Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
I P
NAPPROPRIATE  AYMENTS 
 
 
Q B
AND  UESTIONABLE  ILLING 
 
M P B 
FOR  EDICARE  ART   
A T  
MBULANCE  RANSPORTS 
 
Suzanne Murrin  
Deputy Inspector General 
for Evaluation and Inspections  
 
September 2015 
OEI-09-12-00351   
   
EXECUTIVE SUMMARY:  INAPPROPRIATE PAYMENTS AND QUESTIONABLE 
BILLING FOR MEDICARE PART B AMBULANCE TRANSPORTS   
OEI-09-12-00351 
 
WHY WE DID THIS STUDY 
 
In 2012, Medicare Part B paid $5.8 billion for ambulance transports, almost double the amount it paid 
in 2003. Historically, Medicare has been vulnerable to fraud involving ambulance transports.  In 
2013 and 2014, the Centers for Medicare & Medicaid Services (CMS) imposed temporary moratoria 
on the enrollment of new ambulance suppliers in two metropolitan areas. Medicare billing for 
ambulance transports warrants scrutiny, given its rapid growth and its vulnerability to fraud and 
abuse. 
 
HOW WE DID THIS STUDY  
 
To identify inappropriate payments and questionable billing, we analyzed claims data for 7.3 million 
ambulance transports during the first half of 2012.  We examined aspects of the transports including, 
but not limited to, transport destinations, transport levels, distance of urban transports, other Medicare 
services that beneficiaries received, and the geographic locations where the beneficiaries who 
received transports resided. 
WHAT WE FOUND 
 
We identified both improper payments for ambulance transports and questionable billing by 
ambulance suppliers.  We found that Medicare paid $24 million in the first half of 2012 for 
ambulance transports that did not meet certain program requirements to justify payment.  For 
example, Medicare paid $17 million for transports that were to or from noncovered destinations such 
as physicians offices.  In addition, Medicare paid $30 million for transports for which the 
beneficiaries did not receive Medicare services at the pick-up or drop-off locations, or anywhere else.  
These claims may have been inappropriate.  We  also found that about one in five suppliers had 
questionable billing. For example, a supplier may have had an unusually high average mileage for 
the transports that it provided to beneficiaries residing in urban areas.  Questionable billing is 
geographically concentrated; more than half of all questionable transports were provided to 
beneficiaries residing in four metropolitan areas.   
 
WHAT WE RECOMMEND  
 
Our findings indicate that inappropriate and questionable billing for ambulance transports pose 
vulnerabilities to Medicare program integrity.  In response, CMS should enhance existing fraud and 
abuse safeguards. Our report made five recommendations.  CMS concurred with our 
recommendations for it to (1) determine whether a temporary moratorium on ambulance supplier 
enrollment in additional geographic areas is warranted, (2) require ambulance suppliers to include the 
National Provider Identifier of the certifying physician on transport claims that require certification, 
(3) increase its monitoring of ambulance billing, and (4) determine the appropriateness of claims  
billed by ambulance suppliers identified in the report and take appropriate action.  CMS partially 
concurred with our recommendation for it to implement new claims processing edits or improve 
existing edits to prevent inappropriate payments for ambulance transports.  CMS indicated that it will 
review data on claims identified in this report; CMS should use the results of its review to implement 
new, or modify existing, claims processing edits needed to prevent inappropriate payments.   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................6 

Findings......................................................................................................12 

Medicare paid $24 million for ambulance transports that did  

not meet certain Medicare requirements justifying payment .........12 

Medicare paid $30 million for potentially inappropriate    

ambulance transports for which the beneficiary did not         

receive Medicare services at any origin or destination ..................14 

About one in five ambulance suppliers had questionable  
billing .............................................................................................15 

More than half of questionable ambulance transports  

were provided to beneficiaries who resided in four  

metropolitan areas ..........................................................................20 

Conclusion and Recommendations ............................................................23 

Agency Comments and OIG Response..........................................25 

Appendixes ................................................................................................26 

Appendix A:  Ambulance Transport Levels and Medicare 

Payments in 2012 by Level ............................................................26 

Appendix B: Detailed Description of Measures of  

Questionable Billing for Ambulance Transports ............................27 

Appendix C: Questionable and All Ambulance  

Transports That Occurred in Fourteen Additional Areas, 
 
First Half of 2012...........................................................................31 

Appendix D: Agency Comments ..................................................32 

Acknowledgments......................................................................................35 

 
   
   
   
OBJECTIVES 
To determine the extent to which: 
1. 	  Medicare paid for ambulance transports that did not meet certain 
Medicare requirements, 
2. 	  Medicare paid for ambulance transports for beneficiaries who did not 
receive Medicare services at any origin or destination, 
3. 	  ambulance suppliers had questionable billing, and 
4. 	  questionable billing for ambulance transports is geographically 
concentrated. 
BACKGROUND 
In 2012, Medicare payments for ground ambulance transports covered 
under Part B totaled $5.8 billion, up from $2.9 billion in 2003.1  Medicare 
beneficiaries received a total of 14.9 million transports in 2012.2    
Investigators have uncovered a variety of fraud schemes involving 
ambulance suppliers.  For example, in May 2015, a Florida supplier paid 
$1.25 million to settle allegations that it knowingly upcoded transport 
claims from basic to advanced life support, unnecessarily transported 
patients, and transported patients unnecessarily to their homes at a level of  
care meant for emergencies.3   In June 2014, employees of a supplier 
operating in Philadelphia and other areas of Pennsylvania received prison 
sentences for fraudulently billing Medicare $3.6 million for transports that 
did not meet coverage requirements.  The supplier recruited patients who 
could walk and did not require transport by ambulance, and was also 
convicted of falsifying documents to support the transports and paying the 
patients illegal kickbacks.4 In January 2014, owners of a supplier in 
Tennessee received prison sentences for fraudulently billing Medicare and 
____________________________________________________________ 
1 Medicare also  covers ambulance transports  by airplane and helicopter.  All references in  
this report to ambulance transports apply only to ground transports. 
2 Centers for Medicare & Medicaid Services (CMS), 2003 and 2012 Part B National 
Summary Data Files.  Throughout this report, references to  Medicare payments represent 
the total amounts allowed by  Medicare, which consist of  payments  made by Medicare  
plus beneficiary cost-sharing  payments.  Medicare payments we report include the 
amounts paid for the transports mileage.   
3  United States Department of Justice,  United States Settles False Claims Act Allegations  
Against Multiple Jacksonville Hospitals and  an Ambulance Company For $7.5 Million, 
May 8,  2015.  Accessed at http://www.justice.gov/usao-mdfl/pr/united-states-settles-
false-claims-act-allegations-against-multiple-jacksonville on June 9,  2015.  
4 United States Department of Justice, EMT sentenced for role in ambulance fraud  
scheme, June 5, 2014.  Accessed at http://www.fbi.gov/philadelphia/press-
releases/2014/emt-sentenced-for-role-in-ambulance-fraud-scheme on June 12, 2014.  
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   1 
   
   
Medicaid $1.2 million for transports to and from dialysis facilities.  
During these transports patients were  seatedsometimes in the front of 
the ambulancerather than being transported on stretchers.  Other 
fraudulent claims reported that the supplier transported patients 
individually when the supplier actually transported the patients together in 
one ambulance.  The supplier also used the names and Medicare numbers 
of patients without lawful authority when submitting the claims and 
falsified documents to support the transports.5    
Medicare Coverage of Ambulance Transports  
Medicare covers ambulance transports when a beneficiarys medical 
condition at the time of transport is such that other means of transportation 
would endanger the beneficiarys health.6  In addition, the transport must 
be to receive a medically necessary Medicare service or to return from  
such a service.7  For example, Medicare would not cover a transport to a 
hospital if the beneficiary was not treated at the hospital.  Transports that 
occur during a beneficiarys Part A stay at an inpatient hospital, skilled 
nursing facility (SNF), or hospice are generally covered as part of the stay.  
Medicare Part B generally does not make separate payments for transports 
that occur during Part A stays.8   Medicare does not cover other means of 
transport such as wheelchair vans or taxicabs.  If the transport meets 
coverage requirements, Medicare also reimburses suppliers for miles 
traveled with the beneficiary on board.9    
Medicare covers seven different levels of ambulance transport.10   
Transport levels vary in terms of the qualifications of the ambulance crew 
and the level of medical care provided.11 The transport level also depends 
on whether the transport is provided in an emergency or nonemergency 
____________________________________________________________ 
5  United States Department of Justice, Former Owners of Murfreesboro Ambulance 

Service Sentenced to Federal  Prison for Defrauding Medicare, January 17, 

2014.  Accessed at http://www.fbi.gov/memphis/press-releases/2014/former-owners-of-
murfreesboro-ambulance-service-sentenced-to-federal-prison-for-defrauding-medicare on 
 
June 12, 2014.  

6 CMS, Medicare Benefit Policy Manual, ch. 10  10.2.1.   

7 Ibid.  

8 Ibid., ch. 10   10.3.3 and ch.  9  40.1.9.  Transports of  SNF residents to receive dialysis
  
or certain  other high-end outpatient services are covered under Part B.  CMS, Medicare 
 
Claims Processing Manual, ch. 15,  30.2.2. 
  
