Preventing Fraud-"Medical Necessity"

[FirstResponder]

For those involved in non-emergent/inter-facility transfers, does anyone else feel as though there is more to our job than simply receiving a signature and packaging a patient? Some companies still require RN's (sometimes a doctor or NP) to provide a written medical necessity for transport before providing a signature. There are some options to choose from, most of which are outdated, that allow a nurse to check off a box. If not, there is a space at the bottom of the list of options where the RN can provide a written comment as to why the patient requires an ambulance as opposed to any other means of transportation. In many instances, the nurses aren't responsible for booking transportation for their patients. It's usually the receptionist or the case manager, oddly enough. Understandably, this leads to a tough situation for everyone. If a patient is ambulatory and is not on oxygen, for one example, and transportation by ambulance is not medically necessary from a legal standpoint, this is a problem...If they qualify for chair car transportation, simply saying "chair cars usually aren't available when we call" still doesn't change the fact that the patient does not require an ambulance for transport. Hospital staff lying on the medical necessity form should be cause for concern to any EMT. They should, under normal circumstances, contact a supervisor at the very least.

The problem has nothing to do with "not wanting to do a call." It has to do with there being no legal medical necessity for ambulance transport on this particular call. That's considered fraud...and it does nothing good for the patient and their family. Billing them for an ambulance ride that they didn't need, and weren't even aware that they wouldn't be covered for it, is WRONG. From a business perspective, it unfortunately makes sense why management and higher-ups on both sides get angry when a provider "causes a fuss" or "delays the process," because they could very easily except the untruthful comment provided by the RN and be on their merry way with that money-making IFT. Way too much pressure is put on EMT's and hospital personnel responsible for the transfer of care process. The hospital's job is to get the patient out because "we need the open bed." Delaying this process to make a phone call to management not only makes hospital staff unhappy, it makes management at the ambulance company unhappy because now the staff at their contracted facility is unhappy! Wow, what a mess. Nevertheless, doing the right thing should be to prevent fraud when you see the potential for it to happen. It happens all the time. There are numerous articles, including EMS websites, that specifically spell out the responsibilities of EMT's in these situations. We have more responsibility than we think. It's easy to avoid the head ache and just accept whatever the staff writes (better yet...illegally tell them what to write on the medical necessity form) but it's also ILLEGAL. Is anyone else finding themselves in these situations where ambulances are being booked for absolutely no medically necessary reason whatsoever and they are now in the position of having to contact a supervisor, or explain to hospital staff that lying is not okay, which ironically ends up pissing everybody off? Besides the fact that it's unfair to your patient, who doesn't know how this process works, it's also taking an ambulance off the road for 20-40 minutes while someone who might actually need an ambulance is now being affected by this medically unnecessary use of resources. Lastly, it's your EMT license number that will be on that PCR form when you eventually sign off on the run which began with a fraudulent, untruthful medical necessity that was provided. How do we stop such a simple and preventable issue in the first place? Have dispatchers obtain medical necessity over the phone before BOOKING the call? Have someone familiar with the patient be the one who is responsible for booking the proper transportation? Provide hospitals and facilities with a list of appropriate medical necessities that would be acceptable (according to the law)? It's time to change the culture...and it really won't be difficult to do.

 

[Akulahawk]

Certain insurance providers will accept an RN, PA, NP, or Physician's signature for the purpose of certifying medical necessity. Some will only accept a Physician's signature. If the insurance company does not require a medical necessity form, then they'll likely be using your patient care report to determine this on their own. Private pay patients do NOT have this limitation. Transfers from one medical facility to another, via taxi/Uber/Lyft or even POV is likely not medically appropriate either.

If your patient, who looks perfectly OK, needs to be evaluated at another facility because the sending facility cannot provide the appropriate evaluation, then the sending facility cannot transfer that patient via non-medical transportation.

Also, something to consider, if your patient is found to be appropriate for a chair car transport and all that's available is an ambulance, the ambulance can still take the patient, but the company cannot bill it for anything other than a chair car transport and that transport is considered to be at the same level of medical supervision.

