01-012 Emergency Ambulance Findings of Medical Review
Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Part B emergency ambulance services billed on dates of service from January 1, 2018 through December 31, 2018. Below are the review results:
The Office of Inspector General (OIG), under Report A-09-17-03017, dated August 2018, titled “Medicare Made Improper and Potentially Improper Payments for Emergency Ambulance Transports to Destinations Other Than Hospitals or Skilled Nursing Facilities (SNFs)” noted that Medicare improperly paid $2.7 million during the first half of calendar year (CY) 2012 for emergency ambulance transports that providers indicated were to non-hospital destinations. The OIG activities focused on Medicare payments for emergency ambulance transports to destinations other than hospitals or SNFs for CYs 2014 through 2016. The objective of the report was to determine whether Medicare payments to providers for emergency ambulance transports complied with Federal requirements.
Reason for Review
In response to the OIG study, the CMS provided the SMRC a file of national provider identifiers (NPI) specifically identified by the OIG, while conducting the original study. The SMRC will perform medical record review for the specified NPIs to determine if the emergency ambulance transports were reasonable and necessary for the level of service billed in accordance with applicable statutory, regulatory, and subregulatory guidance.
Common Reasons for Denial
- Level of Service
- CMS Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.2 indicates that “payment is made according to the level of medically necessary services actually furnished.” This must be sufficiently documented in the medical records submitted for review. The documentation received did not support an emergency level of service was provided.
- Dispatch Status
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 20.1.3 relays that “Occasionally, local jurisdictions require the dispatch of an ambulance that is above the level of service that ends up being provided to the Medicare beneficiary. In this, as in most instances, Medicare pays only for the level of service provided, and then only when the service provided is medically necessary.” The documentation submitted did not support the the level of service billed.
- No Response to the Documentation Request
- CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 188.8.131.52 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
- Ambulance Modifiers
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15, Section 30 (A), “For ambulance service claims, institutional-based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates.” The documentation submitted did not support the modifiers billed on the claim.
- Beneficiary Signature
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 20.1.2 indicates that “Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare.” The documentation submitted did not support the a valid beneficiary or representative signature.
- Social Security Act (SSA) Title XVIII, Section §§1833(e). Payment of Benefits
- SSA, Title XVIII, Section §§1861(s)(7). Medical and Other Health Services; Ambulance
- SSA, Title XVIII, Sections §§1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
- SSA, Title XVIII, Sections §§1879(879(a)(1), (g)(2). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
- 42 Code of Federal Regulations (C.F.F), §410.40(a-f). Coverage of Ambulance Services
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 10. Ambulance Service
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15. Ambulance
- Local Coverage Determination (LCD) L35162. Ambulance Services. Effective 10/01/2015
- LCD L34302. Transportation Services: Ambulance. Effective 10/01/2015
- LCD L34549. Ambulance Services. Effective 10/01/2015
- Local Coverage Article (LCA) A52883. Ambulance Billing When Patient Refuses Transport. Effective 10/01/2015
- LCA A54574: Ambulance Services (Ground Ambulance). Effective 10/01/2015
- LCA A55096: Reminder Regarding Ambulance Transports- Dual Diagnoses (Provider Bulletin). Effective 6/9/2016
- LCA A52588: Billing for Ground Ambulance Services When the Beneficiary is Pronounced Deceased. Effective 10/01/2015
Last Updated Jan 28, 2022