DEPARTMENT OF HEALTH AND HUMAN SERVICES 
OFFICE OF INSPECTOR GENERAL 
WAS HINGTO N, DC  2020! 
SEP  2 4 2013 
TO: 	 Marilyn Tavenner 
Administrator 
Centers for Medicare & Medicaid Services 
FROM:  Stuart Wright 
Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Memorandum Report:  Utilization ofMedicare Ambulance Transports, 
2002-2011, OEI-09-12-00350 
This memorandum report provides an overview of the changes in utilization of Medicare 
Part B ambulance transports from 2002 through 2011. 
SUMMARY 
The number of ambulance transports reimbursed by Medicare Part B increased 69 percent 
from 2002 to 2011.  This memorandum report provides information about the patterns of 
this utilization growth.  In a forthcoming report, the Office oflnspector General (OIG) 
will identify ambulance suppliers that exhibited characteristics ofquestionable billing in 
the first half of2012 and geographic areas with high numbers of these suppliers. 
From 2002 to 2011, the number of Medicare fee-for-service beneficiaries who received 
transports and the number ofambulance suppliers both increased.  The number of 
beneficiaries who received transports increased 34 percent, although the total number of 
Medicare fee-for-service beneficiaries increased just 7 percent during the same 
period.  The number of ambulance suppliers increased 26 percent.  In addition, the 
number of ambulance suppliers that primarily provided basic life support (BLS) 
nonemergency transports nearly doubled. 
The increase in ambulance transports from 2002 to 2011 varied by the origin and 
destination of the transport.  The number of transports to or from independent dialysis 
facilities (dialysis-related transports) increased 269 percent.  Further, beneficiaries with 
end stage renal disease (ESRD) , a condition that often requires dialysis treatment, used a  Page 2  Marilyn Tavenner 
 
growing and disproportionate amount of transports each year.1 Although transports to or 
from hospitals increased at a significantly slower rate from 2002 to 2011 (55 percent) 
than did dialysis-related transports, they represented a larger proportion of all transports             
(79 percent).  Outpatient visits to receive partial hospitalization program services at 
community mental health centers by beneficiaries who received transports increased    
829 percent.2    
 
We also found that although all States experienced increases in transports from 2002 to 
2011, utilization changes varied widely by State.  States with particularly high growth in 
ambulance utilization experienced increases in dialysis-related transports that were  
greater than the national increase.  These States also experienced increases that were 
greater than the national increase in BLS nonemergency transports and in inpatient 
hospital visits to treat renal failure in  beneficiaries who received transports.   
 
BACKGROUND 
 
Utilization of Medicare Ambulance Transports 
Medicare Part B payments for ambulance transports continue to grow at a faster rate than 
all Medicare Part B payments.  In 1998, OIG reported that Medicare Part B payments for 
ambulance transports more than tripled between 1987 and 1996from $602 million to 
almost $2.1 billion, although during this time all Medicare Part B payments doubled.3, 4   
This trend continued after that period. From 2002 to 2011, Medicare Part B payments for 
ambulance transports increased 130 percent, from $2.0 billion to $4.5 billion.5 During 
this period, all Medicare Part B payments increased 74 percent.6    
 
Several factors have contributed to the increase in payments for ambulance transports.  
The increase was caused in part by inflation and the transition to the national fee schedule 
for Medicare ambulance transports, which was phased in from 2002 through 2005.7   
                                                 
1  ESRD is permanent kidney failure that requires a regular course of dialysis or a kidney transplant.  
Centers for Medicare & Medicaid Services (CMS), Medicare Coverage of Kidney Dialysis & Kidney 
Transplant Services. Accessed at http://www.medicare.gov/Pubs/pdf/10128.pdf, p. 53  on July 3, 2013. 
2 Partial hospitalization programs provide intensive psychiatric care and resemble structured, short-term  
hospital inpatient programs.  Patients admitted to a partial  hospitalization program  (1) do not require  
24-hour supervision as provided in an inpatient setting, (2) must have a support system outside the 
program, and (3) must not  be an imminent danger to themselves or others.  CMS, Medicare Benefit Policy 
Manual, ch. 6   70.3.  
3 OIG,  Medical Necessity of Medicare Ambulance Services, OEI-09-95-00412, December 1998. 
4 Medicare Part B payments totaled $28.4  billion in  1987 and $59.1 billion in  1996. CMS, Medicare and 
Medicaid Statistical  Supplement. 2001  Edition, Table 12.  
5 OIG analysis of CMS Physician/Supplier Part B claims file.  Total Medicare-allowed amounts increased  
from  $2.5 billion to $5.7 billion. 
6 Medicare Part B payments totaled $92.4  billion in  2002 and $160.9  billion  in 2011.  CMS, Medicare and 
Medicaid Statistical  Supplement. 2012  Edition, Table 3.3.   
7 Ambulance fee-schedule amounts are adjusted for inflation using the urban consumer price index,  which 
increased  25 percent from 2002 to  2011.  After taking inflation into account, average allowances are an 
estimated 3 percent higher than they  were before the national fee schedule was implemented.  United States 
Government Accountability Office (GAO), Ambulance Providers:  Costs and Expected Margins Vary 
Greatly, GAO-07-383, p.  6.  
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 3  Marilyn Tavenner 
 
Continued growth in the utilization of transports has also contributed to the increase.  
From 2002 to 2011, the number of Medicare ambulance transports increased 69 percent 
(from 8.7 million to 14.8 million).8     
 
Findings from past OIG reports indicate that the ambulance benefit is vulnerable to 
abuse. One report found that in 1996, two-thirds of ambulance transports that did not 
result in expected hospital or nursing home admissions or emergency room care were 
medically unnecessary.9  Another report found that 25 percent of ambulance transports in 
2002 did not meet Medicare program requirements, resulting in an estimated  
$402 million in improper payments.10  The report also found that 27 percent of transports 
to and from independent dialysis facilities in 2002 did not meet coverage requirements.  
 
Recent cases involving ambulance suppliers also indicate that the ambulance benefit is 
vulnerable to fraud. For example, in October 2012, administrators of a Houston-based 
ambulance supplier pleaded guilty to submitting claims for $1.7 million to Medicare for 
transports that were miscoded, not medically necessary, and in some cases, not 
provided.11  In February 2013, an ambulance supplier operating in South Carolina paid 
$800,000 to settle allegations that it fraudulently billed Medicare for routine, 
nonemergency transports that were not medically necessary and that it created fraudulent 
documents to support the transports.12    
 
Medicare Coverage of Ambulance Transports  
Medicare covers ambulance transports when a beneficiarys medical condition at the time 
of transport is such that using other means of transportation would endanger the 
beneficiarys health.13, 14  In addition, the transport must be to receive a Medicare-covered 
service or to return from such a service.15  Medicare does not limit the number of 
ambulance transports per beneficiary.16  Medicare does not cover means of transport other 
than ambulance.   
 
Covered destinations.  A medically necessary ambulance transport may be covered to and 
from the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic 
                                                 
8 OIG analysis of 2002 and  2011 Physician/Supplier  Part B claims file. 

9 OIG,  Medical Necessity of Medicare Ambulance Services, OEI-09-95-00412, December 1998. 

10  OIG,  Medicare Payments for Ambulance Transports, OEI-05-02-00590, January 2006.   

11 United States Department of Justice, Houston Ambulance Company Administrator Pleads  Guilty to 

Fraud. Accessed at http://www.justice.gov/opa/pr/2012/October/12-crm-1242.html on March 1, 2013. 

12 United States Department of Justice, South Carolina Ambulance Company to Pay U.S. $800,000  to 
 
Resolve False Claims Allegations. Accessed at http://www.justice.gov/opa/pr/2013/February/13-civ-
232.html on March 1, 2013. 

