A lack of understanding of EMS by Medicare (Centers for Medicare and Medicaid Services) encourages fraud.
When patient care is determined by the fraud investigators, is it patient care or does it transform into what the investigators focus on?
Citing a “significant potential for fraud, waste, and abuse,” federal Medicare officials put a moratorium on the enrollment of new ambulance operators in Philadelphia and six surrounding counties.
In other words – Ambulance companies have a lot of potential for fraud. Our rules do not prevent fraud. We can’t even keep track of the ambulances companies that defraud us. So, we will stick with the frauds we know, rather than to potential frauds we do not yet know.
In EMS, we have competition on everything except quality.
How does an insurance company (Medicare) assess quality of care? By assessing surrogate endpoints that it can track.
At issue is the medical necessity for nonemergency ambulance transportation. Medicare is supposed to pay for an ambulance only if a cheaper form of transportation would endanger the patient’s health.
How do they determine what would endanger the patient’s health?
Getting a doctor, or the doctor’s representative, to check off some boxes on a standard form, because we cannot expect the insurance computer to understand patient care. We can have the computer search for words that indicate that the patient is too healthy for ambulance transport.
Sitting or lying are a couple of words the computer programmers think indicate robust health.
If my acute CHF (Congestive Heart Failure) patient is sitting upright, which is actually an indication of good patient care, the word sitting is an indicator of being too healthy for ambulance transport.
If I fraudulently transport a completely healthy person by ambulance, but check off the bed-confined box on the form, and get a signature, Medicare does not appear likely to recognize the fraud until after I have gone out of business.
Rather than encouraging people to mindlessly check off boxes to justify what should be clearly and accurately documented, the rules discourage good patient care.
When more attention is paid to jumping through hoops than to actual patient care, the rules are making things worse.
Most recently, in January, an emergency-medical technician who worked for Brotherly Love Ambulance Inc., of Philadelphia, pleaded guilty to signing up patients for relatively expensive ambulance rides when he knew they could walk or use cheaper transportation.
In addition, the EMT gave riders cash to entice them to keep using Brotherly Love, which fraudulently collected more than $2 million from Medicare from July 2010 through October 2011, the U.S. attorney in Philadelphia said.
This was going on for over a year and Medicare was blissfully ignorant, but they will solve the problem by preventing new companies from entering the market.
However, only 10 percent to 20 percent of dialysis patients actually need ambulance transportation, according to government and industry estimates. Medical necessity is determined on the “honor system,” said Herman’s partner, Joseph Zupnik.
When insurance companies extrapolate appropriate care for chronic treatment patients, such as dialysis, to patients with acute medical conditions, they make fools of themselves.
“The ambulance business, I think, because of what happened to my dad, became extremely focused on compliance, because we had to be,” Strine said.
We need to get the ambulance companies to focus on good patient care, not extremely focused on compliance with insurance rules.
With the exclusion of new ambulance companies, is any fraud being prevented?
Frustrated by a large number of small, fraudulent competitors, two of the largest Philadelphia-area ambulance operators recently joined forces.
Large companies are merging because small corruption is being addressed?
Any fraud will be among the already existing ambulance companies, but will it be concentrated in the smaller companies or the larger companies?
Are the larger companies benefiting from the economies of scale that FedEx and UPS benefit from?
Are patients more than just packages to be delivered, with the appropriate boxes checked off?
The focus of the insurance companies appears to be on the package delivery model.
If our model is the package delivery model, your patients would be better off with some else.