 

[johnrsemt]

Used to have this problem when I worked IFT; and your right it is a pain: and it can be fraud if you aren't careful; and not just to the company it can come back on the crew.
We had a billing manager that told me to re write a run report to make it sound like the pt needed to be transported via ambulance, not WC van. So I did, along with the notation in the narrative that I was being forced to do so by the billing manager not the company management. She didn't catch that note when she submitted it. Management fired her; she got the fine from Medicare. And the company changed things after that.


We tried hard to get management to put a Wheel Chair van and driver on night shift and weekends; and pay them a shift differential to make it worth their time to be on the shift. It would have paid off; and freed BLS trucks from doing WC runs all night. But they never did it.
We had to WC runs; and we documented them as such both on the Medical necessity form and on the run report (Pt walked to the truck, or pt. walked to the cot, sat on it, and put on her own seatbelts). They could only bill them as WC runs. Fun using a BLS ambulance and crew for a $35 transport, with $5 a mile charge.

We (my partner and I) did 17 WC transports from 1 hospital 1 night; dispatch hated it, ALS crew hated us; management loved us (even though they didn't make that much money from that night) because that hospital called us a lot more after that.

 

[Kevinf]

The deeper legal side of being a medic or EMT seems to be very much glossed over in most programs I've heard of, leaving new providers woefully under-prepared to deal with shady employers. We are under-educated, and not just clinically.

Document accurately and inform the patient/surrogate that their transport may not necessarily be covered and let them decide if they want the ride or not. You've done your due diligence at that point.

 

[FirstResponder]

Used to have this problem when I worked IFT; and your right it is a pain: and it can be fraud if you aren't careful; and not just to the company it can come back on the crew.
We had a billing manager that told me to re write a run report to make it sound like the pt needed to be transported via ambulance, not WC van. So I did, along with the notation in the narrative that I was being forced to do so by the billing manager not the company management. She didn't catch that note when she submitted it. Management fired her; she got the fine from Medicare. And the company changed things after that.


We tried hard to get management to put a Wheel Chair van and driver on night shift and weekends; and pay them a shift differential to make it worth their time to be on the shift. It would have paid off; and freed BLS trucks from doing WC runs all night. But they never did it.
We had to WC runs; and we documented them as such both on the Medical necessity form and on the run report (Pt walked to the truck, or pt. walked to the cot, sat on it, and put on her own seatbelts). They could only bill them as WC runs. Fun using a BLS ambulance and crew for a $35 transport, with $5 a mile charge.

We (my partner and I) did 17 WC transports from 1 hospital 1 night; dispatch hated it, ALS crew hated us; management loved us (even though they didn't make that much money from that night) because that hospital called us a lot more after that.

I've heard that suggestion countless times before. The idea of putting a WC van & driver on night shifts as well as weekends, particularly at times when ambulance staffing is a bit short. Why this hasn't been implemented by most ambulance companies is beyond me...unless they're willfully attempting to weasel their way into making any transfer they can appear to be medically necessary or BLS in nature.
"It makes sense if you don't think about it."

 

[hometownmedic5]

There exists only one possible solution to this problem, and that is to make individual providers responsible for the fraud. If the doctor, the nurse, and the EMTs were each individually assessed a fine for having lied or been complicit in the fraud, this problem would end overnight. Of course, this would require a new, very large, very expensive regulatory agency(or expansion of a current agency) to oversee this process.

Until such time as we as individuals have a vested interest in preventing this type of fraud, no progress can be made. You will never convince a private ambulance company to bill straight up. The hospital doesnt care because they arent directly culpable. The nurses don’t care because theyre just doing what the doctor said, or what they erroneously believe to be true. The ambulance staff cares, but even if it isnt true, the assumption is that we just dont want to work(and, by the way, if we only took people by ambulance in medically necessary circumstances, about half of us would be out of work, so keep that in mind).