9 CMS, Medicare Benefit Policy Manual, ch. 10    10.3. 
   
10  Ibid.,  ch. 10  30.1. 
  
11 Basic life support transports  require an ambulance crew certified at least as basic 

emergency medical technicians.  Advanced life support transports require an ambulance 

crew certified at least as intermediate or paramedic emergency medical technicians.  

Specialty care transports require a health professional in an  appropriate specialty area, 

such as critical care nursing. 

Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   2 
   
   
situation.  Medicare beneficiaries most commonly receive basic life 

support transports provided in a nonemergency setting.  The next most 

common transport level is advanced life support transports provided 

during an emergency.  See Appendix A for a list of the transport levels 

and information about Medicare payments for each level.   

Medicare covers ambulance transports to the nearest appropriate facility to 

obtain necessary diagnostic and/or therapeutic services, as well as the 

return transport.12  Appropriate facility means that the institution is 

generally equipped to provide the needed hospital care or skilled nursing 

care for the illness or injury.13 Medicare covers transports to only the 

following destinations: 14
  
   hospitals, 
 
   SNFs, 

   dialysis facilities for end-stage renal disease (ESRD)15 patients who 

require dialysis, and 
   beneficiaries residences. 
For emergency transports, destinations other than hospitals are presumed 
to be inappropriate.16  For specialty care transports, hospitals and SNFs are 
the only appropriate origins and destinations.17       
Although dialysis facilities are a covered destination, most beneficiaries 
who have ESRD do not need to be transported by ambulance to receive 
dialysis.18   One Medicare Administrative Contractor (MAC) estimated that 
only 10 percent of beneficiaries with ESRD who receive hemodialysis 
one of the two main types of dialysisrequire ambulance transports to 
____________________________________________________________ 
12 CMS, Medicare Benefit Policy Manual, ch. 10    10.3. 
   
13 CMS, Medicare Benefit Policy Manual, ch. 10    10.3.6. 

14 Ibid., ch. 10  10.3.  Critical access hospitals are included as a type of covered hospital 

destination.  The site of a transfer  between ground and air ambulance transports is also a  
covered destination.  Ibid., ch. 10  10.5.   

15 ESRD occurs from the destruction of normal kidney tissues over a long  period  of time.  

Dialysis removes waste products from the body by  diffusion from one  fluid compartment 

to another across a semipermeable membrane.  People with ESRD typically receive 

dialysis three times per week.  
 
16 One Medicare contractor expressly states that hospitals are the only appropriate 

facilities to receive emergency ambulance transports.  Novitas Solutions, Inc., Ambulance  

(Ground) Services L32252. Several appropriate destinations are allowed per 42 CFR 
 
 410.40(e)(1) and  CMS, Medicare Benefit Policy Manual, ch. 10,  10.3 and 10.3.6.  

However, by definition emergency services are provided by  hospitals.  42  CFR 

 424.101.
   
17 CMS, Change Request 5533, March 30, 2007.  71  Fed. Reg. 69624, 6971669717 
 
(Dec. 1,  2006).  For specialty care transports, hospitals include hospital-based  facilities 

that meet CMSs requirements for  provider-based status.   

18 Palmetto GBA, Nonemergency Services. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   3 
   
   
and from hemodialysis treatment.19, 20, 21   
To receive Medicare payment for an ambulance transport, the ambulance 
supplier submits a claim and indicates on it the transport level, the origin,  
the destination, and the total miles for the one-way transport.  The supplier 
indicates the transport level using a Health Care Procedure Coding System 
code (procedure code). Suppliers must indicate the transports origin and 
destination,22 and do so by using modifier codes.  The supplier bills for the 
mileage on the same claim, using a different procedure code. 
Program Integrity Safeguards for Ambulance Transports 
CMS uses a variety of safeguards to prevent and detect fraud, waste, and 
abuse of ambulance transports in the Medicare program.  
Provider Screening. CMS and its contractors screen all providers seeking 
to enroll or reenroll in the Medicare program according to the risk of 
fraud, waste, and abuse that is posed by each provider category.23 CMS 
created three levels of risk:  limited, moderate, and high.24 Ambulance 
suppliers are categorized as moderate risk.   
Enrollment Moratoria. CMS has temporarily suspended the enrollment of 
new ambulance suppliers into Medicare, Medicaid, and the Childrens 
Health Insurance Program in two areas of the country.25  The enrollment 
moratoria became effective in the Houston, Texas, area in July 2013 and 
in the Philadelphia, Pennsylvania, area in January 2014.26  The enrollment 
moratoria have been extended three timesmost recently, in July 2015.27  
Physician Certification Statements. For those ambulance transports that 
are scheduled ahead of time and for some unscheduled transports, the 
beneficiarys attending physician, nurse, or discharge planner must 
prepare a written statement (physician certification statement) certifying 
____________________________________________________________ 
19 MACs process claims and pay for services  provided to  beneficiaries in the Medicare 

fee-for-service program.
     
20  Novitas Solutions, Inc., Ambulance (Ground) Services L32252. 

21 The other main type of  dialysis, peritoneal  dialysis, is usually performed at home. 

22 CMS, Medicare Claims Processing Manual, ch. 15  30. 
   
23 42 CFR   424.518.  

24 Screening  for providers categorized as limited  risk consists of basic verifications, such 
 
as verifying that the provider  has a valid medical license.  Screening for providers 

categorized as  moderate risk consists of the  same verifications as for limited-risk 
 
providers, as well as unscheduled or  unannounced site visits.  Screening for providers 

categorized as  high risk consists of the same procedures as for limited-risk and 

moderate-risk  providers, plus an additional  fingerprint and criminal background check. 
 
25 CMS may suspend the enrollment of certain types of Medicare providers  and suppliers 

if there is a significant potential for fraud, waste, or abuse.  42 CFR   424.570.  

26  78  Fed.  Reg. 46339 (July 31, 2013); 79  Fed. Reg. 6475 (Feb. 4,  2014). 

27  80  Fed.  Reg. 44967 (July 28, 2015). 

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that the transport is medically necessary.28  Transports to and from dialysis 
facilities (dialysis-related transports) are one type of transport that is 
typically scheduled ahead of time.  Physician certification statements are 
not required for unscheduled transports provided to beneficiaries who live 
at home or in facilities where they are not under a physicians direct care.     
Prior-Authorization Demonstration.  In December 2014, CMS began a 
prior-authorization demonstration for  repetitive, scheduled nonemergency 
ambulance transports in New Jersey, Pennsylvania, and South Carolina.29   
Before providing these transports, ambulance suppliers must submit the 
necessary information to CMS to ensure that the transports meet all 
relevant clinical or medical documentation requirements.  The 
demonstration focuses on these transports because nonemergency 
transports, particularly those that  are dialysis-related, have increased 
noticeably in recent years.  The demonstration is meant to test whether 
prior authorization can help to reduce expenditures while maintaining or 
improving quality of care.    
Claims Processing Edits. Claims processing edits prevent inappropriate 
payments for ambulance transports and other services.  These electronic 
edits automatically pay, deny, or suspend for manual review all or part of 
a claim, as necessary.  MACs may choose to use local edits to enforce 
their local coverage decisions and reduce payment error.30  For example, 
one MAC uses an edit to deny payment for transport claims with origin 
and destination codes that are unlikely to meet coverage requirements.31   
CMS can also direct MACs to implement shared system edits to enforce 
Medicare coverage requirements. 
Monitoring of Suppliers Billing. CMS conducts data mining to identify 
potentially fraudulent ambulance suppliers and other providers.  CMS 
contracts with Zone Program Integrity Contractors to investigate potential 
fraud, waste, and abuse; identify improper payments; and refer cases to 
law enforcement.32  CMS also uses its Fraud Prevention System to run 
predictive analytics against all Medicare fee-for-service claims data.33   
 ____________________________________________________________ 
28 42 CFR   410.40(d).    
29 CMS, Fact Sheets: Prior Authorization Process for Repetitive Scheduled 
 
Non-Emergent Ambulance  Transport. 

30 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 3,  3.4.1.5(A). 

