Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
MEDICARE  AMBULANCE  PAYMENTS 
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4  JUNE  GIBBS  BROWN 
/  Inspector  General 
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NOVEMBER  1997 
f3fl&- OFFICE  OF  INSPECTOR  GENERAL 
The  mission  of  the  Office  of  Inspector  General  (OIG),  as  mandated  by Public  Law  95-452, 

is to  protect  the  integrity  of  the  Department  of  Health  and  Human  Services  programs 

as well  as  the  health  and  welfare  of  beneficiaries  served  by  them.  This  statutory 

mission  is carried  out  through  a nationwide  program  of  audits,  investigations, 

inspections,  sanctions,  and  fraud  alerts.  The  Inspector  General  informs  the  Secretary 

of  program  and  management  problems  and  recommends  legislative,  regulatory,  and 

operational  approaches  to  correct  them. 

Office  of  Evaluation  and  Inspections 
The  Office  of  Evaluation  and  Inspections  (OEI)  is one  of  several  components  of  the 

Office  of  Inspector  General.  It  conducts  short-term  management  and  program 

evaluations  (called  inspections)  that  focus  on  issues  of  concern  to  the  Department,  the 

Congress,  and  the  public.  The  inspection  reports  provide  findings  and 

recommendations  on  the  efficiency,  vulnerability,  and  effectiveness  of  departmental 

programs. 

The  OEIs  Chicago  Regional  Office  prepared  this  report  under  the  direction  of 

William  C.  Moran,  Regional  Inspector  General,  and  Natalie  A.  Coen,  Deputy 

Regional  Inspector  General.  Principal  OEI  staff  included: 

CHTCAGO  REGION  HEADQUARTERS 
John  Traczyk  Stuart  Wright 

Thomas  Komaniecki  Barbara  Tedesco 

Suzanne  Johnson  Alan  Levine 

Nora  Leibowitz 

Anne  Maxwell 

Charles  Friedrich 

TO obtain  a copy  of  this  report,  call  the  Chicago  Regional  Office  at  (312)353-4124.  Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
MEDICARE  AMBULANCE  PAYMENTS 
JUNE  GIBBS  BROWN 
Inspector  General 
NOVEMBER  1997 
OEI-05-95-00300  EXECUTIVE  SUMMARY 