If a system were in place whereby anybody who plays along with the fraud gets to take a bite of the crap sandwich, people would stop playing along. Maybe if there was some sort of a back door reporting mechanism so an EMT could do the call(and keep their job) and then essentially report themselves after the fact to avoid consequences you could avoid punishing the person least responsible and least able to absorb a fine.

I dont know what the answer is, but this isnt by any stretch of the imagination a new problem. We’ve all been part of the problem since day one and theres no end in sight.

 

[Tigger]

This is not a new phenomenon. You are not doing anything against regulation by transporting a patient and documenting what you found. If your documentation does not show any degree of medical necessity and the patient is transported, the bill will likely not be paid by CMS (and probably not private insurance either). Which leaves your employer providing non-reimbursed services which in the long run hurts your pay.

On the flip side, I hear providers complaining about how they aren't using the right language in their report to get paid. If you are not lying by using such documentation (for instance describing how the patient was sheet transferred and transported in a supine position, thus justifying an ambulance), you are only hurting your own pay in the long run.

 

[FirstResponder]

This is not a new phenomenon. You are not doing anything against regulation by transporting a patient and documenting what you found. If your documentation does not show any degree of medical necessity and the patient is transported, the bill will likely not be paid by CMS (and probably not private insurance either). Which leaves your employer providing non-reimbursed services which in the long run hurts your pay.

On the flip side, I hear providers complaining about how they aren't using the right language in their report to get paid. If you are not lying by using such documentation (for instance describing how the patient was sheet transferred and transported in a supine position, thus justifying an ambulance), you are only hurting your own pay in the long run.

That's the overall problem we're trying to address here. "Playing along" is wrong. Suggesting to providers "they're only hurting their own pay in the long run" is exactly the mentality that won't fix this problem. If we continue taking the "that's just the way it is" approach, we're not going to accomplish anything.

 

[Tigger]

That's the overall problem we're trying to address here. "Playing along" is wrong. Suggesting to providers "they're only hurting their own pay in the long run" is exactly the mentality that won't fix this problem. If we continue taking the "that's just the way it is" approach, we're not going to accomplish anything.

That is not what I am suggesting at all. What I am saying is that frequently providers think that they are doing hinking things when they are in fact doing things that will increase their agency's reimbursements in a completely legal way. Like it or not, there are certain buzz phrases that speed reimbursement. It does not mean you are doing anything illicit by using them.

I am not suggesting anyone "play along." But there is nothing illegal about transporting something with a substandard medical necessity, it just means your agency is not going to get paid for that trip. It is up to your billing people to straighten these discrepancies up and that may include educating the crews in what makes a legit PCS and ensuring that facilities write them for patients who need them.

 

[FirstResponder]

That is not what I am suggesting at all. What I am saying is that frequently providers think that they are doing hinking things when they are in fact doing things that will increase their agency's reimbursements in a completely legal way. Like it or not, there are certain buzz phrases that speed reimbursement. It does not mean you are doing anything illicit by using them.

I am not suggesting anyone "play along." But there is nothing illegal about transporting something with a substandard medical necessity, it just means your agency is not going to get paid for that trip. It is up to your billing people to straighten these discrepancies up and that may include educating the crews in what makes a legit PCS and ensuring that facilities write them for patients who need them.

I see what you're saying now. It's a good point- many providers use certain "buzz phrases" simply because they were taught to do that. Or maybe they've been told to go back and "fix" something by their billing department. In any case, I still think there needs to be an emphasis on your second suggestion about "ensuring that facilities write them for patients who need them" rather than on educating the crews on what makes a "legit PCS" and what doesn't. I'm willing to bet the vast majority of EMS providers know what's medically necessary in an non-emergent/inter-facility environment and what isn't. I think the focus needs to be on ensuring that the facilities are held accountable or, better yet, educated on what requires ambulance transportation and what doesn't. Also, rather than management at private ambulance companies being unhappy with their crew members in the event that one of their contracted facilities' staff members calls and complains about having a hard time because the EMT's didn't just accept a signature and package up the patient (and instead did what's right and perhaps point out that the reason for transport being provided is untrue) they should instead be unhappy with the staff from the facility that they're contracted with for putting their crews/company in a potentially compromising situation.