31  Noridian Healthcare Solutions, which processes Medicare Part B claims in 

Jurisdiction E, implemented the edit in  August 2014.  Jurisdiction  E consists of  
California, Hawaii,  Nevada, and  the U.S. Pacific territories. 
32 CMS, Medicare Program Integrity Manual, Pub. 100-08, ch. 1  1.7.B.    
33 CMS, Center for Program Integrity: New  Strategic Direction and Key Antifraud 
Activities. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   5 
   
   
Related Work 
In September 2013, the Office of the Inspector General (OIG) published a 
report that provides a detailed analysis of the changes in utilization of 
Medicare Part B ambulance transports from 2002 through 2011.34 During 
that time, the number of beneficiaries who received transports increased 
34 percent, compared to an increase of 7 percent in the number of 
beneficiaries enrolled in the Medicare fee-for-service program.   In 
particular, the number of transports for beneficiaries with ESRD grew 
during this time period, increasing 269 percent from 2002 to 2011.  OIG 
also found that not all transports were to covered destinations.  The type of 
noncovered destination to which transports increased the most was 
community mental health centers.    
In June 2013, the Medicare Payment Advisory Commission (MedPAC) 
reported on Medicares ambulance fee schedule.  MedPAC recommended 
that medical necessity requirements for transports be more precisely 
defined, that a set of national edits based on those requirements be 
developed, and that geographic areas and suppliers that display unusual 
patterns be identified. To support these recommendations, MedPAC cited 
the rapid growth in the enrollment of for-profit suppliers and program  
integrity issues within the Medicare ambulance benefit.35    
METHODOLOGY 
Scope  
This study is based on our analysis of Medicare Part B claims for 
ambulance transports provided by ambulance suppliers from January 1 to 
June 30, 2012.36  Our population includes claims for 7.3 million transports 
and their associated mileage, totaling $2.9 billion in Medicare payments.37   
These claims were submitted by 15,614 unique ambulance suppliers and 
represent transports for 2.9 million Medicare beneficiaries.38   We also 
____________________________________________________________ 
34 OIG,  Utilization of  Medicare Ambulance Transports, 20022011, September 2013  
(OEI-09-12-00350).  
   
35 MedPAC, Report to the Congress:  Medicare and the Health Care Delivery System, 

Mandated report:  Medicare payment for ambulance services, pp. 178179, June 2013. 

36  We  did not analyze claims from institutional ambulance providers.  In  2012, 4  percent 
of ambulance providers were based at institutions, such as hospitals.   

37  We combined Medicare payments for the transports themselves and the transports 

mileage. One percent of transports were billed without corresponding mileage claims.  

We did  not analyze such transports, with  the exception of paramedic intercepts.  

Paramedic intercepts occur when a paramedic meets a basic life support transport and 
 
provides advanced life support services.   

38 We  identified suppliers  by using the provider identification number combined with the 

MAC number. 

Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   6 
   
   
analyzed claims for Medicare services that beneficiaries received at the 
facilities they were transported to and from.   
Data Collection 
Our data sources were the 2012 National Claims History Physician/ 
Supplier Part B claims file; the 2012 Inpatient, Outpatient, SNF, and 
Hospice Standard Analytical Files; the 2012 Denominator File from the 
Medicare Enrollment Database; and the Compromised Numbers 
Contractor database.39   The Physician/Supplier Part B claims file contains 
claims submitted by independent ambulance suppliers and other 
noninstitutional providers. These claims detail information such as the 
transport level and the transport origin and destination.40 The Standard 
Analytical Files contain claims submitted by institutions, such as 
hospitals.   The Medicare Enrollment Database contains Medicare 
beneficiaries enrollment information, such as date of birth.  The 
Compromised Numbers Contractor database contains provider and 
beneficiary identification numbers that have been involved in or are 
vulnerable to medical identity theft.41      
Identification of Ambulance Transports That Did Not Meet 
Certain Medicare Requirements  
Noncovered Destinations.  We identified transports that were to 
destinations to which Medicare does not cover ambulance transports, and 
the return transports from those destinations.  We identified transports that 
suppliers billed using a modifier on the ambulance claim to indicate that 
the beneficiary was transported to a physicians office or to a diagnostic or 
therapeutic site.  We also identified transports thataccording to our 
analysis of other Medicare claims for the same beneficiarieswere to 
noncovered destinations or were the return transports from noncovered 
destinations.  For these transports, the beneficiaries received Medicare 
services only at noncovered destinations within 1 day of their transports.  
These included transports that (for example) the suppliers indicated were 
to hospitals but for which the beneficiaries instead received services at 
community mental health centers.  We calculated the total Medicare 
payments for transports to or from noncovered destinations.  We also 
____________________________________________________________ 
39  We also analyzed claims for services provided on December 31, 2011, for beneficiaries 
who received transports on January 1, 2012.   
40 For 99.98 percent of transports in  our population, transports origins and  destinations  
were reported in the first modifier field.   For less than one-tenth of 1 percent  of  
transports, origins and destinations  were reported in two modifier fields on the same  
claim line.  For those transports, we analyzed the first modifier field.  
41 Medicare beneficiaries identification numbers are also known as Health Insurance  
Claim numbers.  In this report, we refer to Medicare beneficiary identification numbers 
as beneficiary numbers.  
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calculated the Medicare payments associated with transports to each type 
of noncovered destination.42    
Inappropriate Combinations of Destinations and Transport Levels.   We  
identified two types of transports billed with inappropriate combinations 
of destinations and transport levels.  First, we identified emergency 
transports that suppliers indicated were to a destination other than a 
hospital or the site of a transfer between ground and air transports.  We  
also identified specialty care transports that suppliers indicated were to or  
from destinations other than hospitals, SNFs, or transfer sites.  We  
calculated the total Medicare payments for transports with inappropriate 
combinations of destinations and transport levels. 
Identification of Ambulance Transports for Beneficiaries Who 
Did Not Receive Medicare Services at Any Origin or Destination 
We identified ambulance transports for which the beneficiaries did not 
receive Medicare services at any origin or destination.  We excluded any 
transport claims for which the beneficiary died within 1 day of the 
transport.  We determined whether the beneficiary received services within 
1 day of the transport at the origin or destination indicated by the supplier 
on the claim.43  To account for the possibility that the supplier had 
incorrectly indicated the origin or destination, we also determined whether 
the beneficiary received Medicare services at another origin or destination 
within 1 day of the transport. We reviewed the Inpatient, Outpatient, SNF,  
and Hospice Standard Analytical Files and the Physician/Supplier Part B  
claims file to determine whether beneficiaries received such services.44   
We verified that no claims for related services were submitted during the 
year after the transport occurred.45, 46   We calculated the total Medicare 
 ____________________________________________________________ 
42  We counted each transport only once when  calculating the same totals across 
destination types. However, some beneficiaries received services at more than one type  
of  noncovered destination within 1 day of  their transports.  In  these cases, we could not  
determine the destination to which the beneficiary was transported,  so  we included the  
transport in each type of  noncovered destinationfor example, counting it as one 
transport to a physicians office and  one transport to a community mental health center 
when calculating the volume of transports and Medicare payments by destination type.   
43  We checked for Medicare services that occurred 1 day before or after the transports in  
case the transports occurred close to midnight.  For example, a beneficiary may have 
been discharged  from a hospital just before midnight and transported home.    
44  We limited our review of the Inpatient, SNF, and Hospice files to services that 
occurred within  1 day of the beneficiarys admission or  discharge.  Medicare Part B  does  
not  pay for transports that occur during stays at these facilities.  We excluded services 
that were provided in  beneficiaries residences, such as in-home hospice services.  
45 Medicare Part A and Part B claims  must be  submitted no later than  1 year after the date 
the service was provided.  CMS, Medicare Claims Processing Manual, ch. 1  70.   
46 For this analysis, we used claims files that include claims processed up to 1 year after 
the first half of 2012.   
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payments for transports for which the beneficiaries did not receive 
Medicare services at any origin or destination.   
Identification of Ambulance Suppliers That Had Questionable 
Billing  
We developed seven measures of questionable billing for ambulance 
services. The measures are based on Medicare coverage and billing 
requirements for ambulance services; the results of past OIG analyses and 
fraud investigations related to ambulance suppliers; and consultations with 
fraud investigators within and outside of OIG.  Table 1 describes the seven 
measures.  
Table 1: Measures of Questionable Billing for Ambulance Transports  
1.  No Medicare Service at the Origin or Destination:  High percentage of a suppliers 
transports for which the beneficiaries did not receive Medicare services at the origin 
or destination indicated on the transport claim.  Such transports may indicate billing 
for transports to noncovered destinations or transports that were not provided.  
2.  Excessive Mileage for Urban Transports:  High average mileage for transports for 
beneficiaries in urban areas.  Such transports may indicate billing for more miles than 
suppliers actually  drove or transports to facilities other than the nearest appropriate 
facilities.  
3.  High Number of  Transports per Beneficiary:  Among suppliers that provided  
dialysis-related transports, high average per-beneficiary number of transports.  Such 
transports may indicate billing for transports that were medically unnecessary.  
4.  Compromised Beneficiary Number:  High percentage of a suppliers transports with 
compromised beneficiary numbers.  Such transports may indicate billing for 
transports that were medically unnecessary or  were not provided. 
5.  Inappropriate or Unlikely Transport Level:  High percentage of a suppliers transports 
with inappropriate or unlikely transport levels given the destinations.  Such transports 
may indicate upcoding or transport levels that  were medically unnecessary.   
6.  Beneficiary Sharing:  High average number  of suppliers providing dialysis-related 
transports to the beneficiaries transported by  a supplier.  Such transports may  
indicate misuse of beneficiaries numbers or shopping by  beneficiaries among 
suppliers to receive higher kickbacks.  
7.  Transports To or From Partial Hospitalization Programs (PHPs)47: The supplier 
provided transports that were to or from PHPs.  Such transports are likely to be 
medically unnecessary  because beneficiaries  who meet Medicare coverage  
requirements for PHPs generally do not meet the requirements for transports. 
 