PURPOSE 
To  determine  whether  Medicare  reimbursement  policies  and  levels  of  payment  for 
ambulance  services  are  prudent. 
BACKGROUND 
From  1987  through  1995,  Medicare  expenditures  for  ambulance  services  have  more  than 
tripled.  In  1987,  Medicare  allowed  charges  for  ambulance  services  amounted  to  slightly 
more  than  $600  million.  In  1995,  carriers  paid  nearly  $2 billion  to  ambulance  providers. 
Medicare  pays  for  medically  necessary  a L,uiance  services  when  the  use  of  other 
methods  of  transportation  would  endanger  the  patients  health.  Two  levels  of  service, 
advanced  life  sups  :t  (ALS)  and  basic  life  support  (BLS),  are  covered  by Medicare. 
Reimbursement  is based  on  the  type  of vehicle  and  personnel  used  (AIS  or  BLS)  and 
the  service  status  (emergency  or  non-emergency). 
FINDINGS 
Medicare paymentsfor ambulanceservicesappear to lack commonsense. 
In  26 States,  Medicare  pays  more  for  routine,  non-emergency  basic  life  support 
transportation  than  it does  for  advance  life  support  emergency  transportation.  The 
difference,  in  some  areas,  is more  than  $200.  In  18 States,  Medicare  pays  more  for  BLS 
emergency  transports  without  supplies  than  with  supplies.  Similar  anomalies  exist  in ALS 
base  rates.  In  1995,  the  modal  allowed  charge  for  basic  life  support  mileage  was  $9.25  a 
mile,more  than  twice  the  allowed  charge  for  advance  life  support  vehicles  and  seven 
times  greater  than  the  cost  of  a gallon  of  fuel. 
Ambulance paymentpoliciesare vulnerableto fraud and abuse. 
Carriers  police  a significant  number  of  ambulance  claims.  The  complexity  of  the  current 
system  enables  transportation  suppliers  to  bill  for  ALS  services  when  BLS  services  are 
provided;  misrepresent  the  patients  true  medical  condition;  and,  avoid  carrier  program 
safeguards.  Carriers  report  wide  spread  abusive  situations  involving  unnecessary 
transports,  oxygen,  EKGs  and  other  services.  Over  the  past  5 years,  the  Office  of 
Inspector  General  has  had  more  than  100 convictions  involving  ambulance  suppliers. 
Problems are the resultof extremelycomplexpaymentmethodsand inconsistentpolicies. 
A  complex  payment  system  encourages  fraud  and  abuse  and  thwarts  efforts  to  control 
expenditures.  This  complexity  stems  from  a payment  system  that  uses  four  different 
billing  methods,  recognizes  BLS  and  ALS  vehicles,  distinguishes  emergency  and  non-
i  emergency  transports,  employs  more  than  240  different  procedure  codes  and  uses  more 
than  35 fiscal  agents.  Payment  levels  to  ambulance  providers  are  not  based  on  the  actual 
cost  of  providing  services  within  geographic  areas. 
Carrier  interpretations  of  policy  contribute  to  variance  in  payments  and  coverage.  In  16 
States  the  carrier  considers  payment  for  oxygen  included  in  the  BLS  base  rate.  Other 
carriers  consider  oxygen  to  be  a prescription  drug  and  allow  ambulance  suppliers  to  bill 
using  a separate  procedure  code.  Policy  differences  also  exist  with  regard  to  EKGs, 
supplies,  injections  and  other  services  provided  during  transport. 
RECOMMENDATIONS 
The  Health  Care  Financing  Administrations  (HCFAs)  well-intentioned  efforts  to  limit 
ambulance  companies  to  four  billing  methods  using  37 procedure  codes  has  been 
circumvented  by  idiosyncrasies  of  the  current  re r;;onable  charge  payment  methodology 
and  the  fee-for-service  system.  At  a time  when  most  Medicare  Part  B services  are  being 
paid  on  a fee  schedule,  ambulance  services  are  among  the  few  services  the  Medicare 
program  still  reimburses  on  a reasonable  charge  basis. 
Tremendous  variation  in  payments  indicates  that  Medicare  reimbursement  in  many  areas 
may  be  too  high.  The  reasonable  charge  payment  mechanism  has  resulted  in  inflated 
charges  for  ambulance  services  and  does  not  accurately  reflect  the  real  cost  of  doing 
business  in  an  area.  More  importantly,  the  reasonable  charge  payment  method  and  the 
fee-for-service  system  provide  little  or  no  incentive  for  providers  to  control  costs.  Efforts 
to  control  expenditures  in  the  fee-for-service  system  often  results  in fragmentation  of 
services  and  increased  utilization.  Extensive  carrier  reviews  of  ambulance  claims  adds  to 
program  costs.  Fraud  and  abuse  in  this  area  has  also  been  well  documented. 
We  believe  that  the  vulnerabilities  we  found  need  to  be  addressed  as  soon  as  possible. 
We  recommend  that  HCFA: 
seek  legislative  authority  to  develop  a fee  schedule  for  ambulance  transportation. 
b 
In  doing  so,  HCFA  should  take  into  consideration  the  competitive  prices  available  in  an 
area  including  the  negotiated  rates  that  exist  between  managed  care  entities/hospitals  and 
ambulance  providers.  A fee  schedule  could  also  take  into  account  the  cost  of  doing 
business  in  an  area,  economies  of  scale  available  to  providers,  adjustments  for  local 
subsidies  and  other  considerations  that  may  affect  the  cost  of  doing  business. 
The  following  interim  steps  should  be  taken  to  help  develop  the  fee  schedule: 
Instruct  carriers  to  examine  the  inherent  reasonableness  of  current  allowable 
b 	
charges  and  adjust  them  as  necessary. 
Work  with  the  ambulance  industry  to  develop  clearer  guidelines  as to  what  is or  is 
b 	
not  included  in  the  base  rate  and  what  mileage  is intended  to  cover. 
ii  b 	 Eliminate  separate  payments  for  oxygen,  supplies,  injectables  and other  services 
such  as EKGs.  These  items  should  be included  in the base rate. 
t 	 Limit  the number  of procedure  codes  available  to ambulance  suppliers  for billing. 
At  a minimum,  restrict  use of procedure  codes  to the  37 specific  codes  designated 
for  ambulance  transportation. 
We believe  that  Medicare  ambulance  policies  could  be simplified  and that  unreasonable 

base rate  and mileage  payment  levels  could  be reduced.  Consistent  coverage  policies 

should  be developed  and the  number  of billing  methods  and procedure  codes  currently  in 

use reduced.  Elimination  of many  procedure  codes  would  discourage  unbundling  and the 

routine  use of some  supplies  and services  designed  simply  to enhance  payment.  Items 

considered  essential  for  life  support  should  be included  in base rate  reimbursement  and 

should  not  be paid  as separate  items  or services. 

Actual  savings  from  simplification  and more  uniform  policies  would  depend  on how  base 

rate  and mileage  are defined  and the  fee schedule  allowances  for these  services.  If 

implemented,  as we have  suggested,  we project  that  Medicare  could  save  at least  $242 

million  annually.  Fifty  million  dollars  of these  projected  savings  could  be derived  solely 

from  elimination  of separate  payments  for oxygen,  supplies,  injectables  and  other  services 

such  as EKGs.  At  least  $192 million  could  be saved  annually  by  limiting  the  allowed 

charge  for  mileage  to the  lower  of actual  charge  or $1 per mile. 

Our  savings  projections  are predicated  on the  current  base rate  levels  remaining 

unchanged  except  for  increases  due to the  inflation  index  charge  or changes  in customary 

and prevailing  charges.  Actual  savings  could  be higher  if the base rate  allowed  charge 

for  non-emergency  transportation  is adjusted  to ensure  that  Medicare  pays  the  same  or 

less  for this  service  than  it does for the base rate  for  emergency  transportation. 

Structuring  payments  to take  into  account  average  miles  per  gallon,  bulk  purchasing 

discounts,  State  and  local  taxes  and other  factors  could  also  impact  projected  savings. 

Savings  may  be lower  if some  base rates  are increased  or policies  developed  that  permit 

unbundling  of some  services. 

