The Office of Inspector General (OIG), U.S. Department of Health and Human Services, recently issued a report highlighting ambulance utilization trends over the past decade. This report contained some downright startling statistics, and sounds an alarm for some areas the OIG views as potential powder kegs of fraud and abuse. There can be little doubt that this report will serve as a road map for some of the federal government’s future enforcement initiatives.

The report, titled Utilization of Medicare Ambulance Transports, 2002–2011, looks at data pertaining to ambulance transports of Medicare beneficiaries based on claims filed and paid during this 10-year period.¹ With Medicare comprising the single largest payer in the mix for most ambulance services, this data provides a critical glimpse into utilization patterns—and provides clear lessons for where the OIG believes that improved compliance and enforcement are necessary.

Although we first revealed the results from this report in last month’s EMS Insider, it’s worth summarizing a few key findings again so that we can discuss the implications for EMS agencies. Medicare ambulance transports increased 69 percent from 2002–2011. There were more than 14 million total ambulance transports paid by Medicare in 2011 alone. Between 2002 and 2011, Medicare spending on ambulance services increased 130%, even though spending on Medicare services generally rose only 74 percent. In other words, the growth in ambulance service spending by Medicare far outpaced the rate that spending grew on all Medicare services. However, during this same period, the total number of Medicare beneficiaries increased only 7%. This means that a much greater percentage of Medicare beneficiaries are being transported by ambulance today than 10 years ago. The number of transports per beneficiary increased 26%. In 2011, 4.8 million Medicare beneficiaries received ambulance services.

It is probably not a coincidence that during the same 10-year span, the number of ambulance services enrolled with Medicare increased by 26%. As of 2011, there were 17,776 enrolled ambulance services providing transportation to Medicare beneficiaries. It is interesting that some states experienced a decrease in the number of ambulance suppliers (Mississippi experienced a drop of 25%) while others posted large increases (207% in Virginia).

The report signals the continuation of a trend in which multiple governmental agencies have been closely scrutinizing the provision of Basic Life Support (BLS) non-emergency ambulance services. The number of ambulance services that primarily provided BLS non-emergency transport only increased 92% during the period 2002–2011. In 2002, those entities represented 7% of all ambulance suppliers; in 2011, they represented 11% of all suppliers and billed for 30% of all ambulance transports.

A specific type of BLS non-emergency transport drew significant attention from the OIG, as in several previous government reports. The increase in dialysis transports was particularly shocking. Between 2002 and 2011, transports related to dialysis increased 269% (just so you know that wasn’t a typo, I’ll repeat that: 269%). In some states, the trends were downright startling: South Carolina experienced an increase in dialysis transports of 6,920%, in California, it was 2,727%. In 2002, dialysis transports comprised 9% of all ambulance trips nationally; in 2011, they represented 19% of all transports. The OIG makes no secret of its disdain for the fact that Medicare covers these types of services at all. On page 4 of the report, the OIG asserts: “[a]lthough dialysis facilities are a covered destination, transports to them do not usually meet coverage requirements under Medicare.”

Some of the specific conditions cited as the reason for transport have increased markedly in recent years. For instance, between 2002 and 2011, transports for patients with gastritis and duodenitis increased 3,090%. Patients being transported for nervous system disorders increased 239%. Patients transported with headaches or migraines increased 136%, and transports for dementia and nausea increased 133% and 128%, respectively. There was also an increase of 829% in transports to community mental health centers between 2002 and 2011.

Growth in the utilization of ambulance services varied significantly by state. For instance, utilization in Utah increased only 8%, while it increased 289% in California. In fact, 10 states experienced utilization increases greater than 100%.

Overall, this data paints a picture of ambulance utilization that defies demographic changes in the population over the past decade. In other words, the increase in utilization cannot be attributed just to an increase in the number of people on Medicare. Therefore, the OIG believes that these increases are driven in large part by fraud and abuse on the part of ambulance suppliers. Whether this is true or not isn’t really the point; the point is that the OIG believes it to be true, and will target its enforcement activities accordingly.

While of course there are many other factors at play in the increase in utilization and Medicare spending on ambulance services (aging population, implementation of the ambulance fee schedule, improved access to care and a host of other factors), it is true that overall utilization in some areas is explosive. The increase in the number of ambulance suppliers alone signals a trend that is alarming to the OIG. In fact, using new authority given to the federal government under the Affordable Care Act, the Department of Health and Human Services (HHS) recently imposed the first-ever enrollment moratorium for new suppliers. The industry they chose to target for this moratorium? You guessed it—ambulance service in Houston and surrounding counties.

All of this means that ambulance services must have aggressive and meaningful compliance programs in place. You must have a living, breathing, functioning compliance program—one that is truly operationalized. Your agency should be able to document that it actually does the things its compliance plan says it will do. In fact, it would probably be worse to have a written compliance plan and not follow it than to not have one at all.

There are undoubtedly ambulance companies out there who are intent on committing fraud one way or the other. I doubt they are the ones reading this column. On the other hand, the overwhelming majority of providers are honest agencies trying to do their best to understand and comply with the confusing laws, rules, regulations and guidelines that Medicare imposes on ambulance services. The problem is that the feds often can’t tell the difference between the bad guys and the good guys—they seem to presume that ambulance services are committing fraud until proven otherwise.

This means that your agency must go above and beyond when it comes to demonstrating and documenting its commitment to compliance. It should be able to document that it has a compliance officer designated, that it regularly performs internal claim audits, that it promptly refunds overpayments to Medicare and Medicaid, that it performs appropriate background checks and OIG exclusion checks on its providers, billers, managers, supervisors and other staff members, that it provides role-specific training and education to staff to be able to properly do their jobs, and much, much more.

The days of paying lip service to compliance are over. The numbers are in, and they paint a remarkable picture of explosive growth in the use of ambulance services by Medicare patients over the past decade. While some of this growth can be attributed to demographics, most of it cannot be, and therefore, our industry will have an even bigger target on its back in years to come.

REFERENCES

1. Report OEI-09-12-00350. Office of Inspector General, U.S. Department of Health & Human Services. Retrieved on Oct. 28, 2013, from https://oig.hhs.gov/oei/reports/oei-09-12-00350.asp.