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

14 Although they are not required to do  so, suppliers may include on a transport claim a diagnosis code that 

characterizes the beneficiarys medical condition at the time of transport.   This  diagnosis code is  used by 
 
suppliers to communicate the beneficiarys condition as reported by the dispatch center and as observed  by  

the ambulance crew.  

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

16 Social Security Act  1861(s)(7). 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 4  Marilyn Tavenner 
 
services.17  Medicare covers ambulance transports only to hospitals (including critical 
access hospitals), skilled nursing facilities, the beneficiarys home, and (for beneficiaries 
with ESRD who require dialysis) dialysis facilities.18  
 
Although dialysis facilities are a covered destination, transports to them do not usually 
meet coverage requirements under  Medicare.19  One Medicare Administrative Contractor 
estimated that 10 percent of beneficiaries who receive hemodialysisone of the two 
main types of dialysisrequire ambulance transportation to receive treatment.20   
Beneficiaries who receive dialysis typically have three dialysis sessions per week.21   
Therefore, beneficiaries who require transportation by ambulance to dialysis facilities 
would typically receive six transports per week.   
 
Transport levels. Medicare covers seven levels of ground ambulance transports 
(transport levels).22  Each transport level is billed using a Health Care Procedure Coding 
System code (procedure code).  Table 1 lists each procedure code, transport level, the  
corresponding total amount allowed by Medicare, the total number of transports, and the 
average allowed amount per transport by Medicare in 2011. 
 
Table 1: Medicare Allowances in 2011 for Ambulance Transports and 
Corresponding Mileage, by Procedure Code 
Procedure   Total Allowed  Number of   Average Allowed 
Transport Level   
Code   Amount*  Transports   Amount per Transport*  
Advanced life support 
A0426    $153,146,601  318,886   $480 
(ALS) nonemergency  
A0427   ALS emergency    $2,336,057,963  4,859,616  $481 
A0428   BLS nonemergency    $1,938,054,934  6,714,246  $289 
A0429   BLS emergency    $1,084,838,255  2,643,313  $410 
A0432   Paramedic ALS intercept   $1,137,377  13,079  $87 
A0433   ALS2  $76,074,065   112,038  $679 
A0434   Specialty care transport  $91,540,103   103,641  $883 
*Includes amounts allowed for corresponding mileage for these transports.  Mileage, billed using procedure  code A0425, is billed  
together with the  transport procedure  code.  Mileage does not apply to paramedic ALS intercepts transports.  Dollar amounts have been 
rounded to the nearest whole number.   
 
Source:  OIG analysis of 2011 Medicare Part  B ambulance transports, 2013. 
 
The transport levels are distinguished by the qualifications of the ambulance crew and the 
medical care provided.23  All BLS transports require an ambulance crew certified at least 
                                                 
17  CMS, Medicare Benefit Policy Manual, ch. 10    10.3.  Appropriate facility means that the institution  is 

generally equipped to  provide the needed hospital care or  skilled  nursing care for the illness or injury. 

18 CMS, Medicare Benefit Policy Manual, ch. 10    10.3. 
   
19 Palmetto GBA, Nonemergency Services. Accessed at 

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%201%20Part%20B~
 
Browse%20by%20Specialty~Ambulance~8EEMHW2614?open&navmenu=Browse^by^Specialty|||| on 

May 1,  2012.   

20  Novitas Solutions, Inc., Ambulance (Grounds) Services L32252. 

21 CMS, Medicare Benefit Policy Manual, ch. 11    30.1. 
   
22 Medicare also  covers air ambulance transports by airplane and helicopter. 

23 CMS, Medicare Benefit Policy Manual, ch. 10    30.1.1.  This chapter defines the transport levels. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 5  Marilyn Tavenner 
 
as basic emergency medical technicians.24  All ALS transports require an ambulance crew 
certified at least as intermediate or paramedic emergency medical technicians.  For the 
ambulance transport to be covered as an ALS transport, the beneficiarys condition must 
require an assessment or a service that can be provided only by an ALS crew.  Paramedic 
ALS intercept transports and ALS2 transports are variations of ALS transports.25   
Specialty care transports are interfacility transports for critically injured or ill 
beneficiaries and require that the ambulance crew include a health professional specialist 
(e.g., emergency nurse) or a paramedic emergency medical technician with additional 
training. 
 
The transport level depends not only on the level of service, but also on whether the 
transport is provided in an emergency or nonemergency situation.26  Emergency 
transports are provided according to the protocol of the local 911 or equivalent dispatch.27   
Lack of immediate medical attention in these cases could reasonably be expected to place 
the beneficiarys health in jeopardy, result in serious impairment of bodily functions, or 
result in serious dysfunction of any bodily organ.  Symptoms or conditions that may 
warrant an emergency transport include, but are not limited to, severe pain, bleeding, or 
unconsciousness.28  Nonemergency transports are provided in the absence of an 
emergency to beneficiaries who are bed-confined before and after transportation, or when 
transportation by ambulance is medically required.29, 30  Nonemergency transports may be 
scheduled or unscheduled and may be one-time or recurring.   
 
Medicare covers mileage to and from the nearest appropriate facility when the ambulance 
transport is covered.31  Only miles traveled with the beneficiary onboard are covered.    
 
Related Work 
Both GAO and the Medicare Payment Advisory Commission (MedPAC) have reported 
on the growth in ambulance utilization as part of their work on Medicare Part B payments 
for ambulance transports.  In October 2012, GAO reported on the effect of the ambulance 
                                                 
24  State and local laws that establish  qualifications for emergency medical technicians vary.  For example, 
only in some jurisdictions are basic emergency  medical technicians permitted to establish a peripheral 
intravenous line.  
25 Paramedic intercept transports are provided when a BLS ambulance is dispatched, but the beneficiary 
needs ALS service.  For these transports, a paramedic emergency medical technician meets the BLS 
ambulance at the scene or once the ambulance is on the way to the hospital.  ALS2 transports include the 
provision of at  least three separate administrations of one or  more medications or the provision of at least  
one ALS2  procedure (e.g., central venous line, chest decompression). 
26 CMS, Medicare Benefit Policy Manual, ch. 10  30.1.1.  
27 Ibid. 
28 CMS, Medicare Coverage of Ambulance Services, pp. 56.  Accessed at 
http://www.medicare.gov/Publications/Pubs/pdf/11021.pdf  on May 25, 2012. 
29 CMS, Medicare Benefit Policy Manual,  ch.  10  10.2.3.  To be considered bed-confined, the beneficiary  
must be unable to  get up  from bed  without assistance, ambulate, or sit in a  chair or wheelchair.   
30 While bed-confinement is important in  determining the appropriateness  of nonemergency ambulance 
transports, bed-confinement alone is neither  sufficient  nor necessary to determine coverage for Medicares 
ambulance benefit.    
31 CMS, Medicare Benefit Policy Manual, ch. 10    10.3.  Mileage is billed  on the same claim as the 
transport using procedure code A0425. 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 6  Marilyn Tavenner 
 
fee schedule on beneficiaries access to care.  GAO noted that the increase in utilization 
from 2004 to 2010 was due primarily to an increase in BLS nonemergency transports, 
and that the increase was the greatest in super-rural areas.32 In addition to fraud and 
abuse, the GAO report cites the following as potential reasons for utilization increases:    
(1) new or increased billing by local governments under budgetary pressures that 
previously refrained from billing Medicare for transports and (2) the introduction of the 
national fee schedule for ambulance transports.33 In June 2013, MedPAC reported on the 
ambulance fee schedule.  MedPAC also noted that the utilization of BLS nonemergency 
transports, particularly those that were dialysis-related, grew  faster than the utilization of 
other transport levels from 2007 to 2011.34  
 
OIG is conducting additional analysis of national Medicare ambulance claims data.  This 
analysis will identify ambulance suppliers that exhibited characteristics of questionable 
billing in the first half of 2012, as well as geographic areas with high numbers of these 
suppliers. 
 