AGENCY  COMMENTS 
Since  issuing  our draft  report,  Congress  passed  the  Balanced  Budget  Act  of  1997.  This 
legislation  implements  our recommendation  and requires  that  HCFA  establish  a fee 
schedule  for Medicare  ambulance  payments.  We look  forward  to HCFAs  regulation 
that  will  carry  out the  legislation. 
... 
111  TABLE  OF  CONTENTS 

PAGE 

EXECUTIVESUMMARY  ..........................................  i 

INTRODUCTION  .................................................  1 

FINDINGS  ......................................................  4 

Payments  lack  common  sense  ......................................  4 

 
Policy  vulnerabilities  ............................................  7 

 
Complex  payment  methods  and  inconsistent  policies  .....................  8 

 
RECOMMENDATIONS  ...........................................  12 

AGENCYCOMMENTS  ...........................................  13 

APPENDIX..  ..................................................  A-l 
 INTRODUCTION 

PURPOSE 
To  determine  whether  Medicare  reimbursement  policies  and  levels  of  payment  for 
ambulance  services  are  prudent. 
BACKGROUND 
Ambulance  services  provided  to  Medicare  beneficiaries  are  covered  by  Part  B of  the 
Medicare  program,  commonly  called  Supplemental  Medical  Insurance.  Medicare  pays 
for  medically  necessary  ambulance  services  when  ...the  use  of  other  methods  of 
transportation  is contraindicated  by  the  individuals  condition,  but  only  to  the  extent 
provided  in  regulations.  The  Health  Care  Financing  Administration  (HCFA) 
regulations  state  that  ambulance  services  are  covered  only  if other  forms  of 
transportation  WOUcIl endanger  the  Medicare  beneficiarys  health. 
Ambulance  providers  must  satisfy  State  and  local  requirements  to  operate  within  a State 
and  must  comply  with  HCFA  regulations  to  qualify  for  Medicare  reimbursement.  The 
HCFA  defines  an  ambulance  vehicle  as  one  that  must:  (1)  be  designed  specifically  for 
transporting  the  sick  or  injured;  (2)  contain  a stretcher,  linens,  first  aid  supplies,  oxygen 
equipment,  and  other  lifesaving  equipment  required  by State  or  local  ordinances;  and, 
(3)  be  staffed  with  personnel  trained  to  provide  first  aid  treatment. 
Two  distinct  levels  of  service,  advanced  life  support  (ALS)  and  basic  life  support  (BLS), 
are  furnished  by  ambulance  providers.  To  be  considered  an  ALS  ambulance,  the  vehicle 
must:  be  equipped  with  specialized  equipment  and  medications,  such  as  defibrillators 
and  pulmonary/cardiac  monitors;  and,  maintain  radio-telephone  contact  with  physicians 
or  hospitals.  In  most  States,  the  more  intensive  ALS  services  are  rendered  by paramedic 
emergency  medical  technicians  (EMTs),  while  BLS  services  are  usually  rendered  by basic 
or  ilztemediate  EMTs.  Types  of  ALS  services  include: 
b  administering  intravenous  medications; 

b  defibrillating  the  patient;  and, 

b  performing  other  advanced  life  support  services,  such  as  electrocardiogram 

monitoring  and  airway  monitoring. 
Currently,  ambulance  reimbursement  is based  on  the  type  of vehicle  and  personnel  used 
(BLS  or  ALS)  and  the  service  status  (emergency  or  non-emergency).  Ambulance 
providers  submit  itemized  bills  for  the  services  they  provide  to  the  Medicare  carrier 
serving  their  area.  According  to  HCFA,  approximately  10 percent  of  the  Medicare  Part 
B patient  population  uses  ambulance  services  each  year. 
l  Section  1861(s)(7)  of The Social Security kf. 
1  Carriers  process  and  pay  claims  based  on  the  information  provided  by the  ambulance 

companies.  From  1987  through  1995,  Medicare  expenditures  for  ambulance  services 

more  than  tripled.  In  1987,  Medicare  allowed  charges  for  ambulance  services  amounted 

to  slightly  more  than  $600  million.  In  1994,  carriers  paid  $1.8  billion  for  21 million 

ambulance  services.  In  1995,  carriers  approved  nearly  52  million  ambulance  services  and 

paid  nearly  $2 billion  to  ambulance  providers.  The  average  annual  rate  of  increase  in 

ambulance  expenses  (16  percent)  exceeds  the  average  Part  B (Supplemental  Insurance) 

rate  of  growth  of  9.9 percent.  This  annual  rate  of  growth  for  ambulance  services  is 

comparable  to  the  growth  in  expenditures  Medicare  has  seen  in  home  health,  cataract 

surgery,  medical  supplies  and  other  problematic  areas. 