____________________________________________________________ 
47 PHPs provide intensive psychiatric care and  resemble structured, short-term hospital 
inpatient  programs.  They are provided in two settings:  community mental health centers 
and hospital outpatient departments.  Beneficiaries admitted to a PHP do  not  require 
24-hour supervision as provided in an inpatient setting.  These beneficiaries must have a 
support system outside the PHP, and must not be an imminent danger to themselves or 
others.  
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We calculated suppliers levels of each measure.  We then identified 
suppliers that had unusually high levels on at least one measure relative to 
other suppliers (i.e., had questionable billing).  We considered a suppliers 
level to be unusually high if it was greater than the threshold for 
questionable billing (i.e., greater than the 75th percentile plus 1.5 times the 
interquartile range for the measure).48   We identified suppliers that 
exceeded the thresholds in comparison to other suppliers to which the 
measures applied.  We also calculated the median level of each measure 
among those suppliers to which the measures applied.49 Appendix B 
provides a detailed description of how we calculated each measure.    
We calculated Medicare payments for ambulance transports associated 
with suppliers questionable billing (i.e., questionable transports).  For 
four of the measures, we identified transports that exhibited the 
characteristic described in the measure (for example, a compromised 
beneficiary number) and were billed for by suppliers that had unusually 
high levels of the measure.  Because the other three measures of 
questionable billing were calculated as averages across transports, we 
could not identify individual transports with the characteristics described  
in these measures.  Therefore, we considered all urban transports billed by 
suppliers that had questionable billing for the measure excessive mileage 
for urban transports to be questionable.  Similarly, we considered all 
dialysis-related transports billed by suppliers with questionable billing for 
the measures high number of transports per beneficiary and beneficiary 
sharing to be questionable. 
Geographical Analysis of Questionable Ambulance Transports  
We analyzed the geographic locations of questionable ambulance 
transports.  We assigned each transport claim to a Core Based Statistical 
Area (area) using the location of the beneficiarys residence.50   We  
identified the areas (on the basis of where beneficiaries resided) that 
accounted for the most questionable transports.  We compared the top 
areas, which were metropolitan areas, with other metropolitan areas with 
____________________________________________________________ 
48 This is a standard exploratory method for identifying members of a population  with  
unusually high values  on a given statistic compared to the rest of the population when  no  
established benchmarks exist.  See J.W. Tukey,  Exploratory Data  Analysis. 
Addison-Wesley, 1977.    
49  For purposes of  this report, we use the phrase typical  supplier  to describe suppliers  
that billed the median levels of the measures.  Half of the suppliers to  which the measure 
applies had levels that fell below the level of the typical supplier.    
50 Core Based Statistical Areas are associated  with at least one core urban area with a  
population  of at least 10,000.  Core Based  Statistical Areas with populations of  at least 
50,000 are metropolitan areas.  In the first half of 2012, there were 955 Core Based  
Statistical Areas in the United States and Puerto Rico, including  373 metropolitan areas. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   10 
   
   
regard to the average Medicare payments per supplier and the average 
number of beneficiaries per supplier.    
Limitations 
We relied on claims data to identify ambulance transports for which the 
beneficiaries received services only at noncovered destinations.  We also 
relied on claims data to identify transports for which the beneficiaries did 
not receive Medicare services at any origin or destination.  We did not 
review medical or other records from facilities to verify whether the 
beneficiaries received Medicare services at the facilities.   When  
beneficiaries received Medicare services associated with their transports, 
we did not determine whether the services were provided at the nearest 
appropriate facilities.  These limitations could result in either  
overestimating or underestimating inappropriate or potentially 
inappropriate billing. 
The seven measures of questionable billing used in this study do not 
provide conclusive evidence of fraudulent billing.  Rather, the measures 
are intended to identify scenarios that, on the basis of claims data, are 
questionable.  We identify ambulance suppliers that, relative to other 
ambulance suppliers, had unusually high levels of questionable billing 
during the first half of 2012. Further investigation would be required to 
determine whether these suppliers have, in fact, submitted fraudulent or  
inappropriate Medicare claims for ambulance transports.  We did not 
review beneficiaries medical records or the physician certification 
statements to determine whether the transports met coverage requirements.   
We identified urban ambulance transports and analyzed the location of 
questionable transports on the basis of beneficiaries primary residences, 
as recorded in their enrollment data.  Not all transports may have occurred 
in the same area as the beneficiarys primary residence.  This limitation 
may result in either overestimating or underestimating inappropriate or 
potentially inappropriate billing. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.   
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   11 
   
   
FINDINGS 
Medicare paid $24 million for ambulance transports
that did not meet certain Medicare requirements 
justifying payment 
In the first half of 2012, Medicare paid $24.2 million for ambulance 
transports that did not meet Medicare requirements regarding the 
transports destination. These transports were either to a destination not 
covered by Medicare or to a destination that was inappropriate given the 
transport level.51    
Medicare paid $17 million for transports to noncovered 
destinations and return transports 
Medicare inappropriately paid $17.4  million for ambulance transports to 
destinations to which Medicare does not cover transports and for the 
return transports.  For these transports, the beneficiaries did not receive 
Medicare services at covered destinations (that is, at a hospital, dialysis 
facility, or SNF).  Rather, the beneficiaries received services at 
noncovered destinations. Transports to or from noncovered destinations 
represented 0.6 percent of total Medicare ambulance payments in the first 
half of 2012. 
Physicians offices were the most common type of noncovered destination 
where beneficiaries received services. In the first half of 2012, Medicare 
paid $8.7 million for transports provided to beneficiaries who received 
services at physicians offices but not at covered destinations.  Medicare 
also paid $5.8 million for transports provided to beneficiaries who 
received services at community mental health centers or psychiatric 
facilities but not at covered destinations.  Table 2 presents the numbers of 
transports and Medicare payments, by the type of noncovered destination, 
for transports provided to beneficiaries who received services at 
noncovered destinations instead of at covered destinations. 
 ____________________________________________________________ 
51 Transports that met neither  requirement  accounted for $266,963 of  this  total.  
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   12 
   
   
Table 2:  Ambulance  Transports Provided to Beneficiaries Who Received Services at  
Noncovered Destinations, First Half of 2012 
Number of Transports for 
Which the Beneficiary  
Received a Service at the  Medicare 
Noncovered Destination  Noncovered Destination  Payments 
Physicians office  25,829   $8,724,161  
Community mental health center or 
18,097  $5,816,778  
psychiatric facility  
Independent laboratory or other diagnostic or  
12,019   $4,090,113  
therapeutic site   
Nursing facility  (non-SNF) or long-term-care 
6,220  $1,971,327  
facility 
Other noncovered destination*   1,779   $641,293  
Hospice facility   1,203   $391,012   
    Total**   52,421   $17,440,431  
* Other noncovered destinations include, for example, rural health centers and federally qualified health centers. 

** Column sums exceed totals because some beneficiaries received services at more than one noncovered destination within 

1 day  of their transport.  In these cases, we  included the transport in each  type of noncovered destination.   
  
Source:  OIG analysis of Part B data for ambulance services, 2013. 

Medicare paid $7 million for transports with inappropriate 
combinations of destinations and transport levels 
Medicare paid $7.1 million for ambulance transports for which suppliers 
used destination modifiers that were inappropriate for the transport levels 
billed. These included specialty care transports that suppliers indicated 
were between origins and destinations other than hospitals or SNFs, and 
emergency transports that suppliers indicated were to nonhospital 
destinations.52  If suppliers indicated the correct origins and destinations 
on these transport claims, they either billed Medicare for more expensive 
transports levels than they actually provided, or provided transport levels 
that did not meet Medicare coverage requirements.  Transports with 
inappropriate combinations of destinations and transport levels 
represented 0.2 percent of total Medicare ambulance payments in the first 
half of 2012. 
Specialty care transports. During the first half of 2012, Medicare paid 
$4.3 million for specialty care transports that ambulance suppliers 
indicated were between origins and destinations other than hospitals or 
SNFs.  The most common inappropriate destination for these specialty 
care transports was independent (i.e., nonhospital) dialysis facilities.  
Medicare paid $2.6 million for specialty care transports between SNFs and 
____________________________________________________________ 
52 Emergency transports to nonhospital destinations are presumed to be inappropriate. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   13 
   
   
independent dialysis facilities and $0.9 million for specialty care 
transports between independent dialysis facilities and beneficiary 
residences.  Medicare paid an additional $0.4 million for specialty care 
transports between beneficiary residences and hospitals.  
Emergency transports.   During the first half of 2012, Medicare paid 
$2.7 million for emergency transports that ambulance suppliers indicated 
were to nonhospital destinations.  The most common inappropriate 
destination for these emergency transports was SNFs.   Medicare paid 
$1.6 million for emergency transports to SNFs.  Medicare paid an 
additional $0.7 million for emergency transports to beneficiary residences.   
Medicare paid $30 million for potentially inappropriate 
ambulance transports for which the beneficiary did 
not receive Medicare services at any origin or 
destination 
To be covered by Medicare, ambulance transports must be for the purpose 
of receiving or returning from a Medicare-covered service.53  In the first 
half of 2012, Medicare paid $30.2 million for transports for which the 
beneficiaries did not receive Medicare services at any origin or  
destination. These beneficiaries did not receive Medicare services within 
1 day of their transports at the origin or destination indicated by 
suppliers. In addition to not receiving services at the origin or destination  
indicated by suppliers, these beneficiaries did not receive Medicare 
services at other facility types within 1 day of their transports.54 These 
transports represented 1.1 percent of total Medicare payments in the first 
half of 2012. 
In these instances, Medicare likely inappropriately paid for the ambulance 
transports. The transports may not have occurred or, if they occurred, the 
beneficiaries may not have received Medicare-covered services that would 
justify the need for the transports.  It is also possible that the transports 
occurred during an inpatient hospital or SNF stay and should have been 
billed for as part of the stay. 
   