METHODOLOGY 
 
Scope 
This evaluation is national in scope and is based on all claims for ground ambulance transports 
from CMSs Physician/Supplier Part B claims  files from 2002 to 2011.  We analyzed claims  
billed under the procedure codes A0425A0429 and A0433A0434.35  We did not review 
transports billed by institution-based ambulance suppliers.36   We analyzed only transports for 
which mileage was also billed.37    
 
We did not review the medical records of beneficiaries who received transports. 
Therefore, we did not determine whether the transports were medically necessary or met 
coding and documentation requirements for coverage.  Generally, we cannot conclude 
whether fraud, waste, or abuse, or other potential reasonssuch as new or increased 
billing by local governments or the introduction of the national ambulance fee  
schedulecaused the changes in ambulance utilization that we report.  
 
                                                 
32 Super-rural areas have  population  densities lower than  rural areas. GAO, Costs and Margins Varied 

Widely; Transports of  Beneficiaries Have Increased, GAO-13-6, October 2012. 
 
33 Ibid. 

34 Ambulance suppliers in this report include independent and institution-based ambulance suppliers.  

MedPAC, Report to the Congress, Medicare  and the Health Care Delivery System, ch. 7, Mandated  

report:  Medicare payment for ambulance services, pp. 178-179, June  2013. 

35  We  did not analyze claims for paramedic ALS intercept transports, which accounted for less than  

one-tenth  of 1 percent  of all transports and were provided only in  New York.  In our analysis, we also
  
included mileage procedure codes A0380 and A0390 and transport procedure codes Q3019 and Q3020, 
 
which  were phased  out as part of the transition to the national fee schedule.  

36 Four percent of ambulance suppliers in  2011 were institution-based suppliers.  OIG analysis of CMSs 

2011  Outpatient 100-percent  Standard  Analytic File.   

37 In  2011, less than 2 percent of transports were billed without mileage.  These include paramedic ALS 

intercept transports and transports for which the beneficiary died after the ambulance was dispatched  but 

before it arrived. 
 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 7  Marilyn Tavenner 
 
Data Sources and Analysis 
We used CMSs Physician/Supplier Part B claims  file, the Denominator file for         
2002 through 2011, and the Medicare Enrollment Database for 2011.  We also used 
CMSs Inpatient and Outpatient 100-percent Standard Analytic Files for 2002 and 2011. 
The Physician/Supplier Part B claims file contains claims submitted by independent 
ambulance suppliers and other noninstitutional providers such as physicians, physician 
assistants, and nurse practitioners. The Denominator file and Medicare Enrollment 
Database both contain enrollment information, such as date of birth and eligibility 
category, about each Medicare beneficiary. The Inpatient and Outpatient Standard 
Analytic Files contain claims submitted by institutions, such as hospitals.  We used the 
18-month files, which include claims processed as of June 30th of the year following the 
dates of service.  
 
We determined the extent to which the utilization of ambulance services changed from  
2002 to 2011. For each year, we analyzed the characteristics of beneficiaries, suppliers, 
and transports and calculated the percentage differences since 2002.  We also calculated 
changes in utilization by State. Furthermore, we calculated the change in certain 
transport characteristics in the States with the largest utilization increases that also 
accounted for at least 3 percent of 2011 transports nationally (high-growth States).  See 
Appendix A for more details of our data analysis.    
 
This inspection was  conducted in accordance with the Quality Standards for Inspection 
and Evaluation approved by the Council of the Inspectors General on Integrity and 
Efficiency. 
 
RESULTS  
 
The Number of Beneficiaries Who Received Transports Increased 34 Percent, 
Compared With the 7-Percent Increase in All Fee-For-Service Medicare 
Beneficiaries, From 2002 to 2011 
Over 1 million more beneficiaries received transports in 2011 than in 2002, an increase of 
34 percent.  In 2002, 3.6 million beneficiaries received transports, compared with         
4.8 million beneficiaries in 2011.  In contrast, the number of Medicare fee-for-service 
beneficiaries increased just 7 percent from 2002 to 2011.   
 
On average, beneficiaries received more transports.  Among beneficiaries receiving 
transports, the number of transports a beneficiary received each year increased from an 
average of 2.4 in 2002 to an average of 3.1 in 2011.   
 
Beneficiaries who received transports were younger, on average, and more likely to be  
eligible for Medicare because of a disability in 2011 than in 2002.  The average age of 
beneficiaries who received transports decreased from 76.7 years to 75.4 years.  This 
change resembled that of the Medicare fee-for-service population, among whom the 
average age decreased from 70.6 years to 69.7 years.  The percentage of beneficiaries 
who received transports and were eligible because of a disability increased from             
13 percent in 2002 to 19 percent in 2011. Similarly, the percentage of Medicare 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 8  Marilyn Tavenner 
 
fee-for-service beneficiaries who were eligible because of a disability increased from    
15 percent in 2002 to 18 percent in 2011. Table 2 presents the percentages of 
beneficiaries who received transports by their Medicare eligibility status from 2002 to 
2011. 
 
Table 2: Percentage of Beneficiaries Who Received Transports  
From 2002 to 2011, by Medicare Eligibility Status 
Disabled  Has ESRD 
Aged  65 and Over 
Year   (Under 65 and  (Regardless of Age  
Without ESRD   Without ESRD)   or Disability Status) *  
2002  85.1%   13.0%   2.3%  
2003   84.4%   13.6%   2.7%  
2004  83.2%   14.4%   3.0%  
2005   82.6%   15.0%   3.1%  
2006  82.2%   15.2%   3.3%  
2007   81.5%   15.7%   3.4%  
2008  81.1%   16.1%   3.4%  
2009   80.4%   16.7%   3.6%  
2010  80.0%   17.4%   3.3%  
2011   78.3%   18.8%   3.2%  
*There are five Medicare eligibility categories.  We combined into a single  category the three  
categories of beneficiaries with ESRD.  (These  three categories distinguish ESRD beneficiaries  
by age and disability status.)  
Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013.  
Note: Percentages do not add to 100  percent  because  transport-receiving beneficiaries whose   
age or ESRD status  changed during the course of the year were counted more than once.  
Less than 1 percent of  beneficiaries who received transports were counted more than once   
in each year.   
 
Twenty-Six Percent More Ambulance Suppliers Provided Transports in 2011 Than 
in 2002 
Over 3,500 more ambulance suppliers provided transports in 2011 than in 2002 and, on 
average, suppliers provided more transports.  The number of suppliers increased            
26 percent (from 14,087 to 17,776).  Additionally, suppliers provided an average of       
34 percent more transports in 2011 than in 2002 (increasing from 619 to 830 transports 
per supplier). 
 
Ambulance suppliers billed for greater average transport distances.  The average trip 
length increased 1.6 miles (from 7.8 to 9.4 miles).  Furthermore, suppliers billed for 
longer-mileage transportsi.e., those that were more than 20 miles111 percent more 
often in 2011 than in 2002. However, Medicare beneficiaries were no more likely to live 
in a rural location in 2011 than in 2002.38  
                                                 
38 In  2002, 31.2  million Medicare beneficiaries lived in  urban locations and 9.3 million in rural
  
locations.  In 2011, 39.1 million Medicare beneficiaries lived in urban locations and  9.8  million in rural  

locations.  CMS, Medicare and Medicaid  Statistical Supplement. 2004 Edition, Table 6,  and 2012 Edition, 

Table 2.3.  

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 9  Marilyn Tavenner 
 
The number of ambulance suppliers that primarily provided BLS nonemergency 
transports nearly doubled.39   The number of ambulance suppliers that primarily provided 
a single transport level increased from 2002 to 2011.  In particular, the number of 
suppliers that primarily provided BLS nonemergency transports increased 92 percent 
during this period. In 2002, these suppliers represented 7 percent of all suppliers and 
billed for 16 percent of all transports. In 2011, they represented 11 percent of suppliers 
and billed for 30 percent of all transports.  Table 3 presents the growth in the numbers of 
suppliers that usually provided a single transport level.   
 
