Tuesday, January 24, 2006

OIG Report on Medicare Payments for Ambulance Transports

The Office of Inspector General (OIG) released the following report on Medicare Payments for Ambulance Transports(OEI-05-02-00590). The OIG evaluated whether ambulance transports met Medicare’s coverage and level of service criteria and to evaluate safeguards in place to identify improper payments.

Access to health care in West Virginia is a major issue because of the rural nature of the state. We also face of the hurdle of having a very poor and elderly population who often don't have access to transportation. I'd be interested to see the percentage in West Virginia that do not meet the Medicare program requirements. I suspect the number might be even higher.

I certainly recognize the need to hault purely fraudelent activities involving unnecessary transportation of patients by emergency vehicles but there also have to be initiatives to assist the poor and elderly in getting to and from providers, dialysis treatment and other nonemergency care.

Following is a summary of the findings and recommendations by the OIG:

Medicare covers and pays for emergency and nonemergency ambulance transports when a beneficiary's medical condition, at the time of transport, is such that other means of transportation, such as taxi, private car, wheelchair van, or other type of vehicle, would jeopardize the beneficiary's health. We found that 25 percent of ambulance transports in calendar year 2002 did not meet Medicare program requirements, resulting in an estimated $402 million in improper payments. Despite previous OIG inspections indicating that transports for dialysis treatment and other nonemergency transports were particularly vulnerable to abuse, the error rates for these kinds of transports continue to be high. We found that 27 percent of dialysis transports and 20 percent of other nonemergency transports did not meet Medicare's coverage requirements. In contrast, only seven percent of emergency transports were found not to meet requirements. We also determined that contractor safeguards are insufficient to identify and prevent improper payments for ambulance transports. Contractors use few ambulance-specific prepayment edits consistently and fewer than half of the contractors conducted postpayment reviews of ambulance claims. When reviews are conducted, there is no uniform requirement regarding the documentation that should be reviewed. While almost two-thirds of the coverage errors involved a transport from a dialysis facility, hospital, or other third-party provider, these providers received little education regarding Medicare's coverage requirements for ambulance transports.

OIG recommends that CMS implement program integrity activities designed to reduce improper payments for ambulance transports at greatest risk for error, such as dialysis and other nonemergency transports. Included in these activities should be: (1) instructing all Medicare contractors to implement prepayment edits that target dialysis and nonemergency ambulance transport claims; (2) instructing all Medicare contractors, when conducting postpayment medical reviews, to obtain documentation from ambulance suppliers and third-party providers to determine that ambulance transports meet program requirements; and (3) directing all Medicare contractors to educate third-party providers responsible for initiating ambulance transports. Once this is accomplished, CMS may want to examine whether third-party providers continue to order noncovered ambulance transports. If third-party providers are still problematic, CMS may want to examine other administrative actions that can be taken and any potentially fraudulent or abusive providers should be referred to OIG.

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