EMS Compliance Guidance Alert

Inspector General Delivers Final Compliance Guidance for Ambulance Suppliers
March 25, 2003

Ambulance suppliers now have a new weapon in their arsenal to fight waste, abuse and fraud in connection with federal government health care programs.

Blanco Wilczynski, P.C. has learned that the federal government on Monday issued a final compliance program guidance to assist ambulance suppliers in the ongoing process of establishing compliance programs. The program, issued by the Office of Inspector General for the Department of Health and Human Services, will also be a useful resource for any ambulance suppliers that have existing compliance programs.

The release of the guidance is a positive step in the ongoing battle to combat fraud, said Inspector General Janet Rehnquist. "This guidance provides a blueprint for ambulance suppliers to design a compliance program that best fits the needs of their own particular organization. This is not a one size fits all document," Rehnquist said.

The program guidance was developed with an eye toward the fact that there exists great variance among suppliers in the ambulance industry. Thus, factors such as the size of the company, whether for-profit or not-for-profit, affiliated with a hospital or independent, and run by municipalities/counties or commercially owned will determine the applicability of the information provided in the program guidance.

The program focuses on risk areas relevant to the ambulance industry and recommends ways ambulance suppliers can address these and other compliance risks. That is because the Inspector General acknowledges in the program guidance that the ambulance industry is already familiar with compliance fundamentals, such as the role of the compliance officer.

To that end, the guidance urges suppliers to follow the Medicare program's criteria for the coverage of scheduled and unscheduled non-emergency transports, including the requirement that suppliers obtain physician certification statements (PCS) to verify that the transport was medically necessary. Such a strategy will help you address the potential for abuse in the area of non-emergency transports, in particular.

Highlights include an advisory that the PCS should provide adequate information for each individual beneficiary and be signed by the appropriate physician or other health care professional. Moreover, the guidance reviews some of the fraudulent and abusive practices that have occurred in prior years in the ambulance industry. Such areas include:

• Improper transport of individuals with other acceptable means of transportation;
• Medically unnecessary trips;
• Trips claimed but not rendered;
• Misrepresentation of the transport destination to make it appear as if the transport was covered by a federal health care program;
• False documentation;
• Billing for each patient transported in a group as if he/she were transported separately
• Upcoding from basic life support to advanced life support services; and
• Payment of kickbacks

Indeed, this is the tenth compliance program guidance document released by the OIG. Other compliance guidance documents cover sectors ranging from clinical laboratories, hospitals, home health agencies, third-party medical billing companies, durable medical equipment suppliers, hospices, Medicare+Choice Organizations, nursing facilities, and individuals and small group physician practices.

As always, Blanco Wilczynski, P.C. is here to provide counsel and assistance as you confront these and other issues in the now rapidly changing health care industry. If you would like to discuss how this program guidance can work for you, or seek advice in the areas of HIPAA compliance, Medicare funding, fraud, or any of the myriad of health care issues arising these days, contact Kevin E. Sralla, Esq., of Blanco Wilczynski, P.C.'s Healthcare Practice Group. He can be reached at 248-519-9000.