Table 3: Ambulance Suppliers That Primarily Provided a Single Transport Level 
in 2002 and 2011 
Suppliers That  Suppliers That  Suppliers That  Suppliers That 
Primarily Provided  Primarily Provided  Primarily Provided  Provided a Mix  All  
Year 
BLS Nonemergency   ALS Emergency  Another Single  of Transport  Suppliers  
Transports   Transports   Transport Level*   Levels  
2002   981  2,862  2,839   7,405   14,087  
2011   1,881  4,060  3,067   8,768   17,776  
Percentage 
92%  42%   8%   18%   26%  
Change  
*Most of these  suppliers primarily provided BLS emergency transports (94 percent in 2002 and 97 percent in 2011). 

Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013. 

 
The number of suppliers that primarily provided ALS emergency transports also 
increased at a greater rate than the overall number of suppliers.  In 2002, these suppliers 
represented 20 percent of all suppliers and billed for 8 percent of all transports.  In 
2011, they represented 23 percent of suppliers and billed for 10 percent of all transports. 
 
In addition to the growth in the numbers of suppliers that primarily provided BLS 
nonemergency transports or ALS emergency transports, the overall use of these transport 
levels increased more than that of other transport levels.  In 2002, beneficiaries received 
3.5 million BLS nonemergency transports, a figure that increased to 6.7 million in     
2011 (a 94-percent increase).  Similarly, the total number of ALS emergency transports 
increased from 2.9 million in 2002 to 4.9 million in 2011 (a 68-percent increase).  See 
Appendix B for the changes from 2002 to 2011 in the use of each transport level.  
 
The Number of Dialysis-Related Transports Increased 269 Percent From 2002 to 
2011 
Dialysis-related transports increased the most, compared with transports to or from other 
origins and destinations.40  These transports increased 269 percent (from 753,741 to 
2,780,323). They represented 9 percent of all transports in 2002 and 19 percent of all 
transports in 2011. 
 
                                                 
39 For the purpose of this report, we use the term primarily provided to mean those suppliers for which a 

single transport level accounted  for at least 75 percent of the suppliers transports. 

40  We considered a transport to be dialysis-related if the two-letter modifier on the claim indicated an 
 
independent dialysis facility as  the origin or destination.  

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 10  Marilyn Tavenner 
 
Beneficiaries with ESRD who received transports accounted for an increasing percentage 
of all ambulance transports. Although beneficiaries with ESRD did not make up a large 
percentage of beneficiaries who received transports, this group used a growing and 
disproportionate number of transports.  From 2002 to 2011, the percentage of 
beneficiaries with ESRD who received transports varied little.  However, the percentage  
of transports associated with these beneficiaries increased from 11 percent to 22 percent.  
Most of these transports were dialysis-related.  Figure 1 presents the percentage of 
beneficiaries with ESRD who received transports and their share of all transports from  
2002 through 2011. 
 
Figure 1: Percentage of Beneficiaries With ESRD Who Received Transports  
and Their Share of All Ambulance Transports From 2002 to 2011 
30% 
25% 
24%  24%  25% 
25%  22% 
21%  21% 
20%  19% 
14% 
15% 
11% 
10% 
5%  2%  3%  3%  3%  3%  3%  3%  4%  3%  3%
0%
 
2002  2003  2004  2005  2006  2007  2008  2009  2010  2011
 
Percentage of beneficiaries  Percentage of transports 
 
Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013.  
Note: Percentages are rounded  to the  nearest whole number. 
 
More Medicare fee-for-service beneficiaries with ESRD received transports and, on 
average, received a greater number of transports in 2011 than in 2002.  The number of 
transport-receiving Medicare fee-for-service beneficiaries with ESRD increased 
85 percent. In contrast, the number of all Medicare fee-for-service beneficiaries with 
ESRD increased 24 percent during the same  period.  In addition, the average number of 
transports a beneficiary with ESRD received each year increased from 12 transports to  
21 transports. 
 
The Number of Transports To or From Hospitals Increased 55 Percent From 2002 
to 2011 
The number of transports to or from hospitals increased significantly less than the 
number of dialysis-related transports but accounted for 79 percent of all transports in 
2011.41  The number of transports to or from hospitals increased 55 percent, from  
7.5 million in 2002 to 11.7 million in 2011.  In 2011, over three-quarters of transports to 
or from hospitals had hospitals as their destinations (for example, from the beneficiarys 
                                                 
41  We considered a transport to be to  or from the hospital if the two-letter modifier indicated a hospital as 
the origin or destination.  
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 11  Marilyn Tavenner 
 
residence to the hospital), and the remainder were from hospitals to other destinations.  
Between 2002 and 2011, there were changes in the origins, transport levels, medical 
conditions of beneficiaries at the time of transport, and destination facilities of transports 
to hospitals. 
 
The origins of transports to hospitals changed. Notably, transports to hospitals 
originating from the scene of an accident or acute event increased 112 percent from   
2002 to 2011, representing 13 percent of transports to hospitals in 2011.  Transports 
originating from a residence increased 51 percent, representing half of all transports to  
hospitals in 2011. 
 
Suppliers provided certain levels of transports more frequently for transports to hospitals. 
Emergency transports to hospitals increased 65 percent from 2002 to 2011, compared 
with the 14-percent increase in nonemergency transports to hospitals.  The type of 
emergency transport level that increased the most was ALS emergency transports, which 
increased 69 percent and represented 55 percent of all transports to hospitals in 2011.  
BLS emergency transports increased 60 percent from 2002 to 2011, and represented      
30 percent of transports to hospitals in 2011. 
 
For transports to hospitals, the respective prevalences of 15 diagnosis codes that represent 
the beneficiarys medical condition at the time of transport increased at least 
100 percent.42  Of all the diagnosis codes used to report the beneficiarys medical 
condition at the time of transport, 15 codes were reported more than twice as often in 
2011 than in 2002 among transports to hospitals.43 Transports using these 15 codes 
represented a combined 35 percent of transports to hospitals in 2011.  See Table 4 for the 
changes from 2002 to 2011 in medical conditions reported at the time of transport among 
transports to hospitals.  
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
42 This analysis is based  on transports to  hospitals for which the supplier reported the diagnosis code that 
represents the beneficiarys medical condition at the time of transport.  The diagnosis code was reported on  
92 percent and 100 percent  of  transport claims in  2002 and 2011, respectively.  OIG analysis of 2002 and 
2011 CMS Physician/Supplier Part B claims file. 
43  We  report only the diagnosis codes that each represented at least 0.5 percent of transports to  hospitals in  
2011. 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 12  Marilyn Tavenner 
 
Table 4: Most Frequent Medical Conditions Reported at the Time of Transport 
Among Transports to Hospitals by Percentage Change From 2002 to 2011 
Percentage Change,  Percentage of 2011 
Medical Condition at the Time of Transport  
20022011   Transports  
Gastritis and duodenitis  3,090%   0.7%  
Crushing injury or internal injury   939%   0.8%  
Diabetes mellitus without complication  606%  0.7% 
Other fractures   468%   1.1%  
Other nervous system disorders  239%   1.4%  
Schizophrenia and other psychotic disorders  193%   1.5%  
Residual codes, unclassified  176%   13.1%  
Other circulatory disease  143%   1.8%  
Other injuries and conditions due to external causes  143%   5.8%  
Headache, including migraine  136%   1.0%  
Complication of device, implant, or graft   135%   0.7%  
Delirium, dementia, and amnestic and other cognitive 
133%   0.7%  
disorders 
Nausea and vomiting  128%   2.6%  
Open wounds of extremities   123%   0.5%  
Other connective tissue disease   101%   2.1%  
Source:  OIG analysis of 2002 and 2011 Medicare Part B  ambulance transports, 2013. 