 

[CCCSD]

I’m confused. You get a call to transfer X from A to Z. There is an order or paperwork for it. You are saying that we need to challenge this and refuse to transfer the patient if you don’t think it’s an acceptable use of a rig? Then you want to accuse people of fraud? You want to do a full work up and come up with a diagnosis for each transfer, then decide what is best?

Congrats. You just lost the contract and your job. You DO realize that IFT is a glorified Uber for 90% of the time, right?

Please provide legal documentation of each of these “fraud cases” that you’ve filed and testified in court for.

 

[Tigger]

I’m confused. You get a call to transfer X from A to Z. There is an order or paperwork for it. You are saying that we need to challenge this and refuse to transfer the patient if you don’t think it’s an acceptable use of a rig? Then you want to accuse people of fraud? You want to do a full work up and come up with a diagnosis for each transfer, then decide what is best?

Congrats. You just lost the contract and your job. You DO realize that IFT is a glorified Uber for 90% of the time, right?

Please provide legal documentation of each of these “fraud cases” that you’ve filed and testified in court for.

This is a legitimate industry issue that the AAA (which leans significantly towards private ambulance interests) is trying to work on. If you transport a patient that did not have medically necessary need as documented in your PCR, your agency is not getting paid and the ordering facility has no obligation to pick up that bill. Sometimes, it is 100% appropriate to educate the sending facility on what constitutes medically necessary, especially when patients often have conditions that qualify for ambulance transport yet the facility filled out the CMS to reflect a service that is not needed.

For instance, if the facility documents that the patient requires "post medication administration monitoring" yet in your narrative you document that the patient's pain was well controlled by medications administered hours ago, CMS is not going to pay that claim. But perhaps, as a result of the patient's condition, they require positioning that would not be feasible in a wheelchair van. I think it is entirely appropriate to ask for a PCS that reflects this and my chief pushes for us to do this. Otherwise, your service gets stuck with an unpaid transport, which for those of us that lack significant tax support, is an issue.

 

[Kevinf]

I’m confused. You get a call to transfer X from A to Z. There is an order or paperwork for it. You are saying that we need to challenge this and refuse to transfer the patient if you don’t think it’s an acceptable use of a rig? Then you want to accuse people of fraud? You want to do a full work up and come up with a diagnosis for each transfer, then decide what is best?

Congrats. You just lost the contract and your job. You DO realize that IFT is a glorified Uber for 90% of the time, right?

Please provide legal documentation of each of these “fraud cases” that you’ve filed and testified in court for.

Nonsense, providers absolutely should question the transport if they are unable to ascertain medical necessity. Last week we were requested to pickup a patient for a hospital to SNF transfer. On scene at the nurses station I receive a PCS that states; Pt requires oxygen, pt is bed bound.

I enter the patient's room; pt is walking around their room without difficulty and breathing nothing but room air. I walk back to the nurses' station. I state my findings upon entering the patient's room. It turns out the supplemental o2 order was for activity only (sitting or laying for transport is not activity) and the bed confinement was a mistake. The patient was rescheduled to go by wheelchair van (the SNF transported them without charge). We could have transported this patient, and we would not have been paid. We ended up picking up a paying psych 201 transport from the same facility immediately after clearing from that assignment.

Transporting without ascertaining medical necessity is a waste of everyone's time and could a huge financial hit to either or both parties. Your providers should be able to competently assess their transports, and if they cannot divine a reason that someone needs to be on a stretcher, and a good reason is not clear on the PCS, the transport is a waste of time and effort.

 

[chriscemt]

I tend to transport and let billing figure it out. I don't falsify (I know, I'm so very awesome, I guess) anything in the PCR but I happen to wish that sending facilities had a check box at the bottom. It would include jargon such as, "There is no Medicare-approved reason for transport" and would include a box that the facility would secondarily check that the sending facility recognizes that financial responsibility for transport would be to sending facility.