____________________________________________________________ 
53 CMS, Medicare Benefit Policy Manual, ch. 10  10.2.1.   
54 To account for the possibility that the supplier incorrectly indicated the origin  or 
destination on the claim, we also determined whether the beneficiary received Medicare  
services at another type of facility.  Other facility types we checked included covered  
destinations (such as SNFs) and noncovered destinations (such as physicians offices).  
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   14 
   
   
About one in five ambulance suppliers had 
questionable billing 
In the first half of 2012, 21 percent of ambulance suppliers had 
questionable billing for at least one of the seven measures of questionable 
billing that we examined.  These suppliers received $207 million for 
transports associated with questionable billing during the first half of 
2012. 
Seventeen percent of ambulance suppliers had questionable billing for one 
of the seven measures.  Four percent of suppliers had questionable billing 
for two, three, or four measures. No suppliers had questionable billing for 
more than four measures.  Table 3 presents the number of measures for 
which suppliers had questionable billing. 
Table 3: Number of Measures for Which Ambulance Suppliers Had 
Questionable Billing, First Half of 2012 
Percentage of 
Number of Measures of   Suppliers  Number of 
Questionable Billing   (N=15,614)   Suppliers   
1  17.1%   2,668  
2  3.2%   501  
3  0.9%   140  
4  0.1%   11 
    Total   21.3%   3,320  
Source:  OIG analysis of Part B data for ambulance services, 2013. 
 
The measure of questionable billing associated with the largest percentage 
of suppliers is based on transports for which the beneficiaries did not 
receive Medicare services at the origins or destinations indicated on the 
transport claims.  Over three times as many ambulance suppliers had 
questionable billing for this measure as the number of suppliers that had 
questionable billing for the next most common measure.  Table 4 presents 
the levels of the measures of questionable billing among all suppliers, the 
thresholds above which suppliers had questionable billing for each 
measure, and the numbers of suppliers that had questionable billing.  
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   15 
   
   
Table 4: Questionable Billing Among Ambulance Suppliers, First Half of 2012  
Suppliers That Had Questionable Billing 
Median Among  Number of 
Measure of Questionable Billing  All Suppliers  Threshold   Suppliers  
No Medicare Service at the Origin or 
0 transports  3%   2,038  
Destination  
Excessive Mileage for Urban Transports  10 miles  34 miles   642  
High Number of  Transports per 
4 transports  21 transports  533  
Beneficiary1  
Compromised Beneficiary Number   1%  7%   358  
Inappropriate or Unlikely Transport Level   <1%  3%   268  
Beneficiary Sharing1,  2   1.2 suppliers  2.3 suppliers  168  
Transports to or From PHPs  0 transports  <<1%3   127  
Note: We identified suppliers  that had questionable billing and  calculated median levels for each measure among all suppliers  to which the 
measures applied.   For example, the measure excessive mileage for urban transports applies to suppliers with urban transports.  Appendix B 
provides a detailed description of how each measure was calculated.   
1 Among suppliers that provide dialysis-related  transports. 
2 As represented by the number  of suppliers per beneficiary.  
3  <<1 means that the number would round to 0, but is  above 0. 
Source:  OIG analysis of Part B data for Medicare ambulance services, 2013. 
No Medicare Service at the Origin or Destination. Thirteen percent of 

ambulance suppliers (2,038 out of 15,614) had questionable billing in 

terms of their percentages of transports for which the beneficiaries did not 

receive Medicare services at the origins or destinations indicated on the 

transport claims.  Suppliers with questionable billing for this measure may 

have transported the beneficiaries to different destinations than those 

indicated on the transport claims.  If so, these suppliers may be billing for 

transports to noncovered destinations.  Alternatively,  the transports may 

not have occurred and these suppliers may have billed for transports that 

were not provided. Medicare payments for these questionable transports 

totaled $41.2 million in the first half of 2012.   

For a typical supplier, beneficiaries always received Medicare services at 

the indicated origins or destinations.  For the 2,038 suppliers that had 

questionable billing for this measure, beneficiaries did not receive Medicare 

services at the indicated origins or destinations for at least 3 percent of the 

suppliers  transports.  For 46 of these suppliers, beneficiaries did not 

receive Medicare services at the indicated  origins or  destinations for at 

least 95 percent of the transports they billed.  
 
Excessive Mileage for Urban Transports. Four percent of ambulance 
 
suppliers (642 out of 15,614) had questionable billing in terms of their 

average distances for transports for beneficiaries residing in urban areas.  

Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   16 
   
   
Suppliers with questionable billing for this measure may not have 
transported beneficiaries to the nearest appropriate facility, as required, or 
may have billed  for more miles than they actually drove.  Medicare 
payments for these questionable transports totaled $7.3 million in the first 
half of 2012.    
For a typical supplier providing urban transports, the average urban 
transport distance was 10 miles.  For the 642 suppliers that had 
questionable billing for this measure, the average urban transport distance 
was at least 34 miles.  The average urban transport distance for 48 of these 
suppliers was over 100 miles.   
High Number of Transports per Beneficiary.  Three percent of ambulance 
suppliers (533 out of 15,614) provided dialysis-related transports and had 
questionable billing in terms of the average number of transports per 
beneficiary.  These suppliers may have billed for dialysis-related 
transports that were medically unnecessary or were not provided.  
Medicare payments for these questionable transports totaled 
$132.5 million in the first half of 2012.   
Beneficiaries transported by a typical supplier of dialysis-related 
transports received an average of four transports from all suppliers during 
the first half of 2012.  Beneficiaries transported by the 533 suppliers that 
had questionable billing for this measure received an average of at least 
21 transports.    
Compromised Beneficiary Number. Two percent of ambulance  suppliers 
(358 out of 15,614) had questionable billing in terms of their percentages 
of  transports associated with compromised beneficiary numbers.  
Compromised beneficiary numbers are those that have been involved in or 
are vulnerable to medical identity theft.  Suppliers with questionable 
billing for this measure may have billed  for transports that were medically 
unnecessary or were not provided.  Past OIG investigations have 
uncovered schemes in which providers have used stolen beneficiary 
numbers to submit false claims to Medicare.55 Medicare payments for 
these questionable transports totaled  $28.8 million in the first half of 2012.   
For a typical supplier that billed for any transports with compromised 
beneficiary numbers, 1 percent of the suppliers claims for transports had 
compromised beneficiary numbers. For the 358 suppliers that had 
questionable billing for this measure, at least 7 percent of their claims for 
transports had compromised beneficiary numbers.  Transports with 
____________________________________________________________ 
55 Testimony of  Gerald T. Roy, OIG Deputy  Inspector General for Investigations, before 
the U.S. House of Representatives, Committee on Energy & Commerce, Subcommittee 
on Oversight  & Investigations, March 2, 2011.  
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   17 
   
   
compromised beneficiary numbers accounted for at least  95 percent of the 
transports billed by 31 of these suppliers.   
Inappropriate or Unlikely Transport Level.  Two percent of ambulance 
suppliers (268  out of 15,614) had questionable billing in terms of their 
percentages of transports with inappropriate or unlikely combinations of 
destinations and transport levels.  Suppliers with questionable billing for 
this measure may have billed for more  expensive transport levels than they  
actually provided or for transports that were medically unnecessary.  
Emergency transports to destinations other than hospitals that were billed 
by these suppliers were inappropriate, as were specialty care transports 
between origins and destinations other than hospitals and SNFs.56   
Advanced life support transports between origins and destinations other 
than hospitals and SNFs were unlikely to be medically necessary, 
according to fraud investigators.  Medicare payments for these 
questionable transports totaled $5.6 million in the first half of 2012.   
For a typical supplier that billed any transports with an inappropriate or 
unlikely combination of destination and transport level, less than 1 percent 
of its transports were billed with inappropriate or unlikely combinations.  
For the 268 suppliers that had questionable billing for this measure, at 
least 3 percent of their transports were billed with inappropriate or 
unlikely combinations. For 19 of these suppliers, transports billed with 
inappropriate or unlikely combinations accounted for at least 25 percent of 
their transports.   
Beneficiary Sharing.   One percent of ambulance  suppliers (168 out of 
15,614) were associated with beneficiaries who, on average, received 
dialysis-related transports from an unusually high number of suppliers.  
When multiple suppliers bill for dialysis-related transports for the same  
beneficiary, the suppliers may have fraudulently shared beneficiaries or 
beneficiaries identification numbers with other suppliers.  Alternatively,  
beneficiaries transported by these suppliers may have shopped among 
suppliers to receive kickbacks.  Medicare payments for these questionable 
transports totaled $4.5 million in the first half of 2012.   
For a typical supplier of dialysis-related transports, on average, 
beneficiaries each received these transports from a single supplier during 
the first half of 2012.  For the 168 suppliers with questionable billing for 
____________________________________________________________ 
56  Novitas Solutions, Inc., Ambulance (Ground) Services L32252. CMS, Change Request 
5533, March 30, 2007.   
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   18 
   
