Common Examples of Ambulance and Ambulette Fraud
Ambulance and ambulette fraud involves intentionally deceiving government healthcare programs such as Medicare and Medicaid for financial gain by improperly billing for transportation services.
Federal authorities, including the Department of Justice (DOJ) and the Office of Inspector General (OIG), actively investigate and prosecute these schemes, viewing them as a significant drain on public resources and a threat to the integrity of the healthcare system.
An investigation can expose companies and individuals to serious criminal charges.
In straightforward terms, ambulance and ambulette fraud generally involves billing for services that never occurred (phantom trips) or upcoding-charging for more complex care than provided, like using a stretcher when a chair would suffice.
It also involves transporting ineligible patients (such as non-emergency cases, deceased individuals, or hospitalized patients), falsifying records, paying kickbacks for referrals, and engaging in double-billing or billing for unnecessary services to illegally boost profits from Medicare/Medicaid.
Key Takeaways
- The U.S. Department of Justice (DOJ) has taken on several cases accusing ambulance and ambulette company owners of Medicare fraud.
- The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) has also investigated similar cases.
- With over ten years of enforcement experience and tens of billions lost annually to Medicare fraud, it is evident that violations of the False Claims Act by healthcare providers, including ambulance and ambulette services, remain a top priority for the DOJ and HHS-OIG.
- Owners of ambulance and ambulette companies must prioritize compliance. Given the potential civil and criminal penalties, they need to take all necessary steps to safeguard their companies and themselves.
- Like other healthcare organizations, ambulance and ambulette companies must adhere to various compliance requirements under the Medicare and Medicaid programs.
- Effectively managing Medicare billing compliance demands a dedicated, systematic approach initiated by strong leadership that maintains a commitment to necessary actions.
- Medicaid investigations may take months or even years, depending on the case's complexity, the amount of evidence, and whether they are conducted at the state or federal level.
Let's take a look at a few common examples that frequently lead to federal investigations and criminal prosecution.
Billing for Non-Medically Necessary Transports
This is one of the most widespread forms of ambulance fraud. It occurs when a provider bills for emergency or stretcher transport for a patient who did not medically require that level of service.
For example, a patient may have been able to walk, sit upright, or travel safely and more cost-effectively by other means, such as a wheelchair van or a private vehicle.
When a company submits claims for ambulance transport in these situations, it may face prosecution under federal statutes like 18 U.S.C. § 1347 (Health Care Fraud) and 18 U.S.C. § 1035 (False Statements in Health Care Matters).
Upcoding
Upcoding involves submitting claims for a higher level of service than what was actually provided. For instance, a company might bill for Advanced Life Support (ALS) or Basic Life Support (BLS) services when the patient only received routine, non-emergency transport.
Claiming an emergency response for a pre-scheduled trip or billing for medical interventions that were not performed are common examples. Such actions can be prosecuted under statutes such as 18 U.S.C. § 1347 (Health Care Fraud) and 31 U.S.C. §§ 3729-3733 (the False Claims Act).
Billing for "Phantom Runs"
This type of fraud involves billing for services that were never rendered. "Phantom runs" occur when an ambulance company submits a claim for a trip that never happened.
This can also include billing for multiple transports for the same patient on the same day when only one occurred.
Federal prosecutors may use 18 U.S.C. § 1347 (Health Care Fraud) to charge these offenses. If a patient's identity was used without authorization to create the fraudulent claim, charges under 18 U.S.C. § 1028A (Aggravated Identity Theft) may also apply.
Kickbacks for Patient Referrals
The federal Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) makes it illegal to offer, pay, solicit, or receive anything of value to induce or reward patient referrals for services paid for by federal healthcare programs.
In the context of ambulance services, this could involve a transport company paying a hospital, nursing home, or dialysis center in exchange for patient referrals.
Both the party paying the kickback and the party receiving it can be criminally liable under the Anti-Kickback Statute and other laws, such as 18 U.S.C. § 371 (Conspiracy).
Transporting Ineligible Patients to Dialysis
A major focus of federal enforcement involves the transport of dialysis patients. While some dialysis patients legitimately require ambulance transport, many do not.
A common scheme involves routinely transporting patients who can walk or sit in a wheelchair and billing Medicare as if they required a stretcher.
Due to the high volume of these transports, this practice can result in substantial fraudulent billing. Charges are often brought under 18 U.S.C. § 1347 (Health Care Fraud) and 18 U.S.C. § 1035 (False Statements).
Falsifying Run Sheets or Medical Necessity Forms
To justify billing for non-medically necessary transports, company employees or managers may falsify patient care reports (run sheets) or Physician Certification Statement (PCS) forms.
This can involve exaggerating a patient's condition, fabricating symptoms, or falsely documenting that a patient was "bed-confined" or "unable to ambulate."
Such actions can lead to prosecution under 18 U.S.C. § § 1001 (False Statements) and 1519 (Falsification of Records in Federal Investigations), in addition to healthcare fraud charges.
Possible Penalties and Defense Strategies
A conviction for ambulance fraud can result in severe penalties. These may include substantial fines, restitution to the government, and imprisonment, with sentences for healthcare fraud potentially reaching 10 years per offense.
Furthermore, individuals and companies can face exclusion from participating in federal healthcare programs, effectively ending their careers and businesses in the industry.
When facing federal allegations, a federal criminal defense attorney can employ various strategies to protect your rights and build a strong defense. Here's what they may do:
- Challenge intent: Argue that any billing errors were unintentional mistakes, not deliberate fraud.
- Scrutinize evidence: Question the accuracy of data analysis or the credibility of whistleblowers.
- Use procedural defenses: Challenge the legality of search warrants or investigative methods to suppress evidence.
These strategies aim to weaken the prosecution's case and secure the best possible outcome for you. Contact Eisner Gorin LLP for a case review.