There are many types of insurance and healthcare frauds. A person with insurance could commit this crime by filing a false claim. If the said person is pretending to be injured, they are breaking the law that will lead to prison. Not only that, even hospitals and pharmacies can make the mistake of trying to fool the government. One of the most prevalent frauds taking $60 billion in tax dollars away is ambulance billing fraud. Ambulance companies tend to make almost the same scams that put them under strict observation.
The way it works is that Medicaid and Medicare reimburse ambulance companies conditionally. If the use of the ambulance is necessary, the company has the right to a claim. Reimbursements vary in amounts and will depend on the type of medical assistance the patient receives and who is caring for the patient. However, both programs only cover the trip ambulances make if there are no other means for patients to be brought to the hospital, hospice, or any other medical facilities. That means there is a limit to the use of an ambulance wherein the company can cash out. Any untruthful claims are punishable by the False Claims Act.
What Are The Different Types Of Ambulance Fraud?
Here are some typical ambulance company scams according to the Medicaid Fraud Hotline, a page run by the Coalition of State Healthcare Services dedicated to stopping Ambulance or EMS fraud. The following also mentions to what extent Medicare would pay for the provision of services by ambulance companies.
- Falsely Billing For Unprovided Services
This has to do with ambulance companies that are asking for reimbursements for trips that did not happen. It also includes falsely claiming for first aid procedures that patients did not receive. These procedures, as well as use of medical supplies and medications, typically happen during emergency cases, such as when an individual sustains injuries. It is during these uneventful timelines that some ambulance companies come up with such a type of scam.
- Falsification Of Reports
An ambulance company may file a report by submitting documents to be able to receive claims. However, the documentation may not be entirely correct. Personnel in charge of these reports may have orders to tweak or change essential data. Pieces of information, such as the mileage used up, origin and destination of the trip, fuel consumption, and more, may fall under falsification to claim a more substantial sum from Medicaid. Some companies may even create a non-existing trip if they can think they could get away with it.
Medicare pays only for trips made to the hospital, treatment and assisted-living facilities, and dialysis centers. They also pay to have the patient moved to his or her own home or rehabilitation centers. Unauthorized use of an ambulance, such as for personal but falsified under proper use, is against the law.
- Billing For Unnecessary Medical Services
Patients are not always in need of an ambulance. They can make a trip to the hospital or any nearby medical facility. A family member may call for an ambulance for convenience, but these trips are not for free. The patient has the option of taking public transportation instead, such as taxis or personal vehicles, like cars, vans, and wheelchairs. Medicaid does not cover such possibilities. Typically, when a hospital needs an empty hospital bed, doctors will sign a certificate to take patients back home. During this event, the use of an ambulance is not necessarily required.
In the case of Medicare, they will only pay for non-emergency situations if there is an absolute need for an ambulance to transport the patient. A doctor should be able to provide a written order first as proof. Medicare acknowledges cases when any other vehicle could endanger the health of the patient. Patients with renal disorders must be transported to a dialysis center by an ambulance.
- Operating Against Regulations
An ambulance is not a regular vehicle that one may use without permission. Aside from a driver’s license, they must get authorization first. One must obtain a Physician Certification Statement prior to the transportation of patients. Otherwise, billing is not allowed. Filing claims is also prohibited when an emergency medical technician is using the ambulance and not a certified paramedic who must provide the service. Paramedics are those with proper training to give shots and administer IV therapy. An EMT’s scope is limited and is, therefore, not allowed to perform any medical treatment without appropriate certification.
- Overcharging For Services
Ambulance companies also make the mistake of charging too much for the services they give. It happens when they bill for full service when a patient does not necessarily need an ambulance. The rule includes both the use of the patients who are well enough to use their cars, ride buses or taxis, or be in wheelchairs. Medicare won’t also pay if the patient can walk. The use of life support inside the ambulance also varies. If a paramedic provides essential life support, the company cannot charge for advanced life support.
- Kickback Violations In Any Form
Any agreement between ambulance companies and hospitals or medical facilities is a kickback violation through the following:
- Exchanging money, discounts, or any type of gift to the hospital/facility in return for referring patients to the ambulance company.
- You are disregarding the best interest of the patient to receive favors or bribes in various forms.
- A hospital or other assisted facility provides payment of any form to the ambulance company to get patients instead of transportation to the nearest or the most appropriate place of care.
- The Practice Of Billing Inaccuracy Or Upcoding
As far as cheating goes, some companies will administer unnecessary advanced services to elevate the cost of reimbursements. Some will apply treatments that a patient doesn’t need. Because of this, simple transportation becomes a situation where they give advanced life support. The company then sends an unexpectedly higher bill to the patients.
What Started Such Fraudulent Deeds?
Individuals who pay for health insurance may or may not know, but private insurance providers and ambulance companies could not agree on the price for the service provided. The result of this is that a patient unknowingly agrees to the charges that did not undergo negotiation. An ambulance company commits these scams, leaving patients in the open to paying more than they should. The crackdown on such companies continues, but there is still the problem of respawning companies under a different name. For example, an ambulance company may shut down, but a close relative of the owner may start their own company and may commit the same fraud.
Tips To Prevent Ambulance Fraud
- Health insurance holders must have an understanding of the type of coverage they are paying. The easiest way to do this is to ask questions and speak only to authorized insurance agents who have the knowledge and can explain things in layman terms. Understand that you have the right to know every corner and crevice of the insurance package you want and need.
- Check your billing regularly to ensure that you are paying for only what you need. Stay vigilant and cautious whenever you are about to make a payment.
- Never make deals with any hospital or ambulance staff with talks of swapping favors. Most of the time, this can only lead to actions against you. You may also report such individuals to your insurance company or seek help from the proper authorities. The best way to avoid scams is never to involve yourself with strangers you cannot trust.
- If your insurance provider recommended a specific ambulance company, it is within your rights to inquire about the reputation of the latter. Don’t hesitate to research and ask for a second and third opinion on the company. When you are dealing with other parties outside of your insurance company, it is a must to find out more about them as well to protect yourself.
- Know the ins and out of the system. Knowing your health insurance should be coupled with knowing what you can do if you suspect overbilling from the ambulance company. You may turn to your insurance company and review your insurance package. You can ask for help as well to confirm any suspicions and report to either Medicare or Medicaid.
- Ask for legal advice from your lawyer so you are aware of the twists and turns of the law. They will offer the best counsel who will represent you when things take a wrong turn. They know best what to do in various situations.
Everyone has the right to health insurance, and it is best for you to know your rights and how much you’re only supposed to pay. Ambulance fraud is gaining attention, and companies are shutting down due to continuous complaints and reports. Ignoring your suspicions could lead to your downfall. Knowledge is your most powerful tool when it comes to dealing with such companies that could be scamming you and other clients. Do your diligence and stay informed on any news and updates regarding your insurance.