   
this measure, beneficiaries received dialysis-related transports from an 
average of at least two suppliers. 
PHP Transports. One percent of ambulance  suppliers (127 out of 15,614) 
had questionable billing for PHP transports.  Suppliers with questionable 
billing for this measure may have billed for transports to or from PHPs for 
beneficiaries who do not qualify to receive the transports.  Beneficiaries 
who meet Medicare coverage requirements for PHPs generally do not 
meet the requirements for transports.57  For example, a beneficiary who is 
being transported because he is a danger to himself would not qualify to 
receive PHP services. Medicare payments for these questionable 
transports totaled $10.7 million in the first half of 2012.   
For a typical supplier, no transports were to or from PHPs.  For the 
127 suppliers that had questionable billing for this measure, at least one 
transport was to or from a PHP.  For 59 of these suppliers, transports to or 
from PHPs accounted for at least  75 percent of their transports.   
Suppliers that had questionable billing provided 
nonemergency basic life support transports more often than 
other suppliers 
Ambulance suppliers that had questionable billing differed from other 
ambulance suppliers in terms of transport levels they commonly billed.  
Sixty-five percent of the transports billed by suppliers that had 
questionable billing were basic life support transports provided in 
nonemergency settings.  In comparison, basic life support transports 
provided in nonemergency settings accounted for only 36 percent of the 
transports billed by all other suppliers. This difference between suppliers 
that had questionable billing and those that did nota higher proportion 
of nonemergency basic life support transportscould assist efforts to 
monitor questionable billing. 
 
 
 
____________________________________________________________ 
57 Trailblazer Health Enterprises, LLC, Ambulance, June 2012, pp. 6162.  (Trailblazers 
MAC contract  ended later in  2012, and its  Ambulance  publication was retired.)   
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   19 
   
   
More than half of questionable ambulance transports 
were provided to beneficiaries who resided in four 
metropolitan areas 
Questionable billing for ambulance transports was concentrated in the 
metropolitan areas that include the cities of Philadelphia, Los Angeles, 
New York, and Houston.58  These four areas accounted for 52 percent of 
questionable transports but only 18 percent of all transports during the first 
half of 2012.59  Table 5 presents the percentages of national totals and the 
Medicare payments for questionable transports and all transports provided 
to beneficiaries who resided in the four metropolitan areas during the first 
half of 2012. 
Table 5: Questionable Ambulance Transports and All Ambulance Transports That 
Were Provided to Beneficiaries Who Resided  in Four Metropolitan  Areas, First Half   
of 2012 
Percentage of National Total   Medicare Payments 
Questionable   Questionable  
Area   Transports  All Transports  Transports  All Transports 
Philadelphia, Pennsylvania  15.2%  3.8%  $27.0 million   $88.1 million 
Los Angeles, California   15.2%  4.7%  $32.3 million   $118.6 million 
New York, New  York  13.4%  7.7%  $26.2 million   $194.6 million 
Houston, Texas   8.3%  1.8%  $18.0 million   $46.6 million 
    Total  in All Four Areas  52.0%  18.0%  $103.5 million   $447.9 million 
    All Other Areas  48.0%  82.0%  $103.9 million   $2,407.6 million 
Notes:  Columns may not sum to totals because of  rounding.  Of  the 951 other areas, 133 did not have any questionable transports.  
Source:  OIG analysis of Part B data for Medicare ambulance services, 2013. 
 
Together, the four metropolitan areas with the most questionable 
transports accounted for $104 million of the $207 million in Medicare 
payments for questionable transports provided during the first half of 
2012. The following examples illustrate the extent to which questionable 
billing for ambulance transports is concentrated in these four areas:    
 
____________________________________________________________ 
58 Specifically, the areas include:  (1) PhiladelphiaCamdenWilmington, Pennsylvania 
New JerseyDelawareMaryland; (2) Los  AngelesLong BeachSanta Ana, California; 
(3)  New YorkNorthern New  JerseyLong Island, New  YorkNew JerseyPennsylvania; 
and (4) Houston-Sugar LandBaytown, Texas.  

59 An additional 22 percent of questionable transportsbut only 12 percent of  all 

transportswere provided to beneficiaries who resided in  14  other metropolitan areas.  

See Appendix C for a list of these 14 areas and information about the concentration of 

questionable billing in each area.   

Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   20 
   
   
 	  Although 4 percent of all transports were for beneficiaries who resided 
in the Philadelphia area, 21 percent of questionable dialysis-related 
transports associated with high numbers of transports per beneficiary 
were for beneficiaries who resided in that area.  The Philadelphia area 
accounted for $25.6 million of the $132.5 million in Medicare 
payments for these questionable transports. 
 	  Although 5 percent of all transports were for beneficiaries who resided 
in the Los Angeles area, 45 percent of questionable transports billed 
with compromised beneficiary numbers were for beneficiaries who 
resided in that area.  The Los Angeles area accounted for $12.7 million 
of the $28.8 million in Medicare payments for these questionable 
transports.  
	   Although 8 percent of all transports were for beneficiaries who resided 
in the New York area, 17 percent of questionable transports for which 
the beneficiary did not receive a Medicare service at the origin or 
destination indicated on the transport claim were for beneficiaries who 
resided in that area.  The New York area accounted for $6.5 million of 
the $41.2 million in Medicare payments for these questionable 
transports.  
	   Although 2 percent of all transports were for beneficiaries who resided 
in the Houston area, 97 percent of questionable transports to or from  
PHPs and 39 percent of questionable transports billed with 
compromised beneficiary numbers were for beneficiaries who resided 
in that area. The Houston area accounted for $10.4 million of the 
$10.7 million and $11.0 million of the $28.8 million, respectively, in 
Medicare payments for these types of questionable transports. 
Suppliers that provided transports to beneficiaries who 
resided in the four metropolitan areas received more Medicare 
payments on average than suppliers that provided transports 
to beneficiaries who resided in other metropolitan areas 
On average, ambulance suppliers that provided transports to beneficiaries 
who resided in each of the four metropolitan areas received more 
Medicare payments for the transports than suppliers that provided 
transports to beneficiaries in other metropolitan areas.60 For transports 
provided to beneficiaries who resided in the four metropolitan areas, 
suppliers transported an average of 24 to 69 beneficiaries and beneficiaries 
each accounted for an average of $1,264 to $1,525 during the first half of 
____________________________________________________________ 
60 Among the 955 CBSAs in the Nation, the 373 with the largest populations are 
classified as metropolitan areas. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   21 
   
   
2012. In all other metropolitan areas, suppliers transported an average of 
18 beneficiaries and beneficiaries each accounted for an average of $880.61   
Suppliers each received Medicare payments of $105,696, on average, for 
transporting Los Angeles beneficiaries during the first half of 2012more 
than six times the average supplier payment of $16,137 for transporting 
beneficiaries who resided in metropolitan areas other than the four areas.  
Table 6 compares the four metropolitan areas with all other metropolitan 
areas in terms of the average number of beneficiaries per supplier, 
Medicare payments per beneficiary, and Medicare payments per supplier.   
Table 6:   Medicare Payments for Transports Provided  to Beneficiaries Who 
Resided  in  Metropolitan Areas, First Half  of 2012 
Average Number  Average Medicare  Average Medicare 
of Beneficiaries  Payments per  Payments per 
Metropolitan Area   per Supplier  Beneficiary   Supplier 
Los Angeles, California   69  $1,525   $105,696 
New York, New  York  68  $1,264   $85,606 
Philadelphia, Pennsylvania   38  $1,507   $56,667 
Houston, Texas  24  $1,432   $34,951 
All Other Metropolitan 
18  $880   $16,137
Areas*  
 * Suppliers averages are based on the transports that they provided to the beneficiaries who resided in each 

metropolitan  area.    