Medicare  pays  ambulances  using  customary  and  prevailing  charge  criteria.  Concerns 

about  the  inflationary  nature  of  this  payment  method  led  to  the  introduction  of  an 

additional  fee  screen  in  198.5 called  the  Inflation  Indexed  Charge.  The  aim  of  the 

Inflation  Indexed  Charge  was  to  limit  annual  inceases  in Medicare  allowable  charges  for 

certain  services,  including  ambulance  services,  by  restricting  the  rate  of  increase.  More 

simply  put,  the  Inflation  Index  Charge  became  the  base  rate  on  which  future  increases  in 

allowed  charges  would  be  based.  When  determining  the  allowable  charge  for  a 

procedure  code  billed  by  an  ambulance  supplier  Medicare  carriers  pay  the  lower  of  the: 

- actual  charge  billed, 
- providers  customary  charge, 
- prevailing  charge,  or 
- Intlation  Indexed  Charge. 
In  1994,  HCFA  undertook  a comprehensive  revision  to  the  procedure  codes  used  by 
ambulance  providers  to  bill  Medicare.  They  instructed  carriers  to  eliminate  all local 
codes  and  to  begin  using  standardized  coding  for  all  ambulance  services.  The  new 
standardized  coding  attempted  to  accommodate  all  billing  patterns  in  use  by  ambulance 
providers  at  that  time,  while  eliminating  local  codes. 
That  same  year,  HCFA  asked  carriers  to  assign  one  of  four  billing  methods  to  each 
ambulance  provider  based  on  the  carriers  past  experience  with  that  ambulance  company. 
The  four  billing  methodologies  are  summarized  as follows: 
Method  1:  A single,  all  inclusive  charge  reflecting  all services,  supplies  and  mileage. 
Method  2: 	 One  charge  reflecting  all  services  and  supplies  and  a separate  charge  for 
mileage. 
Method  3: 	 One  charge  reflecting  all  services  and  mileage  and  a separate  charge  for 
supplies. 
Method  4:  Separate  charges  for  service,  mileage  and  supplies. 
2  Effective  January  1, 1995  ambulance  providers  were  to  begin  using  only  revised 

procedure  codes  and  the  billing  method(s)  they  elected  or  were  assigned  by  the  carrier. 

Most  ambulance  providers  bill  Medicare  using  Methods  2 and  4. 

Previous  studies  by  the  Office  of  Tnspector  General  (OIG)  have  contended  that  Medicare 

pays  unreasonably  high  amounts  for  ambulance  services.  Ambulance  Services for 

Medicare  End-Stage  Renal Disease Patierlts:  Paymerlt Practices, (OEI-03-90-02131),  and 

other  studies  conducted  by  carriers,  reveal  a high  incidence  of  ambulance  transports  that 

do  not  meet  coverage  guidelines.  In  addition  to  medically  unnecessary  transports,  OIG 

and  other  researchers  have  noted  significant  variance  in  payments  to  ambulance 

providers  often  within  the  same  geographical  areas. 

METHODOLOGY 

We  selected  a  1 percent  random  sample  from  all Medicare  claims  billed  by  ambulance 

companies  in  1995  and  1996.  The  1 percent  sample  for  1995 was  arrayed  by  allowed 

charges  per  claim  and  used  to  obtain  statistical  information  about  the  universe  of 

Medicare  expenditures  for  ambulance  services.  Our  sample  contained  189,340  claims. 

The  sample  was  refined  by merging  it with  HCFAs  zip  code  file.  This  enabled  us  to 

analyze  information  by State,  county  and,  in  some  cases,  city.  We  determined  the 

minimum  and  maximum  allowable  charge  for  each  procedure  code  billed  by  ambulance 

providers  in  1995.  The  mean,  mode  and  median  allowable  charge  for  each  ambulance 

procedure  code  billed  was  determined  and  arrayed  by quartile.  The  number  of  services 

provided  and  the  number  of  miles  billed  was  also  taken  into  consideration  when  deriving 

data  about  the  allowed  charge  per  mile. 

Thirty-seven  carriers  participated  in  this  study.  We  visited  5 carriers  and  contacted  32 

carriers  by  mail.  We  a,bo  contacted  the  American  Ambulance  Association  and  three 

HCFA  regional  offices.  The  contacts  were  made  to  obtain  information  that  might  help 

us  determine  why  variance  in  ambulance  payments  and  policies  exists.  Respondents  were 

asked  for  information  about  ambulance  policies  in  each  State,  system  inequities  and 

vulnerabilities.  Information  on  industry  trends  and  their  potential  impact  on  the 

Medicare  program  was  also  solicited  from  respondents. 

The  Internet  was  used  to  obtain  national  and  regional  diesel  fuel  costs  for  1995. 

Additional  information  was  obtained  from  the  Bureau  of  Labor  Statistics,  Department  of 

Transportation  and  U.S.  Census  Department  web  sites.  Information  from  previously 

issued  reports  concerning  the  ambulance  industry  was  also  reviewed. 

