Connecticut Medicare Billing Investigation

Nelson Ambulance, a non-emergency patient transport service in Connecticut, is reported to be the latest health care provider to face a federal investigation for Medicare fraud. The investigation is said to center around improper Medicare billings for transporting ambulatory patients.

Hearst reporters obtained a memo that advised “we are not able to bill some of our medicare and Medicaid patients due to poor documentation… Medicare WILL NOT pay for ambulatory patients or DOCTORS appointments” and instructed “As this effect a good portion of our ambulance patients we ask the following. Please document that ALL patients were moved by sheet lift to our stretcher, even if the patient was ambulatory writing such will make medicare denie (sic) the claim. Also for doctors appointments please document it as a Procedure, not a follow up or Doctor appointment. This will secure billing rights for these calls”.

Defense coverage for ambulance providers and their officers, who can be personally liable, is available under correctly structured insurance policies. “Directors and Officers” insurance can contain a regulatory limit when placed by an experienced broker. Because of the growing risk most insurance companies no longer automatically provide the needed terms. Filing an insurance claim also has the added benefit of providing an experienced claim manager to oversee the process so those involved can focus on continuing to operate their business.

As implementation of the Affordable Care Act continues the strain of new expenditures is stressing Medicare and Medicaid. The administration has been very proactive is pursuing health care providers and aggressively prosecuting any possible over billing.

Implementing a strong risk management culture to deter investigations and provide a defense against allegations is needed in this environment. However, even the most honest, open and well run organizations are not going to be exempt from the costs of defending themselves.

Contact today to discuss the current state of the insurance marketplace and possible enhancements to your insurance program.