Source:  OIG analysis of Part B data for Medicare ambulance services, 2013. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
____________________________________________________________ 
61 The average number of transports per beneficiary was also higher in the four 
metropolitan areas than in other metropolitan areas.  Beneficiaries who resided in the four 
metropolitan areas each received between 3.7 and 4.8 transports on average during the 
first half of 2012.  Beneficiaries who resided in other metropolitan areas each received an 
average of 2.3 transports. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   22 
   
   
CONCLUSION AND RECOMMENDATIONS 
Medicare payments for ambulance transports have increased in recent  
years, and investigators have uncovered a variety of fraud schemes 
involving ambulance suppliers. Our findings suggest that inappropriate 
and questionable billing for ambulance transports continues to pose 
vulnerabilities to Medicare program integrity.   
Medicare paid for ambulance transports that did not meet certain Medicare 
requirements to justify payment.  Medicare also paid for transports that 
may have been billed inappropriately, because our analysis of claims data 
indicates that the beneficiaries did not receive Medicare services at the 
pick up or drop off locations, or anywhere else.  Further, about one in five 
ambulance suppliers had questionable billing, which was geographically 
concentrated among beneficiaries who resided in four metropolitan areas.   
Given the growth of ambulance payments and the findings of this report, 
CMS should enhance existing fraud and abuse safeguards.  Therefore, we 
recommend that CMS:   
Determine whether a temporary moratorium on ambulance 
supplier enrollment in additional geographic areas is 
warranted  
CMS should determine whether to place a temporary moratorium on 
ambulance supplier enrollment in areas where questionable transports are 
concentrated. CMS imposed moratoria in the Houston area in July 2013 
and in the Philadelphia area in January 2014.  However, questionable 
transports were also concentrated in two other metropolitan areas.  The 
Los Angeles area accounted for 15 percent of questionable transports and 
only 5 percent of all transports during the first half of 2012.  The 
New York area accounted for 13 percent of questionable transports and 
only 8 percent of all transports. 
Require ambulance suppliers to include the National Provider 
Identifier of the certifying physician on transport claims that 
require certification 
For ambulance transports that require physician certification, CMS should 
require that the supplier include the National Provider Identifier of the 
physician or other certifying provider on the transport claim.62 Suppliers 
that had questionable billing provided nonemergency basic life support 
____________________________________________________________ 
62 CMS requires that the National Provider Identifier of the ordering provider be included  
on claims for covered imaging and clinical laboratory services and items of durable 
medical equipment, prosthetics, orthotics, and supplies, and that the National Provider 
Identifier of the ordering/certifying provider be included on claims  for home  health  
services.  42 CFR   424.507. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   23 
   
   
transports, which typically require certification, more often than other 
suppliers. The physicians who certified the medical necessity of 
questionable transports cannot be identified in the claims data.  Without 
this identifying information, CMS and other oversight entities are unable 
to conduct certain program integrity activities to ensure that these 
transports meet Medicare coverage requirements.  If necessary, CMS 
should seek legislative authority to make this regulatory change.  The 
National Provider Identifier should also be included on the physician 
certification statement.   
Implement new claims processing edits or improve existing 
edits to prevent inappropriate payments for ambulance 
transports 
CMS should implement claims processing edits in its shared system to 
prevent inappropriate payments for ambulance transports that did not meet 
the requirements that we examined.  These edits should identify claims  
and reject payments for transports that are to or from noncovered 
destinations and transports with inappropriate combinations of  
destinations and transport levels.  
Increase its monitoring of ambulance billing 
CMS should monitor the billing of ambulance transports by using 
measures of questionable billing similar to those that we examined.  
Zone Program Integrity Contractors should identify suppliers that bill at 
unusually high levels for transports with the characteristics described in 
these measures.  CMSs Fraud Prevention System should also be used to 
identify suppliers that have questionable billing for these measures.  As 
appropriate, CMS and its contractors should refer these suppliers to law 
enforcement for investigation.  It may be prudent for CMS to focus its 
monitoring of suppliers billing patterns in geographic areas where 
questionable billing is concentrated.    
Determine the appropriateness of claims billed by ambulance 
suppliers identified in the report and take appropriate action 
In a separate memorandum, we will refer to CMS the claims that did not 
meet certain Medicare requirements and the ambulance suppliers that had  
questionable billing in the first half of 2012.  CMS or its contractors 
should further assess these suppliers  claimsfor example, by reviewing 
medical records or performing unannounced site visits.  CMS should then 
determine what appropriate actions, if any, are needed.  Appropriate 
actions could include recouping any inappropriate payments; suspending 
payments to the supplier; educating the supplier on how to properly bill 
for transports; revoking the suppliers Medicare billing privileges; or 
referring the supplier to law enforcement for criminal investigation.  
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   24 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with our recommendation to determine whether a 
temporary moratorium on ambulance supplier enrollment in additional 
geographic areas is warranted.  CMS stated that it will continue to monitor 
geographic areas for a significant potential for fraud, waste, or abuse, and 
will impose additional temporary moratoria if warranted.   
CMS concurred with our recommendation to require ambulance suppliers 
to include the National Provider Identifier of the certifying physician on 
transport claims that require certification.  CMS stated that it will explore 
the best way to implement our recommendation to require ambulance 
suppliers to include the National Provider Identifier of the certifying 
physician on transport claims that require certification.   
CMS concurred with our recommendation to determine the 
appropriateness of claims billed by ambulance suppliers identified in the 
report and take appropriate action.  CMS stated that it will conduct an 
analysis of the claims identified in this report and determine the 
appropriate number of claims to review.   
Although CMS concurred with our recommendation to increase its 
monitoring of ambulance billing, the actions that it described do not 
appear to fully address the recommendation.  CMS stated that it would 
continue its current monitoring of ambulance billing, whereas we 
recommended that it increase monitoring by using measures similar to 
those outlined in this report to identify ambulance suppliers with patterns 
of questionable billing. In its final management decision, CMS should 
indicate whether and how it plans to increase monitoring.  
CMS partially concurred with our recommendation to implement new 
claims processing edits or improve existing edits to prevent inappropriate 
payments for ambulance transports.  CMS indicated that it will review 
data on claims identified in this report and will consider whether to 
enhance current claims processing edits.  CMS should use the results of its 
review to implement new, or modify existing, claims processing edits 
needed to prevent inappropriate payments. 
We withdrew two recommendations from our draft report. 
For the full text of CMSs comments, see Appendix D.63  
 ____________________________________________________________ 
63 In August  2015, we  offered CMS the opportunity to update its comments on the draft 
report.  CMS provided  updated technical comments, which we incorporated into the final 
report as appropriate.  CMS did not update its formal comments. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   25 
   
   
APPENDIX A    
Ambulance Transport Levels and Medicare Payments in 2012 by Level  
Average 
Procedure   Total Medicare  Number of 
Transport Level   Payment Amount 
Code   Payments  Transports  
per Transport 
Advanced life supportnonemergency    A0426  $82,036,627   315,322   $260  
Advanced life supportemergency   A0427  $2,061,259,816  4,984,105   $414  
Basic life supportnonemergency   A0428  $1,481,128,407  6,685,824   $222  
Basic life supportemergency   A0429  $953,912,406   2,687,644   $355  
Paramedic intercept*  A0432  $1,145,651   3,067   $374  
Advanced life support (level 2)**  A0433   $66,828,516   111,723   $598  
Specialty care transport   A0434  $75,733,041   103,315   $733  
* Paramedic intercept transports are provided when a basic life support ambulance is dispatched but the beneficiary needs advanced life support.   
For these transports, a paramedic emergency medical technician meets the  basic life support ambulance at the scene or once the  ambulance is on   
the way to the hospital.  The paramedic intercept benefit is limited to  certain rural areas, a list of  which is published  periodically in the Federal  
 
Register.  
** Advanced life  support (level 2) transports include the provision of at least three separate administrations of one or more medications or the 
  
provision of at least one level 2 procedure (e.g., central venous line,  chest decompression). 

Notes:  Medicare pays for mileage under procedure code  A0425.  Medicare payments for mileage in 2012 totaled $1,079,084,350.  Dollar amounts  

have been rounded to the nearest whole number.  
 
Source:  CMS, 2012 Part  B National Summary Data File. 
 
 
 
 
 
 
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APPENDIX B 
Detailed Description of Measures of Questionable Billing for 
Ambulance Transports 
We calculated the seven measures of questionable billing as follows: 
1. 	  No Medicare Service at the Origin or Destination. This measure 
represents the percentage of a suppliers transports  to destinations and 
from origins where the beneficiary did not receive Medicare services.  
We identified transports for which the beneficiaries did not receive 
Medicare services within 1 day of their transports at the facilities 
where we expected, on the basis of the origins and destinations 
indicated on the transport claims, that the beneficiaries received 
services. For transports that the supplier indicated were to a covered 
facility (i.e., hospital, dialysis facility, or SNF), we determined 
whether the beneficiaries received services at the destinations.64 For 
transports that the supplier indicated were from a covered facility to a 
residence, we determined whether the beneficiaries received services 
at the origin.65  We did not determine whether beneficiaries received 
services at noncovered facilities.  We identified suppliers with 
unusually high levels of this measure among all 15,614 suppliers.  At a 
minimum, these suppliers incorrectly indicated on their claims the 
transports origin or destination.  Alternatively, suppliers that had 
questionable billing for this measure may have billed for transports 
that were to or from a noncovered destination; transports for which the 
beneficiary did not receive a Medicare service; or transports that were 
not provided. 
 