3  FINDINGS 

Medicare  payments  for  ambulance  services  appear  to  lack  common  sense. 
Medicare  pays  for  an  equal  number  of  non-emergency  transports  and  emergency 
transports  each  year.  In  1995, base  rate  charges  for  emergency  and  non-emergency 
transports  each  accounted  for  approximately  20 percent  of  the  ambulance  services  paid 
for  by  Medicare.  Mileage  procedure  codes  accounted  for  a third  of  the  services  paid. 
Oxygen,  supplies,  injections  and  other  services  make  up  the  remaining  27 percent  of  the 
services  billed  by  ambulance  suppliers  and  paid  by  carriers. 
Medicare  allowed  charges  differ  widely  from  State  to  State,  within  States  and  within 
counties.  We  analyzed  the  variance  in  payment  that  exists  for  the  37 ambulance 
transportation  procedure  codes  listed  in the  HCFA  Common  Procedure  Coding  System 
(HCPCS).  We  found  tremendous  variation  in  payments  for  ALS  and  BLS  base  rates, 
mileage,  supplies,  oxygen  and  other  services  paid  by Medicare.  We  compared  the 
differences  in  allowed  charges  to  the  average  hourly  wage,  housing  costs,  fuel  costs  and 
other  indicators  that  reflect  the  cost  of  doing  business  in  an  area.  There  was  no  logical 
correlation  between  Medicare  allowed  charges  and  these  economic  indicators. 
Base  Rate  Variation 
In  26 States,  Medicare  pays  more  for  routine,  non-emergency  basic  life  support 
transportation  than  it does  for  advance  life  support  emergency  transportation.  In  some 
areas,  the  amount  Medicare  pays  for  basic  life  support,  non-emergency  transportation 
exceeds  the  advance  life  support  emergency  base  rate  by  more  than  $200.  In  some  areas 
there  is no  difference  in  the  allowable 
Differences  Between  Ambulance  Charges:  charge  for  ALS  emergency  and  BLS  non-
Supplies  Included vs. Supp!ks  Billed Scparatcly 
emergency  transportation. 
In  18 States  the  carriers  allow,  on 
average,  more  for  the  BLS  emergency 
base  rate  without  supplies  (A0362)  than 
they  do  for  BLS  emergency  base  rate  with 
supplies  (A0322).  In  10 States,  the  ALS 
base  rate  without  supplies  is greater  than 
the  ALS  base  rate  with  supplies.  The 
ALS  base  rate  without  supplies  in  New 
Jersey  is $175  greater  than  the  ALS  base 
rate  with  supplies.  In  Arkansas  the 
difference  in ALS  base  rates  with  and 
without  supplies  is only  $15.  In  Texas 
and  Illinois  there  is no  difference  in  the 
payment  for  these  two  procedure  codes. 
4  The  allowed  charge  for  base  rate  procedure  codes  that  include  supplies  frequently 
exceeds  the  average  allowance  for  supplies  billed  separately.  In  1995,  the  median 
allowed  charge  for  supplies  billed  under  procedure  code  A0398  was  approximately  $10. 
At  the  same  time,  we  found  that  in  many  States  carriers  allowed  significantly  more  than 
$10  for  supplies  included  in the  base  rate.  In  South  Dakota  Medicares  allowed  charge 
for  ALS  base  rates  with  supplies  was  nearly  $232  more  than  the  allowed  charge  for  base 
rate  without  supplies.  This  charge  is more  than  23  times  greater  than  the  national 
median  allowed  charge  ($10)  for  ALS  disposable  supplies. 
In  most  States,  Medicare  pays  more  for  supplies  when  they  are  included  in  the  base  rate. 
The  difference  in  the  allowed  amounts  when  supplies  are  included  in  the  BLS  base  rate 
ranges  from  less  than  $2 in South  Dakota  to  $88  in  Idaho.  In  22 States,  the  allowed 
amount  for  ALS  with  supplies  (A0328)  differs  from  ALS  without  supplies  (A0368) 
anywhere  from  $4 in  Tennessee  to  nearly  $232  in South  Dakota.  The  amount  allowed 
for  supplies  included  in  the  base  rate,  in .;;::;:c: cases,  appears  unreasonable. 
Mileage  Reimburser  xt  Variation 
Mileage  accounts  for  nearly  1 out  of  every  3 services  paid  and  nearly  15 cents  out  of 
every  dollar.  In  90  percent  of  the  3,844  counties  in  our  sample,  the  allowed  charge  for 
ambulance  mileage  was  $2 or  more  per  mile.2  In  1995,  differences  in  the  average 
allowed  charge  for  mileage  varied  by as  much  as $26.23  a miIe. 
Medicare  pays  more  :or basic  life  support  mileage  than  it  does  for  advance  life  support 
mileage.  The  modal  allowed  charge  for  advance  life  support  mileage  was  $4.35  a mile. 
The  modal  allowed  charge  for  basic  life  support  mileage  was  $9.25  a mile,  more  than 
twice  the  allowed  charge  for  advance  life  support  vehicles.  The  allowed  charge  for 
advance  life  support  mileage  (procedure  code  A0390)  ranged  from  19 cents  to  $11.93  per 
mile. 
The  average  allowed  charge  per  mile  for  a basic  life  support  vehicle  ranged  from  a high 
of  $11.19  a mile  to  a low  of  27 cents  a mile.  When  the  mode  was  used  for  this  analysis, 
carrier  allowances  for  basic  life  support  mileage  ranged  from  $11.46  to  20 cents  a mile. 
Payments  by  one  carrier  for  BLS  mileage  varied  by more  than  $22.14.  This  carrier  paid 
$4.10  per  mile  on  one  ambulance  claim  and  $26.24  per  mile  on  another  claim.  While 
these  claims  represent  the  extremes,  the  average  payment  per  mile  to  ambulance 
providers  by  this  carrier  was  $6.81. 
In  1995,  Medicare  paid  more  per  mile  than  the  cost  of  a gallon  of  diesel  fuel.  During 
1995,  the  average  cost  of  diesel  fuel  was  about  $1.20  per  gallon.3  One  carriers  average 
allowed  charge  was  $6.81  a mile,  five  times  more  than  the  cost  of  a gallon  of fuel.  If 
2  Some counties  pay both  ,413 and  1313 mileage.  If the allowed charge exceeded  $2 for both ALS and BLS 
mileage,  the county  was counted  twice.  The  numhcr  of unique  in our  sample was 3,144. 
counrics 
3  On-highway  diesel prices, self service cash price in cents  per gallon, including  taxes.  Department  of Energy  data. 
5  ambulance  fuel  economy  were  three  miles  per  gallon,  this  carrier  would  be  paying  at 
least  1,250  percent  more  than  the  cost  to  replace  the  fuel  used. 
It  appears  that  Medicares  reimbursement  for  mileage  is unreasonable.  The  Internal 
Revenue  Service  (IRS)  tax  code  and  Federal  travel  regulations  permit  recovery  of  fuel 
and  depreciation  expenses  related  to  privately  owned  vehicles  at  a rate  of  31 cents  a mile 
or  actual  costs.  Medicare  pays  more  than  six times  the  IRS  allowable  rate  for  fuel  cost 
and  considerably  more  than  actual  fuel  replacement  cost.  Medicare  mileage  payments 
exceeding  $1  per  mile  cost  the  program  nearly  $192  million  in  1995. 
Other  Illogical  Variution 
Suppliers  with  high  base  rates  usually  had  high  mileage  rates  and  high  rates  for  other 
procedure  codes  they  billed.  Besides  base  rate  and  mileage  variance,  we  found 
considerable  variation  in virtually  all  of  the  procedure  codes  used  by  ambulance  providers 
to  bill  Medicare. 
Allowable  charges  for  BLS  routine  disposable  supplies  (procedure  code  A0382)  range 
from  just  under  $2 to  more  than  $50  with  a median  allowed  charge  of  $6.50.  Disposable 
supply  codes  used  by  ALS  ambulance 
providers  have  differences  in 
$40 
payments  ranging  from  25 cents  to 
$35 
$95.40  with  a median  allowed  charge 
$30  of  $10.  Some  carriers  consider 
supplies  to  be  part  of  the  base  rate 
$25 
and  do  not  reimburse  ambulance 
$20 
providers  for  supplies  billed 
$15  separately. 
$10 
Allowable  charges  for  oxygen  vary  by 
$5 
over  550  percent.  In  the  State  of 
Wisconsin  allowable  charges  for 
Average  Allowable  Charges  for Oxygen  oxygen  average  less  than  $6 and  in 
Oklahoma  they  are  just  under  $7.  In 
# 	 Washington  @  Vermont 
Washington  allowed  charges  average 
Oklahoma  Wisconsin  nearly  $39  and  in  Vermont  they 
average  over  $36.  The  median 
allowed  charge  for  oxygen  was 
determined  to  be  $18.  In  addition  to  the  wide  variance  in  allowed  charges  for  oxygen  we 