Note:  Includes only  those conditions  that account for more than 0.5 percent of 2011 transports to hospitals. 

 
Not all transports that were billed using the destination modifier code for hospitals were 
to hospitals; the number of transports to nonhospital facilities increased. Transports to 
hospitals resulted in outpatient visits at hospitals and nonhospital facilities more often 
than inpatient hospital visits. Beneficiaries who received transports made 40 percent 
more outpatient hospital visits in 2011 than in 2002 (from 3.6 million visits in 2002 to         
5.0 million in 2011).  In contrast, all Medicare fee-for-service beneficiaries made           
20 percent more outpatient hospital visits.  Beneficiaries who received transports made 
37 percent more outpatient visits at nonhospital facilities (from 373,734 visits in 2002 to 
512,963 visits in 2011).44  In contrast, all Medicare fee-for-service beneficiaries made    
27 percent more outpatient visits at nonhospital facilities.  The number of inpatient 
hospital visits made by beneficiaries who received transports increased 13 percent (from 
3.3 to 3.7 million), mirroring the increase in inpatient hospital admissions from 2002 to 
2011. 
The number of outpatient visits to certain nonhospital facilities made by beneficiaries 
who received transports increased greatly.  In particular, between 2002 and  
2011 there was an 829-percent increase in visits by beneficiaries who received transports 
to receive partial hospitalization program services at community mental health 
                                                 
44 Although beneficiaries who received transports visited nonhospital facilities such as community mental 
health centers and dialysis facilities, the associated transports were billed  by the supplier as though they 
involved a visit to a hospital. 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 13  Marilyn Tavenner 
 
centers.45  In contrast, all outpatient visits to receive partial hospitalization program  
services at community mental health centers increased only 157 percent during this 
period. See Table 5 for the types of visits and facilities associated with transports to 
hospitals. 
 
Table 5: Types of Visits and Facilities Associated With Ambulance  
Transports to Hospitals by Percentage Change From 2002 to 2011 
Percentage of Visits 
Percentage Change,   
Types of Visits and Facilities   Associated With Transports 
20022011  
to Hospitals in  2011  
Inpatient visits at hospitals  13%   40.3%  
Outpatient visits at hospitals*   40%   54.2%  
Outpatient visits at nonhospital facilities**   37%  5.5% 
     Community mental health centers  829%   0.1% 
     Federally qualified health centers  142%   0.7% 
     Independent dialysis facilities  62%   1.9% 
     Rural health clinics  67%   0.9%  
*Includes critical access hospitals and  Medicare Part  B services provided to inpatient  beneficiaries without Part A coverage. 

**We report the  facility types with the greatest increases from 2002 to 2011.   

Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013. 

 
Beneficiaries were transported to hospitals for inpatient visits to treat certain conditions 
more frequently in 2011 than in 2002.46  Visits to treat septicemia increased 164 percent, 
visits to treat renal failure increased 158 percent, and visits related to rehabilitation 
increased 99 percent. 
Increases in Ambulance Utilization From 2002 to 2011 Varied Widely by State  
Although all States experienced increases in transports from 2002 to 2011, utilization 
changes varied widely by State. High-growth States experienced increases that were 
greater than the national increase in dialysis-related transports, BLS nonemergency 
transports, and inpatient hospital visits to treat renal failure in beneficiaries who received 
transports.  
 
Among the States, the change in ambulance utilization varied from an increase of  
8 percent in Utah to an increase of 289 percent in California.  Ten States experienced 
increases of greater than 100 percent and six States experienced increases of 25 percent 
or less. Figure 2 illustrates the percentage change from 2002 to 2011 in ambulance 
utilization by State.   
                                                 
45 Ambulance transports to partial hospitalization  programs generally do  not meet Medicare coverage  
requirements.  Most beneficiaries do  not meet the coverage  criteria for both  partial hospitalization programs 
and ambulance transports.  For example, under a now-retired  policy from Trailblazer Health Enterprises 
LLC, if a beneficiary was transported via ambulance because he was a danger to  himself and/or  others, he  
would not have been eligible for the partial hospitalization program.  Trailblazer Health Enterprises,  LLC, 
Ambulance, June 2012, pp. 6162. (This policy is retired because Trailblazer Health Enterprises, LLC, is 
no longer a MAC.) 
46  We identified claims for inpatient hospital visits that were associated with beneficiaries transports to 
hospitals.  We report the conditions that represent at least 1  percent of all conditions that were treated 
during  beneficiaries inpatient visits.  
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 14  Marilyn Tavenner 
 
Figure 2:   Percentage Change From 2002 to 2011 in Ambulance  
Utilization by State  
 
 
Percentage Change           8%26%               28%42%              42%51% 
                53%64%        66%118%            124%301%  
Note: Two territories experienced significant increases in  ambulance utilization, and another  territory experienced the only decrease in  
utilization.  (Ambulance utilization  increased 34,092 percent in Guam and 31,613 percent in  the  Northern Marianas, and decreased           
71 percent in Puerto Rico.)  However, these three territories together accounted for less than 1 percent  of all transports in 2011. 
Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013.  
 
In addition to the overall increase in the number of transports, changes in beneficiaries 
who received transports and supplier utilization also varied widely by State: 
	   Nationally, the number of beneficiaries who received transports increased 34 percent.  
Among the States, the change in the number of beneficiaries who received transports 
varied from an increase of 1 percent in Pennsylvania to an increase of 110 percent in 
California. 
	   Nationally, the average number of transports per beneficiary increased 26 percent.  
Among the States, the change in the average number of transports per beneficiary 
varied from a decrease of 1 percent in Vermont to an increase of 85 percent in 
California. 
	   Nationally, the number of suppliers increased 26 percent.  Among the States, the 
change in the number of suppliers varied from a decrease of 25 percent in Mississippi 
to an increase of 207 percent in Virginia. 
	   Nationally, the average number of transports per supplier increased 34 percent.  
Among the States, the change in the average number of transports per supplier varied 
from a decrease of 20 percent in Virginia to an increase of 274 percent in California.   
 
See Appendix C for the changes in these utilization measures for all States and territories.  
Appendix C also presents, for all States and territories, changes in the number of  
transports for each transport level and changes in the number of transports between 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 15  Marilyn Tavenner 
 
various origins and destinations. 
 
After California, the other high-growth States were Virginia, South Carolina, Georgia, 
and New Jersey.47  Ambulance utilization in these four States increased between             
126 percent and 145 percent.  Virginia, South Carolina, and Georgia each accounted for  
3 percent of transports in 2011, and New Jersey accounted for 5 percent.  The number of 
beneficiaries who received transports increased between 39 and 110 percent in the 
high-growth States. In contrast, the number of all Medicare fee-for-service beneficiaries 
increased between 8 and 24 percent in those same States.   
 
The increase in dialysis-related transports in the high-growth States was much greater 
than the national increase.  Beneficiaries who received transports in the high-growth 
States received between 329 percent and 6,920 percent more dialysis-related transports in 
2011 than in 2002. Nationally, dialysis-related transports increased 269 percent.  The 
greatest increase in dialysis-related transports occurred in South Carolina.  In 
2002, 2 percent of South Carolinas transports were dialysis-related, a share that grew to 
48 percent in 2011.  Additionally, the numbers of beneficiaries with ESRD who received 
transports in the high-growth States increased between 83 and 166 percent.48 In four of 
the five high-growth States, this increase exceeded the national increase of 85 percent.   
Table 6 presents the changes in dialysis-related transports, the percentage of               
2011 transports that were dialysis-related, and changes in the number of beneficiaries 
with ESRD who received transports within each of the five States and nationally.        
  