  Our identification of transports for the first measure of questionable 
billing resembles our identification of (1) ambulance transports for 
which beneficiaries received services only at noncovered destinations 
(see page 7) and (2) transports for which the beneficiaries did not 
receive Medicare services at any origin or destination (see 
page 7). The first measure includes both sets of transports as well as 
transports for which the beneficiaries received services at different 
covered origins or destinations than those indicated on the transport 
____________________________________________________________ 
64 For transports that the supplier indicated  were between a hospital and  dialysis facility, 
we determined whether the beneficiary received a service at either a hospital or dialysis 
facility. 
65 For transports that the supplier indicated  were between a hospital or dialysis facility 
and a SNF, we treated the SNF as though it were the beneficiarys residence and 
determined whether the beneficiary received a service at either a hospital or dialysis 
facility. 
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   27 
   
   
claims.  For example, this measure would include a transport that the 
supplier indicated was to a hospital, but for which the beneficiary did 
not receive a hospital service.  
2. 	  Excessive Mileage for Urban Transports.  This measure represents a 
suppliers average mileage for transports for beneficiaries in urban 
areas. We used census data and beneficiary addresses to identify 
beneficiaries residing in urban areas.66  We identified suppliers with 
unusually high levels of this measure among the 13,352 suppliers with 
urban transports. Suppliers that had questionable billing for this 
measure may have billed for more miles than they actually drove or 
may not have transported beneficiaries to the nearest appropriate 
facility.   
3. 	  High Number of Transports per Beneficiary. This measure represents 
  
the extent to which a supplier that  provides dialysis-related transports 
is associated with beneficiaries who receive unusually high numbers of 
transports.  We determined the total number of transports that each 
beneficiary received from any supplier.  For each supplier of 
dialysis-related transports, we calculated the average number of 
transports per beneficiary.  We identified suppliers with unusually high 
levels of this measure among the 3,265 suppliers with dialysis-related 
transports. Suppliers that had questionable billing for this measure 
may have billed for dialysis-related transports that are medically 
unnecessary or were not provided. 
4.	   Compromised Beneficiary Number. This measure represents 
the percentage of a suppliers transports that were billed using 
compromised beneficiary numbers.  Using the Compromised Numbers 
Contractor database, we identified transports that were billed with 
beneficiary numbers that were compromised at any time before 
June 30, 2012. Because a supplier may have mistakenly billed for 
transports with compromised beneficiary numbers, we identified 
suppliers with unusually high levels of this measure among the 
2,218 suppliers with at least one of these transports.  This allowed us 
to identify suppliers that were outliers compared to other suppliers 
exhibiting the behavior. Suppliers that had questionable billing for 
this measure may have billed for transports that are medically  
unnecessary or were not provided.    
5. 	  Inappropriate or Unlikely Transport Level. This measure represents 
the percentage of a suppliers transports with inappropriate or unlikely 
____________________________________________________________ 
66 We used  census data from  2010.  We defined urban as a metropolitan area, that is, an  
area with a population of at least 50,000.    
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   28 
   
   
combinations of destinations and transport levels.  We identified 
emergency transports to nonhospital destinations and specialty care 
transports between facilities other than hospitals or SNFs, which are 
inappropriate combinations.67  We also identified advanced life support 
transports between destinations other than hospitals or SNFs which, 
according to fraud investigators, are unlikely to be medically 
necessary.  We identified the origins and destinations using the 
modifiers reported by suppliers on their claims.  Because a supplier 
may have mistakenly billed for transports with an unlikely 
combination of destination and transport level, we identified suppliers 
with unusually high levels of this measure among the 2,036 suppliers 
with at least one transport with an inappropriate or unlikely 
combination.  This allowed us to identify suppliers that were outliers 
compared to other suppliers exhibiting the behavior.  Suppliers that 
had questionable billing for this measure may have billed for more 
expensive transport levels than they actually provided or for transports 
that were medically unnecessary. 
Our identification of transports for the fifth measure of questionable 
billing resembles our identification of transports with inappropriate 
combinations of destinations and transport levels (see page 7).  The 
fifth measure includes an additional combinationadvanced life 
support transports between destinations other than hospitals or SNFs 
that is unlikely to be medically necessary but is not necessarily 
inappropriate. 
6. 	  Beneficiary Sharing.  This measure represents the number of suppliers 
providing dialysis-related transports to the beneficiaries transported by 
a given supplier. We determined the total number of suppliers from  
which each beneficiary received at least one dialysis-related 
transport.  For each supplier, we calculated the average number of 
suppliers per beneficiary. For example, if the beneficiaries transported 
by a supplier did not receive transports from any other suppliers, this 
suppliers average number of suppliers per beneficiary would be 1.  If 
the suppliers beneficiaries also received transports from other 
suppliers, the suppliers average number of suppliers per beneficiary 
would be greater than 1.  We identified suppliers with unusually high 
levels of this measure among the 3,265 suppliers with dialysis-related 
transports. Suppliers that had questionable billing for this measure 
may have fraudulently shared beneficiaries, or beneficiaries 
identification numbers, with other suppliers.  Alternatively, these 
____________________________________________________________ 
67  Novitas Solutions, Inc., Ambulance (Ground) Services L32252. CMS, Change Request 
5533, March 30, 2007.   
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   29 
   
   
suppliers may have been involved with beneficiaries who were 

shopping among suppliers to receive kickbacks.   

7. 	  Transports To or From PHPs.  This measure represents the percentage 
of a suppliers transports that were to or from PHPs.  We identified 
transports for beneficiaries who received PHP services within 1 day of 
their transports.  These beneficiaries received PHP services and did not 
receive services at a covered destination.  We identified suppliers with 
unusually high levels of this measure among all 15,614 suppliers.  
Beneficiaries who meet Medicare coverage requirements for PHPs 
generally do not meet the requirements for transports.68 Suppliers that 
had questionable billing for this measure may have billed for 
transports to or from PHPs for beneficiaries who do not qualify for the 
transports.   
 
____________________________________________________________ 
68 Trailblazer Health Enterprises, LLC, Ambulance, June 2012, pp. 6162.  (Trailblazers 
MAC contract  ended later in  2012, and its  Ambulance  publication was retired.)     
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   30 
   
   
APPENDIX C 
Questionable and All Ambulance Transports That Occurred in 14 Additional Areas, First Half  
of 2012 
 
Percentage of National Total   Total Medicare Payments  
Questionable   Questionable  
Area   Transports  All Transports  Transports  All Transports 
AtlantaSandy SpringsMarietta, Georgia  6.7%  1.8%  $13.1 million  $47.2 million 
ChicagoNapervilleJoliet, IllinoisIndianaWisconsin   2.6%  3.8%  $4.7 million  $97.8 million 
Memphis, Tennessee-Mississippi-Arkansas  1.6%  0.8%  $2.9 million  $18.6 million 
Virginia BeachNorfolkNewport News, VirginiaNorth Carolina   1.5%  1.0%  $2.8 million  $23.6 million 
GreenvilleMauldinEasley, South Carolina   1.5%  0.5%  $2.6 million  $12.3 million 
Columbia, South Carolina   1.2%  0.5%  $2.2 million  $12.6 million 
Macon, Georgia   1.1%  0.2%  $2.2 million  $4.0 million 
MiamiFort LauderdalePompano Beach, Florida   1.0%  1.4%  $2.5 million  $37.8 million 
San JuanCaguasGuaynabo, Puerto Rico   0.9%  0.2%  $1.6 million  $3.5 million 
Florence, South Carolina  0.8%  0.3%  $1.6 million  $6.2 million 
IndianapolisCarmel, Indiana  0.8%  0.6%  $1.5 million  $13.7 million 
CincinnatiMiddletown, OhioKentuckyIndiana   0.8%  0.8%  $1.5 million  $21.4 million 
Gainesville, Georgia  0.8%  0.1%  $1.5 million  $2.7 million 
Flint, Michigan  0.8%  0.3%  $1.3 million  $8.1 million
    Subtotal in the 14 Additional Areas  22.2%  12.3%  $42.0 million  $309.5 million
    Subtotal in the 4 Areas With the Most Questionable Transports   52.0%  18.0%  $103.5 million  $447.9 million
    Subtotal in  Other Areas With Questionable Transports*   25.8%  67.8%  $62.0 million  $2,035.6 million
    Subtotal in  Areas Without  Questionable Transports   -- 1.8%  -- $62.5 million
        Total   100%  100%  $207.5 million  $2,855.5 million 
* Includes transports that did not occur  in a Core Based Statistical Area, i.e., transports that occurred in areas with populations of less than 10,000.  
 
Note: Columns may not sum to totals because of rounding. 

Source:  OIG analysis of Part B data for Medicare ambulance services, 2013. 

 
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APPENDIX D 
Agency Comments 
Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351)  32 
   
   
APPENDIX D 
Agency Comments (continued) 
Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351)  33 
   
   
APPENDIX D 
Agency Comments (continued) 
Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351)  34 
   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Blaine Collins, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Michael Henry,  Deputy Regional Inspector General.  
Sarah Ambrose served as the team leader for this study, and 
Veronica Gonzalez served as the lead  analyst.  Other Office of Evaluation 
and Inspections staff from the San Francisco regional office who 
conducted the study include Timothy Brady, Joyce Greenleaf, and 
Bi Nguyen. Central office staff who provided support include 
Berivan Demir Neubert, Evan Godfrey,  Althea Hosein, Scott Manley, and 
Christine Moritz.   
Inappropriate Payments and Questionable Billing for Medicare Part  B Ambulance Transports (OEI-09-12-00351)   35 
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS) programs, as  well  as the health  and welfare of individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.