did this...as "rid," stated; they will probably be 'Black-Balled'... All for trying to do the right thing.

I am sure if medicare is investigating the ambulance provider for fraud. They were probably cementing their case as far as evidence and witness's. Causing the delay. I believe these cases are probably slam dunks, you wouldn't have to look to hard to uncover fraud in some of these places. Hopefully he wont even have to testify. They maybe just getting their ducks in order in case of trial, contacting possible witness's an such.

No idea what the deal is thus far on the case, guess time will tell......

I would think they have some pretty strong evidence against this provider. I cant see a federal agency basing a whole investigation on one persons testimony. He probably precipitated the investigation, but I'm sure they have loads of evidence to go along with it now. Good luck, let us know how he makes out.

It would see to me that in my anecdotal experience doing this that it wouldn't be 'HARD' to find evidence of this via most EMS agencies...or that due to the sheer number of years and volume of calls that this would quickly add up to big $$$'s.... What do you all think?

Out here,

ACE844