Table 6: Percentage Change in Dialysis-Related Ambulance Transports  
and Beneficiaries with ESRD Who Received Transports From 2002 to 2011 
 
Percentage Change in   Percentage of   Percentage Change in  
 
State   Dialysis-Related   2011 Transports That  Beneficiaries With ESRD 
 
Ambulance Transports  Were Dialysis Related  Who Received Transports    
 
National  269%   19%   85%  
 
South Carolina   6,920%   48%   83%    
 
California  2,727%   28%   166%    
 
Georgia  1,138%   33%   102%    
 
Virginia  329%   26%   133%    
New Jersey   857%   29%   127%    
 
Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013. 
 
The increase in BLS nonemergency transports in the high-growth States was greater than 
the national increase. The high-growth States experienced increases in BLS 
nonemergency transports ranging from 126 percent to 554 percent.  Nationally, BLS 
nonemergency transports increased 94 percent.  The greatest increase in BLS 
nonemergency transports occurred in California.  In 2002, 31 percent of Californias 
transports were BLS nonemergency transports, a share that grew to 53 percent in 2011.  
                                                 
47 Ambulance utilization in Maryland and Alaska increased  138 percent and 136 percent, respectively,  but
  
accounted for 1 percent and less than  1 percent of all 2011 transports, respectively. 

48 In contrast, the numbers of all Medicare fee-for-service beneficiaries with ESRD in these States 

increased between 18 and 36 percent. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 16  Marilyn Tavenner 
 
Table 7 presents the changes in BLS nonemergency transports within each of the five 
States and nationally. 
 
Table 7:  Percentage Change in BLS Nonemergency   
Ambulance Transports From 2002 to 2011 
 
Percentage Change,  Percentage of    
State  
20022011   2011 Transports    
 
National  94%   46%    
 
California  554%   53%    
 
Georgia  301%   51%  
 
South Carolina   218%   68%    
 
New Jersey   144%   71%    
 
Virginia  126%   51%    
 
Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013.  
 
In the high-growth States, the increase in the number of inpatient hospital visits to treat 
renal failure in beneficiaries who received transports was greater than the national 
increase.  High-growth States experienced increases in the numbers of inpatient hospital 
visits to treat renal failure in beneficiaries who received transports.  These increases 
ranged from 184 percent to 403 percent. Nationally, the number of inpatient hospital 
visits to treat renal failure in beneficiaries who received transports increased 158 percent.  
The greatest increase occurred in Virginia. In 2002, 1 percent of Virginias inpatient 
visits associated with transports to hospitals were to treat renal failure, a share that grew 
to 3 percent in 2011. 
 
   
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 17  Marilyn Tavenner 
 
CONCLUSION 
 
Payments for ambulance transports from 2002 to 2011 increased 130 percent, compared 
to the 74-percent increase in overall Medicare Part B payments.  Increases in the 
utilization of ambulance transports are disproportionate in relation to increases in the 
population of Medicare fee-for-service beneficiaries.   
 
We found thatamong many significant changes from 2002 to 2011dialysis-related 
transports were much more common in 2011 than in 2002, increasing 269 percent.  In 
addition, beneficiaries with ESRD who received transports used a growing and 
disproportionate amount of transports each year.  Further, the number of Medicare 
fee-for-service beneficiaries with ESRD who received transports increased 85 percent 
from 2002 to 2011.  In contrast, the number of all Medicare fee-for-service beneficiaries 
with ESRD increased only 24 percent during that period.   We found that high-growth 
States experienced increases in dialysis-related transports greater than the national 
increase. Although dialysis facilities are a covered destination, transports to them do not 
usually meet coverage requirements under Medicare.49  
 
We did not determine whether the utilization changes described in this memorandum  
report were appropriate, that is, whether transports met Medicare coverage requirements.  
In a forthcoming report, OIG will identify ambulance suppliers that exhibited 
questionable billing characteristics in the first half of 2012 and geographic areas with 
high numbers of these suppliers. 
 
This report is being issued directly in final form because it contains no recommendations.  
If you have comments or questions about this report, please provide them within 60 days.  
Please refer to report number OEI-09-12-00350 in all correspondence.   
                                                 
49  Novitas Solutions, Inc., Ambulance (Grounds) Services L32252. 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     APPENDIX A 
 
Detailed Data Analysis Methodology  
 
We calculated the change in beneficiary, supplier, and transport characteristics from   
2002 to 2011. 
 
Beneficiary characteristics. We used the 2002 to 2011 Denominator files to determine 
the percentage of Medicare fee-for-service beneficiaries who received ambulance 
transports.  We calculated the total number of beneficiaries who received transports.  We  
calculated the average number of transports per beneficiary.  We calculated beneficiaries 
average age and the percentage of beneficiaries in each Medicare eligibility category 
using the date of birth and eligibility category reported on each claim.50 As another 
measure of beneficiaries utilization, we also calculated the percentage of transports 
received by beneficiaries in each Medicare eligibility category.51    
 
Supplier characteristics. We calculated the total number of ambulance suppliers.  We  
defined an ambulance supplier as each unique provider identification number, combined 
with a Medicare Administrative Contractor identification number, in our population of 
ambulance claims.52  We calculated the average number of transports per supplier.  In 
addition, we calculated the percentages of each suppliers transports that were billed with 
each procedure code, that is, the suppliers breakdown of transport levels.  We identified 
suppliers for which at least 75 percent of the suppliers transports were billed with the 
procedure code for a single transport level. 
 
Transport characteristics.  Using CMSs Physician/Supplier Part B claims file, we 
calculated the frequency of the different transport levels, the frequency of transport origins 
and destinations, the average transport length in miles, and the beneficiarys medical 
condition at the time of transport.  We determined the origin and destination using the 
two-letter modifier on the claim.  We calculated the average transport length in miles.   We  
determined the beneficiarys medical condition at the time of transport by analyzing the 
International Classification of Diseases code on each ambulance claim.    
 
 
 
 
 
 
                                                 
50 For 2011  only, we used the Enrollment Database file to identify the beneficiarys eligibility category. 
51 People can become eligible for Medicare if  they are 65 years or older.  People under 65  years old can 
become eligible for Medicare if they are disabled and/or  have ESRD. 
52 We did not use the National Provider Identifier because it was not required before May 2008 and 
therefore could not have been  used to identify unique suppliers in all the years included in  our scope.  The 
provider identification  number is unique only  within each Medicare Administrative Contractors 
jurisdiction; combining the provider identification number and the Medicare Administrative Contractor  
identification number allowed us to identify unique suppliers.   
    Page 19  Marilyn Tavenner 
 
Detailed Data Analysis Methodology, continued  
 
We analyzed the type of visits (inpatient or outpatient) made by beneficiaries who 
received transports to hospitals.   We identified claims from CMSs Inpatient and 
Outpatient 100-percent Standard Analytic Files that were associated with transports to 
hospitals. We considered an inpatient claim  to be associated with the transport if the 
beneficiary health insurance claim number matched the number on the transport claim 
and the inpatient admission date was within 2 days of the transport.  If the transport did 
not have an associated inpatient claim, we determined whether the transport had an 
associated outpatient claim.   We considered an outpatient claim to be associated with the 
transport if the beneficiary health insurance claim number matched the number on the 
transport claim and the date of service was within 31 days of the transport.  We allowed 
the additional days for associated outpatient claims because transports may be provided 
during an outpatient billing period (for example, during a skilled nursing facility stay). If 
the transport had multiple associated outpatient claims, we chose the outpatient claim  
with the date of service that was closest to the date of the transport.  For associated 
outpatient claims, we analyzed the type of  bill to determine the most common type of  
outpatient facility that provided medical services to the beneficiary. For associated 
inpatient claims, we determined the most common Medicare severity diagnosis related 
groups (condition) of the inpatient stays.   
 