also  found  that  in  21 States  carriers  do  not  pay  for  oxygen  charges  submitted  by  ALS 

providers.  In  an  equal  number  of  States,  carriers  do  not  pay  for  oxygen  charges 

submitted  by  BLS  providers. 

Supplies,  injectables  and  other  services  (e.g.,  EKGs)  are  not  always  payable  when  billed 

by  ambulance  providers.  The  circumstances  under  which  payment  maybe  made  varies 

from  carrier  to  carrier,  locality  to  locality,  and  by the  type  of vehicle  used  to  transport  the 

6  patient.  Some  carriers  consider  supplies,  injectables  and  other  ambulance  services  that 
are  required  by  law  to  licensing  requirements  as  not  payable.  These  carriers  do  not 
recognize  separate  charges  for  these  services.  In  1995,  Medicare  allowed  charges  for 
supplies,  injectables  and  other  services  provided  by  during  ambulance  transports  totaled 
approximately  $50  million. 
Ambulance  payment  policies  are  vulnerable  to  fraud  and  abuse. 
Carriers  find  it necessary  to  review  a significant  number  of  ambulance  claims.  Their 
experiences  in  processing  and  paying  claims  has  shown  them  that  vulnerabilities  in 
Medicares  policies  and  procedures  for  paying  for  transportation  services  are  pervasive. 
Carriers  report  manually  reviewing  all claims  submitted  by  ambulance  providers  in  23 
States.  A  significant  number  of  claims  submitted  by providers  in  the  remaining  States  are 
also  suspended  for  manual  review. 
Many  carriers  reported  problems  with  claims  that  lack  origin  or  destination  modifier 
codes.  These  codes  help  carriers  identify  transports  that  may  not  be  medically  necessary. 
Despite  carrier  efforts  to  obtain  complete  claim  information,  HCFA  data  shows  that 
more  than  500,000  base  rate  services  were  processed  without  modifiers  indicating  pick  up 
and  destination  points.  Allowed  charges  for  these  services  totaled  more  than  $30  million. 
Manual  intervention  by  the  carriers  in claims  processing  is costly.  Carriers  report 
spending  inordinate  amounts  of  time  and  money  developing  missing  information  and 
verifying  the  accuracy  of  information  provided  on  ambulance  claims.  In  22 States, 
carriers  report  problems  with  providers  who  misrepresent  the  bed  confinement  status  of 
patients  being  transported. 
Another  problem  repo.  ted  by  at  least  one  carrier  involved  providers  who  bill  for  supplies 
when  the  ambulance  was  restocked  free  of  charge  by local  hospitals.  Since  the  provider 
incurred  no  expense  in  securing  the  supplies,  the  carrier  will  not  pay  for  supplies  when 
they  are  billed  by  providers  in  this  area.  Other  carriers  are  aware  of  this  practice  in 
some  of  their  jurisdictions,  but  they  have  not  conducted  any  studies  to  determine  if 
duplicate  payments  may  have  resulted  from  the  practice. 
Another  problem  reported  by  carriers  involves  medically  unnecessary  transportation  to 
dialysis  centers  (8 States).  This  problem  was  also  documented  in  an  earlier  OIG  report 
entitled,  Ambulance  Services for Medicare  End-Stcrge Renal Disease Beneficiaries:  Payment 
Practices,  (OEI-03-90-02131).  In  19 States  the  carrier  reported  problems  with  non-
approved  or  suspect  destinations.  In  14 States  carriers  have  problems  with  providers  not 
properly  disclosing  non-emergency  transports.  These  claims  may  violate  Federal  statutes 
when  ambulance  suppliers  falsify  destination  information  in  order  to  obtain  payment. 
In  10 States,  carriers  report  problems  with  provider  billings  for  oxygen,  mileage,  supplies 
and  other  services.  In  these  10 States  the  carriers  question  medical  necessity  for  oxygen 
that  some  ambulance  providers  routinely  provided  patients.  They  also  find  abusive  situations  involving  unnecessary  EKGs  and  other  services  provided  during  transportation 