We get weakly documented PCSs all the time, some with "weakness" as the medical necessity. It's stretching things at that point, often, in my opinion. (It's truly awful for me when "weakness" and a related inability to withstand wheelchair transport is true) If there's no medical reason to require an ambulance transport back to nursing home at 1am, then the facility should note it, and pay for the fact that they aren't waiting until 7am to transport, when the wheelchair vans are up and running again.

Frankly, I think my operation's billing department is happy to catch a few unpayable wheelchair van trips with the idea that the facility just keeps dialing our number during the day...

 

[Tigger]

Frankly, I think my operation's billing department is happy to catch a few unpayable wheelchair van trips with the idea that the facility just keeps dialing our number during the day...

I'm sure that is part of it. It's not like if the trip doesn't get paid that suddenly the facility is obligated to pay. Hence why many places choose to just contract with an ambulance provider. They pay the same rate per patient and the patient leaves and that's it.

 

[FirstResponder]

This is a legitimate industry issue that the AAA (which leans significantly towards private ambulance interests) is trying to work on. If you transport a patient that did not have medically necessary need as documented in your PCR, your agency is not getting paid and the ordering facility has no obligation to pick up that bill. Sometimes, it is 100% appropriate to educate the sending facility on what constitutes medically necessary, especially when patients often have conditions that qualify for ambulance transport yet the facility filled out the CMS to reflect a service that is not needed.

For instance, if the facility documents that the patient requires "post medication administration monitoring" yet in your narrative you document that the patient's pain was well controlled by medications administered hours ago, CMS is not going to pay that claim. But perhaps, as a result of the patient's condition, they require positioning that would not be feasible in a wheelchair van. I think it is entirely appropriate to ask for a PCS that reflects this and my chief pushes for us to do this. Otherwise, your service gets stuck with an unpaid transport, which for those of us that lack significant tax support, is an issue.

I appreciate the feedback and I'm glad you recognized that this forum was intended to start a conversation about this stuff...thank you.

 

[BillEMTP]

Some of the problem is companies that send back your chart because your narrative doesn't match the medical necessity paper work. PCS says O2 required, and the patient isn't on O2, you don't use O2 and your chart gets kicked back wanting to know why. PCS says bed confined and you chart met at nurses station by patient, your chart gets kicked back. We are supposed to doccument what we see, hear, and do, but if it contradicts the PCS WE are the ones lying. Then there's the QA person who only reads the check boxes and doesn't read the narrative to see that you did great doccumentation. Your chart gets kicked back because you didn't doccument medical necessity. Example: Patient going to cardiac facility from free standing ER. Patient going for higher level of care due to active STEMI. Elevation in V leads, O2, cardiac monitor required, IV, Chart got kicked back for lack of medical necessity. It don't get more medically necessary than that short of cardiac arrest enroute, but I bet it would have got kicked back for some stupid reason.

 

[hometownmedic5]

When I did transfer work, at least once a day I would tranport a patient with at best a questionable med nec and at worst a total fabrication. Cardiad monitor for their baseline, well controlled AFib. Tko saline only. Airway precautions for the patients that had received narcotics(hours ago). Pts going to a non tele facility found not on tele, but requires a monitor for transfer because reasons .

Every single day I would take straight up and down BLS transfers on an ALS truck, and theyd get billed ALS rates for nonsense. It's a big reason why I don't do transfer work anymore .

 

[PotatoMedic]

The company I worked for in Washington told us to make sure the PCS is filled out completely but to ignore what it said and just document what we found. That the billing department would handle any discrepancies. Part of this was because the contract with the sending facility we had was that they would pay for any transports that did not meet medical necessity. They would also "bill" medicare/medicaid with a "hey this is not billable" flag so that they could keep records of "improper" transports. Long story short. Just document what you find. If billing or QA says what you found does not match the PCS then tell them you documented what you found and that they need to talk to the sending facility about why they are filling out PCS's improperly. Just remember, medicare fraud is on the provider as well as the company, so saying that the company told you to say XYZ is not a legal defense and you will get fined!

 

[johnrsemt]

I like Mr Potato's comments. I wish more companies agreed with his