Preventing Fraud-"Medical Necessity"

All this is great. Would anyone be willing to post links to the aforementioned articles? New to the field, undereducated on provider liability, having trouble tracking down the info on my own. Thank you.
 
Ginger1 said:
All this is great. Would anyone be willing to post links to the aforementioned articles? New to the field, undereducated on provider liability, having trouble tracking down the info on my own. Thank you.
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Cms.gov should answer most of those questions
 
former paramedic turned patient currently on Medicare here

We get these bills and depending on how things are documented, it can make a large difference on what we end up getting a bill for. Where I live in AZ, AMR is the main provider for 911 & IFT, though that’s slowly being encroached on by another company though that’s another topic. I have a Medicare plan that covers medically necessary ambulance transports with a copay of $150. However, my plan does NOT cover any other forms of transportation, leaving me solely responsible for all non medically necessary forms of transportations. I’m on continuous oxygen and although I’m ambulatory for short distances ( from bed to gurney, gurney to bed, or bed to wheelchair and occasional walker under close supervision since I’ve broken 5 or 6 bones when not supervised). Lately I’ve been getting bills for approximately 2K whether it’s from hospital discharge to SNF or ALF when it really should be my $150 copay. I think documentation is most of it, and case managers really not knowing what’s going on since out here, they are the ones arranging transportation
 
Munchkin;
I found out if an ambulance crew documents that a patient writes in their narrative that a patient walks to cot at all (even standing up from the bed, pivoting and sitting on the cot) then Medicare/Medicaid usually won't pay for the transport.
So I always left that part out, even if they had to walk to the hall or to the living room. Because like you are maybe finding out, it makes a big difference, where I work part time, it can be $6,000 for a transport (110-130 miles to the hospitals).
 
johnrsemt said:
Munchkin;
I found out if an ambulance crew documents that a patient writes in their narrative that a patient walks to cot at all (even standing up from the bed, pivoting and sitting on the cot) then Medicare/Medicaid usually won't pay for the transport.
So I always left that part out, even if they had to walk to the hall or to the living room. Because like you are maybe finding out, it makes a big difference, where I work part time, it can be $6,000 for a transport (110-130 miles to the hospitals).
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So you’re intentionally lying(by omission) so your employer can get paid. Congratulations, you’re part of the problem. Yeah, yeah, I get it. If you do your job clean, you’ll be fired. Self preservation doesn’t negate the offense. If you steal food because your hungry, you still stole food. You shouldn’t face the same penalty as someone stealing a video game, but you’re still a thief.
 
johnrsemt said:
Munchkin;
I found out if an ambulance crew documents that a patient writes in their narrative that a patient walks to cot at all (even standing up from the bed, pivoting and sitting on the cot) then Medicare/Medicaid usually won't pay for the transport.
So I always left that part out, even if they had to walk to the hall or to the living room. Because like you are maybe finding out, it makes a big difference, where I work part time, it can be $6,000 for a transport (110-130 miles to the hospitals).
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Or you could just document what you did. There are plenty of other reasons that CMS pays for trips that don't include the stretcher.
 
hometownmedic5 said:
So you’re intentionally lying(by omission) so your employer can get paid. Congratulations, you’re part of the problem. Yeah, yeah, I get it. If you do your job clean, you’ll be fired. Self preservation doesn’t negate the offense. If you steal food because your hungry, you still stole food. You shouldn’t face the same penalty as someone stealing a video game, but you’re still a thief.
Click to expand...

probably the best response I've seen
 
Not sure if the transporting EMT has any legal exposure here. As long as your PCR is accurate you are not commuting any fraud. If the person signing the medical necessity form gives false info, they are committing fraud. If your billing Dept is billing for higher acuity, they are committing fraud.

I'm not a lawyer so anyone correct me if I'm wrong, but I don't think the EMT has any say in what gets billed out and is not personally liable
 
Ewok Jerky said:
Not sure if the transporting EMT has any legal exposure here. As long as your PCR is accurate you are not commuting any fraud. If the person signing the medical necessity form gives false info, they are committing fraud. If your billing Dept is billing for higher acuity, they are committing fraud.

I'm not a lawyer so anyone correct me if I'm wrong, but I don't think the EMT has any say in what gets billed out and is not personally liable
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I don’t have any legal training or expertise, but I have to ask why would anybody care about the guy pushing the gurney here? At worst, they might try to pigeon hole you into providing evidence for them, but 1 fraudulent ambulance calls restitution would bankrupt most EMTs I know, and putting them in jail is a non starter.

No sir, nobody cares about the EMT’s involvement in these matters. In so far as anybody cares, they want the business owners who can pay real money fines, not some kid who had to choose between gas to get to work and lunch to eat when you’re there today.
 
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