to  maximize  payments  from  Medicare. 

Over  the  past  5 years,  the  Office  of  Inspector  General  has  had  more  than  100 convictions 

and  civil judgements  involving  ambulance  suppliers.  The  convictions  and  civil judgements 

involve  issues  reported  by carriers  in  this  study  as  ongoing  problems  with  ambulance 

claims  and  providers.  Appendix  A  provides  brief  summaries  of  several  cases  illustrating 

problems  the  Office  of  Inspector  General  has  uncovered  concerning  ambulance  services. 

The  complexity  of  the  current  system  enables  transportation  suppliers  to  bill  for  ALS 

services  when  BLS  services  are  provided;  misrepresent  the  patients  true  medical 

condition;  and,  avoid  carrier  program  safeguards. 

Furthermore,  the  current  appeals  system  works  against  carrier  efforts  to  ensure  payments 

are  made  only  for  medically  indicated  transportation.  All  carriers  expressed  concern 

about  the  incidence  of  medically  unnecessary  ambulance  transports.  One  carrier 

mentioned  a tactic  that  could  be  used  by other  ambulance  suppliers.  This  carrier 

revealed  that  one  ambulance  provider  refuses  to  provide  information  concerning  medical 

necessity.  A  substantial  number  of  claims  are  denied  for  failure  to  provide  the 

information  needed  to  determine  medical  necessity.  The  ambulance  provider  routinely 

appeals  the  carrier  denials  and  provides  the  information  originally  requested  at  the 

appeal.  This  tactic  avoids  scrutiny  for  medical  necessity  by trained  carrier  staff  and,  more 

often  than  not,  results  in  claims  that  do  not  meet  criteria  for  payment  being  paid  at  the 

hearing  level.  While  this  particular  practice  is unique  and  adds  to  program 

administrative  costs,  many  carriers  expressed  frustration  with  an  appeal  system  that  they 

claim  disenfranchises  them  from  the  process. 

