OIG Report – Overpayments For Non-Emergency Ambulance Transports To Non-Covered Destinations

The Office of the Inspector General released its report “Medicare Improperly Paid Providers for Non Emergency Ambulance Transports to Destinations Not Covered by Medicare“.

In sum, the OIG reviewed claims that Medicare paid for 2014 – 2016 non-emergency ambulance transports. The review focused on transports to non-covered destinations. OIG found that $8,633,940 was paid by Medicare for non-emergency ambulance transports under codes A0425 (ground mileage), A0426 (ALS non-emergency) and A0428 (BLS non-emergency) during this period of time.

The review was based solely on the claims and not based on a medical review or interviews of providers.

The claims that should not have been paid were to the following destinations:

• 59% – to diagnostic or therapeutic sites other than a hospital or physician’s office, that did not originate at a SNF.
• 31% – to a residence or assisted living facility (and not meeting the origin/destination requirement).
•  6% – to the scene of an acute event.
•  4% – to a destination code not used for ambulance claims or where no destination modifier was used.
• <1% – to a physician’s office.

OIG recommended (and CMS agreed) that CMS:

1. Notify the Medicare Administrative Contractors to recover that portion of the overpayment that is within the 4-year period in which claims can be re-opened.
2. For the balance of the overpayment that is outside the 4-year period, CMS should provide the information needed for the MACs to notify the providers of the overpayments and have the providers exercise reasonable diligence to investigate and refund improper payments.
3. Direct the MACs to review the origin/destination requirements for any overpayments following the audit period.
4. Require the MACs implement edits to ensure they only pay for non-emergency transports that meet the Medicare requirements.

There is a chart in the report that indicates the improper payments for each jurisdiction. It is interesting to note that the overpayments range from a low of $515 (First Coast) to a high of $5,006,696 (Cahaba).

The report can be obtained at: https://go.usa.gov/xU5vf