Characteristics of utilization growth in States with the highest growth. We assigned each 
transport to a State based on the beneficiarys residence ZIP Code reported on the claim.   
We assigned each ambulance supplier to a State based on the majority of its transports.   
For each State, we calculated the change from 2002 to 2011 in the number of transports, 
number of beneficiaries who received transports, average number of transports per 
beneficiary, number of suppliers, and average number of transports per supplier.  We also 
calculated the change during this period by State in the frequency of transports of 
different levels and transport origins and destinations.   
 
We identified the States with the largest utilization increases that also accounted for at 
least 3 percent of 2011 transports nationally (high-growth States).  We determined the 
extent to which these high-growth States experienced changes from 2002 to 2011 that 
differed from the national changes in transport destinations, transport levels, and medical 
services received by beneficiaries who received transports to hospitals.      
 
 
 
 
 
 
 
 
 
 
 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 20  Marilyn Tavenner 
 
APPENDIX B  
 
Number of Ambulance Transports From 2002 to 2011 for Selected Transport Levels  
 
8 
s 
n
o
Milli 7 
6 
Basic life support 
nonemergency 
5 
Advanced life support 
4  emergency 
3  Basic life support 
emergency 
2 
Advanced life support 
1  nonemergency 
0 
2002  2003  2004  2005  2006  2007  2008  2009  2010  2011 
 
Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013. 

Note: Three of  the  seven transports levels (paramedic advanced life support intercept, advanced life  support 2, and  specialty  care 

transport) are not shown in this figure because collectively they represented less than 2 percent  of all transports each year.
  
 
 
 
 
 
 
 
 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 21  Marilyn Tavenner 
 
APPENDIX C 
 
 
Table  C-1:   Percentage  Changes From 2002 to 2011 in Utilization Measures by 
State 
 
Number of   Average  Average Number  
Number of   Number of  
Beneficiaries  Number of   of Transports per 
State   Ambulance  Ambulance 
Who Received  Transports per  Ambulance 
Transports   Suppliers  
Transports   Beneficiary   Supplier  
National   69%   34%   26%   26%   34%  
Alabama  49%   26%   18%   -13%   71%  
Alaska  136%   108%   13%   93%   22%  
Arizona  42%   33%   6%   -4%   48%  
Arkansas  63%   48%   10%   -1%   65%  
California  289%   110%   85%   4%   274%  
Colorado  77%   52%   16%   6%   66%  
Connecticut  70%   37%   24%   21%   40%  
Delaware  118%   74%   25%   19%   83%  
District of Columbia  301%   239%   18%   -50%   702%  
Florida  46%   23%   18%   7%   36%  
Georgia  133%   44%   61%   13%   107%  
Guam  34,092%   693%   4,214%   *  * 
Hawaii  95%   77%   10%   0%   95%  
Idaho  46%   34%   10%   77%   -17%  
Illinois  64%   45%   13%   41%   16%  
Indiana  118%   36%   60%   31%   66%  
Iowa  42%   31%   8%   12%   26%  
Kansas  42%   30%   9%   4%   37%  
Kentucky  41%   22%   15%   37%   3%  
Louisiana  20%   11%   7%   4%   15%  
Maine  26%   14%   10%   1%   25%  
Maryland  138%   103%   17%   24%   91%  
Massachusetts  41%   30%   9%   1%   39%  
Michigan  41%   12%   25%   16%   22%  
Minnesota  25%   13%   10%   -16%   48%  
Mississippi  53%   36%   12%   -25%   104%  
Missouri  50%   42%   6%   11%   35%  
Montana  33%   23%   8%   6%   26%  
Nebraska  61%   42%   14%   37%   18%  
Nevada  71%   53%   12%   10%   55%  
New Hampshire   53%   35%   13%   5%   46%  
New Jersey   126%   42%   59%   75%   29%  
*We assigned each ambulance supplier to a State based on the majority of the suppliers claims.  Using this method, the State had   
zero suppliers in 2002 and/or 2011. 
continued on next page 
 
 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 22  Marilyn Tavenner 
 
Table  C-1:   Percentage  Changes From 2002 to 2011 in Utilization Measures by 
State, continued 
 
 
Number of   Average  Average Number  
Number of   Number of  
Beneficiaries  Number of   of Transports per 
State   Ambulance  Ambulance 
Who Received  Transports per  Ambulance 
Transports   Suppliers  
Transports   Beneficiary   Supplier  
New Mexico  54%   38%   12%   1%   53%  
New York   31%   9%   20%   23%   6%  
North Carolina   83%   56%   17%   87%   -2%  
North Dakota   24%   10%   13%   -1%   25%  
Northern Marianas  31,613%   413%   6,088%   *  * 
Ohio  54%   27%   21%   60%   -4%  
Oklahoma  51%   42%   7%   -19%   87%  
Oregon  38%   23%   12%   41%   -3%  
Pennsylvania  66%   1%   64%   1%   64%  
Puerto Rico   -71%   -58%   -33%   72%   -83%  
Rhode Island   124%   83%   23%   41%   60%  
South Carolina   140%   39%   73%   93%   24%  
South Dakota   40%   29%   8%   5%   34%  
Tennessee  64%   35%   22%   24%   32%  
Texas  51%   31%   15%   46%   3%  
Utah  8%   2%   5%   11%   -3%  
Vermont  28%   29%   -1%   9%   18%  
Virgin Islands  83%   29%   42%   -33%   174%  
Virginia  145%   96%   25%   207%   -20%  
Washington  60%   43%   12%   86%   -14%  
West Virginia   22%   7%   14%   -1%   23%  
Wisconsin  24%   7%   15%   3%   20%  
Wyoming  51%   39%   9%   2%   48%  
*We assigned each ambulance supplier to a State based on the majority of the suppliers claims.  Using this method, the State had  
 
zero suppliers in 2002 and/or 2011. 

Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 23  Marilyn Tavenner 
 
Table  C-2:   Percentage  Changes From 2002 to 2011 in the Number of Transports in 
Each Transport Level by State 
 
Specialty  
ALS   ALS   BLS  BLS 
ALS2   Care 
State   Nonemergency   Emergency   Nonemergency   Emergency  
(A0433)   Transport 
(A0426)   (A0427)   (A0428)   (A0429)  
(A0434)  
National  -40%   68%   94%   57%   18%   114%  
Alabama  -29%   38%   74%   45%   132%   196%  
Alaska  22%   206%   124%   101%   8%   57%  
Arizona  25%   50%   20%   39%   -31%   21%  
Arkansas  -16%   95%   58%   67%   46%   205%  
California  15%   180%   554%   157%   82%   371%  
Colorado  -46%   96%   83%   87%   29%   -37%  
Connecticut  1%   93%   65%   73%   -69%   58%  
Delaware  -34%   85%   109%   134%   100%   22%  
District of Columbia  137%   2,898%   53%   1,598%   3,333%   500%  
Florida  -60%   58%   69%   34%   4%   229%  
Georgia  -18%   58%   301%   97%   2%   394%  
Guam  0%   274%   143,200%   117%   *  * 
Hawaii  210%   134%   117%   18%   32%   329%  
Idaho  35%   53%   65%   33%   128%   -12%  
Illinois  5%   99%   44%   62%   122%   72%  
Indiana  32%   91%   183%   36%   -24%   283%  
Iowa  -36%   56%   31%   61%   21%   61%  
Kansas  -23%   53%   9%   64%   10%   71%  
Kentucky  -4%   46%   49%   28%   25%   -22%  
Louisiana  -47%   18%   27%   39%   77%   612%  
Maine  -26%   37%   20%   30%   -56%   124%  
Maryland  21%   201%   108%   235%   91%   5%  
Massachusetts  14%   84%   29%   33%   -8%   151%  
Michigan  -24%   32%   70%   28%   17%   309%  
Minnesota  -13%   28%   -3%   47%   -21%   -51%  
Mississippi  -20%   38%   69%   322%   25%   367%  
Missouri  -46%   71%   36%   89%   70%   7%  
Montana  -40%   55%   -7%   28%   149%   92%  
Nebraska  12%   52%   39%   89%   399%   -71%  
Nevada  -21%   106%   8%   21%   63%   54%  
*The State had zero transports billed under that particular  transport level in 2002 and/or 2011.   
continued on next page 
 
 
 
 
 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 24  Marilyn Tavenner 
 
Table  C-2:   Percentage  Changes From 2002 to 2011 in the Number of Transports in 
Each Transport Level by State, continued  
 
Specialty  
ALS   ALS   BLS  BLS 
ALS2   Care 
State   Nonemergency   Emergency   Nonemergency   Emergency  
(A0433)   Transport 
(A0426)   (A0427)   (A0428)   (A0429)  
(A0434)  
New Hampshire   12%   61%   48%   59%   10%   38%  
New Jersey   -69%   359%   144%   79%   525%   75%  
New Mexico  -31%   72%   36%   45%   239%   63%  
New York   -41%   39%   35%   27%   6%   69%  
North Carolina   -33%   99%   75%   105%   161%   41%  
North Dakota   -8%   32%   22%   24%   -38%   -71%  
Northern Marianas  200%   900%   251,600%   40%   *  * 
Ohio  -14%   89%   48%   37%   -33%   84%  
Oklahoma  -32%   82%   16%   49%   97%   282%  
Oregon  -35%   41%   26%   68%   29%   69%  
Pennsylvania  -14%   17%   159%   16%   -19%   127%  
Puerto Rico   -90%   6%   -74%   -51%   231%   -12%  
Rhode Island   -90%   222%   92%   325%   214%   141%  
South Carolina   -21%   57%   218%   87%   -5%   243%  
South Dakota   -45%   76%   -10%   42%   -5%   32%  
Tennessee  -46%   95%   65%   93%   -13%   712%  
Texas  -83%   41%   106%   122%   19%   226%  
Utah  -15%   27%   -26%   4%   -39%   -55%  
Vermont  16%   77%   2%   9%   24%   41%  
Virgin Islands  30%   1,347%   219%   -91%   *  17%  
Virginia  -22%   238%   126%   165%   175%   4%  
Washington  11%   82%   30%   81%   33%   3%  
West Virginia   -3%   10%   26%   37%   -60%   111%  
Wisconsin  12%   55%   29%   0%   40%   -17%  
Wyoming  -42%   92%   53%   42%   140%   84%  
*The State had zero transports billed under that particular  transport level in 2002 and/or 2011. 
Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013.  
 
 
 
 
   
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 25  Marilyn Tavenner 
 
Table  C-3:   Percentage  Changes From 2002 to 2011 in the Number of Transports Between 
Various Origins and Destinations by State  
 
Between an 
Between a  Between an 
Between a  Independent 
Hospital and  From an  Independent 
Hospital and  Between  Dialysis Facility  
State   SNF or  Accident to  Dialysis Facility  
Private  Hospitals   and SNF or  
Residential  a Hospital   and Private 
Residence   Residential 
Facility**   Residence  
Facility   
National  51%   49%   53%   112%   264%   285%  
Alabama  25%   23%   32%   142%   297%   328%  
Alaska  142%   138%   133%   289%   *  * 
Arizona  29%   36%   102%   118%   2,665%   116%  
Arkansas  48%   46%   44%   319%   288%   646%  
California  173%   277%   164%   146%   3,255%   2,652%  
Colorado  74%   62%   58%   136%   1,670%   826%  
Connecticut  77%   61%   35%   114%   184%   86%  
Delaware  144%   41%   112%   121%   604%   228%  
District of Columbia  993%   41%   242%   3,709%   21,300%   432%  
Florida  22%   48%   33%   114%   416%   407%  
Georgia  51%   68%   27%   245%   2,125%   657%  
Guam  7,655%   778%   220%   850%   *  * 
Hawaii  125%   51%   -6%   137%   -13%   400%  
Idaho  37%   96%   15%   31%   *  * 
Illinois  87%   38%   51%   111%   291%   72%  
Indiana  76%   67%   76%   65%   658%   458%  
Iowa  45%   31%   57%   59%   *  -97%  
Kansas  50%   25%   31%   65%   457%   -78%  
Kentucky  12%   24%   65%   242%   189%   146%  
Louisiana  28%   -2%   260%   41%   88%   107%  
Maine  19%   16%   34%   78%   251%   77%  
Maryland  179%   83%   91%   570%   3,824%   225%  
Massachusetts  38%   14%   25%   159%   121%   178%  
Michigan  24%   28%   19%   59%   949%   426%  
Minnesota  33%   -1%   29%   58%   291%   102%  
Mississippi  48%   34%   90%   67%   114%   168%  
Missouri  53%   35%   76%   97%   502%   -16%  
Montana  28%   60%   23%   44%   -39%   -99%  
Nebraska  52%   94%   45%   47%   *  -47%  
Nevada  69%   76%   104%   98%   -67%   551%  
New Hampshire   43%   35%   58%   123%   1,840%   280%  
New Jersey   122%   35%   26%   267%   1,129%   607%  
*The State had zero transports billed  with that particular  origin and destination in 2002 and/or 2011. 

**Residential facilities refers to residential, domiciliary, or  custodial facilities  and includes, for example, assisted living facilities.   

continued on next page 
 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)     Page 26  Marilyn Tavenner 
 
Table  C-3:   Percentage  Changes From 2002 to 2011 in the Number of Transports Between 
Various Origins and Destinations by State, continued  
 
Between an  Between an 
Between a 
Between a  Independent  Independent 
Hospital and  From an 
Hospital and  Between  Dialysis  Dialysis Facility  
State   SNF or  Accident to 
Private  Hospitals   Facility and   and SNF or  
Residential  a Hospital  
Residence   Private  Residential  
Facility**  
Residence   Facility  
New Mexico  42%   23%   42%   149%   7,640%   444%  
New York   23%   17%   -5%   83%   399%   281%  
North Carolina   67%   94%   57%   116%   173%   59%  
North Dakota   -6%   18%   23%   222%   *  * 
Northern Marianas  8,600%   *  *  0%   *  * 
Ohio  73%   17%   66%   132%   272%   156%  
Oklahoma  70%   25%   79%   58%   260%   42%  
Oregon  14%   107%   28%   45%   3,650%   214%  
Pennsylvania  16%   19%   41%   36%   1,436%   422%  
Puerto Rico   -51%   20%   -63%   20%   -67%   9%  
Rhode Island   313%   60%   22%   478%   132%   78%  
South Carolina   59%   83%   45%   48%   9,659%   4,535%  
South Dakota   47%   28%   17%   38%   1,500%   * 
Tennessee  41%   35%   80%   126%   186%   162%  
Texas  56%   95%   72%   35%   -33%   108%  
Utah  -1%   -5%   74%   27%   *  5,350%  
Vermont  27%   27%   73%   92%   *  579%  
Virgin Islands  37%   77%   108%   -27%   *  * 
Virginia  170%   83%   63%   362%   427%   253%  
Washington  43%   71%   86%   109%   192%   137%  
West Virginia   1%   17%   47%   104%   103%   79%  
Wisconsin  15%   27%   50%   20%   226%   298%  
Wyoming  46%   35%   67%   91%   *  500%  
*The State had zero transports billed  with that particular  origin and destination in 2002 and/or 2011. 

**Residential facilities refers to residential, domiciliary, or  custodial facilities  and includes, for example, assisted living facilities.   

Source:  OIG analysis of 2002 to 2011  Medicare Part  B ambulance transports, 2013. 

 
 
Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)