Problems  are  the  result  of  extremely  complex  payment  methods  and 
inconsistent  policie?. 
A  complex  payment  system  encourages  fraud  and  abuse  and  thwarts  efforts  to  control 
expenditures.  This  complexity  stems  from  a payment  system  that  uses  four  different 
billing  methods,  recognizes  BLS  and  ALS  vehicles,  distinguishes  emergency  and  non-
emergency  transports,  employs  more  than  240  different  procedure  codes  and  uses  more 
than  35 fiscal  agents  to  propagate  different  coverage  policies  in  nearly  all  50 States. 
Contributing  to  the  lack  of  simplicity  in the  current  payment  system  are  180 different 
geographical  areas  and  more  than  8,000  individual  providers.  Using  charges  submitted 
during  the  prior  year,  carriers  annually  calculate  a prevailing  charge  and  a customary 
charge  for  each  provider  in  each  geographical  area.  They  also  calculate  an  inflation 
index  charge  for  each  geographical  area  and  each  provider. 
8  Complex  Payment  System 
Medicare  payment  levels  to  ambulance  providers  are  not  based  on  the  actual  cost  of 
providing  services  within  geographic  areas.  They  were  originally  based  on  the  procedure 
code  and  the  charges  submitted  to  the  program  by providers  doing  business  within  a 
specific  geographic  location.  Charges  submitted  during  the  previous  year  for  each 
procedure  code  determined  the  amount  carriers  would  pay.  Higher  charges  in  a year 
meant  higher  Medicare  payments  the  following  year. 
In  1995,  carriers  were  processing  claims  from  ambulance  companies  using  approximately 
180 different  procedure  codes.  These  codes  included  uniform  national  codes  defined  in 
the  HCFA  Common  Procedure  Coding  System  and  local  codes  deemed  necessary  by  the 
carrier.  In  1996,  the  number  of  procedure  codes  billed  by  ambulance  providers  and  paid 
by  carriers  had  increased  nearly  35 percent  to  240  codes.  In  addition  to  the  37 
ambulance  transportation  codes,  carriers  WV-~ paying  for  medical  supplies,  injections  and 
a number  of  unknown  procedures  under  local  codes  in  1996.  At  this  rate,  the  number  of 
different  procedure  codes  being  billed  by  ambulance  suppliers  could  approach  300  by the 
end  of  1997. 
The  fee-for-service  payment  system  encourages  providers  to  unbundle  the  services  they 
provide  and  to  bill  for  individual  components  often  using  procedure  codes  outside  the  37 
transportation  codes  provided  by HCFA.  This,  in effect,  defeats  controls,  such  as  the 
inflation  indexed  charge,  designed  to  control  program  costs.  Since  October  1985, 
payments  for  ambulnce  services  have  been  based  on  the  lower  of  customary,  prevailing, 
inflation  indexed  or  actual  charge  submitted  on  a claim.  In  areas  where  reimbursement 
rates  were  high,  the  resulting  inflation  indexed  charges  were  high;  conversely,  in  areas 
where  reimbursement  rates  were  low,  the  resulting  inflation  indexed  charges  were  low. 
The  inflation  index  charge  may  control  the  growth  rate  in  expenditures  for  specific 
procedure  codes,  however,  this  control  is easily  circumvented  when  services  are 
unbundled  and  when  new  procedure  codes  added.  The  net  result  is that  the  payment  for 
the  original  procedure  is inflated. 
Inherent  in  fee-for-service  reimbursement  is the  temptation  to  accommodate  every  detail 
of  the  services  provided  to  patients.  Fee-for-service  perpetuates  the  need  to  create  more 
and  more  procedure  codes  and  to  develop  policies  to  address  services  provided  by  outlier 
providers.  More  procedure  codes  means  new  sources  for  increasing  revenue.  Overtime, 
providers  begin  to  use  these  new  procedure  codes  not  only  to  bill  for  new  services  but 
also  to  unbundle  the  services  previously  included  in their  base  rate  payment.  Availability 
of  procedure  codes  for  billing  encourages  suppliers  to  provide  services  to  patients, 
whether  medically  indicated  or  not,  and  bill  the  services  to  Medicare.  These  practices 
result  in  increased  expenditures  for  the  Medicare  program. 
Lack  of  Unijorm  Policies 
Policy  differences  exist  concerning  current  billing  methodologies.  Carriers  were 

instructed  by  HCFA  to  assign  1 of  4 methodologies  to  each  ambulance  provider  based  on 
 that  providers  past  billing  practice.  This  policy  was  not  uniformly  implemented  and  in 

12 States  providers  can  use  more  than  one  billing  methodology.  Allowing  providers  to 

choose  more  than  one  method  can  potentially  affect  payment  levels  to  the  detriment  of 

the  program. 

Carrier  interpretations  of  policy  contribute  to  variance  in  payments  and  coverage.  This 

has  resulted  in  fragmentation  of  services  and  disparity  in  coverage  policy.  In  16 States 

the  carrier  considers  payment  for  oxygen  included  in the  BLS  base  rate.  In  21 States  it is 

included  in  the  ALS  base  rate.  These  carriers  consider  a portion  of  the  BLS  or  ALS 

base  rate  payment  as reimbursement  for  oxygen.  Other  carriers  consider  oxygen  to  be  a 

prescription  drug  and  allow  ambulance  suppliers  in  their  area  to  bill  for  oxygen  in 

addition  to  the  base  rate. 

Policy  differences  also  exist  with  regard  to  EKGs,  supplies,  injections  and  other  services 

provided  during  transport.  In  30 States  ambulai;ces  are  paid  additional  amounts  for 

EKG  services  provided  to  patients.  In  37 States  additional  amounts  are  paid  for 

disposable  supplies  and  in  18 States  additional  payments  are  made  for  reusable  supplies. 

In  areas  where  providers  historically  itemized  charges  for  medical  supplies,  injections, 

night  differential  and  other  codes,  carrier  policies  have  evolved  that  perpetuate  this 

fragmentation. 

The  average  amount  paid  per  ambulance  trip  ($500)  does  not  have  a consistent  and 

direct  relationship  to  the  cost  of  doing  business  in  a State,  county  or  municipality. 

Medicares  current  payment  rates  do  not  take  into  consideration  the  cost  savings  that 

have  taken  place  in  the  industry. 

In  many  parts  of  the  country  the  industry  is dominated  by a few  players.  In  these  areas 

providers  can  operate  more  economically  because  they  bulk  purchase  fuel  and  supplies 

and  are  in  a better  position  to  negotiate  discounts  favorable  to  them.  They  also  purchase 

new  technology  that  enables  them  to  use  satellite  tracking  to  monitor  all  of  their  vehicles 

and  to  make  the  most  efficient  use  of  manpower.  The  rise  of  managed  care  has  also 

created  more  aggressive  competition  among  ambulance  providers  for  a share  of  the 

managed  care  marketplace. 

Local  practice  and  the  reasonable  charge  payment  system  have  permitted  the  industry  to 

establish  a reimbursement  environment  that  favors  them  financially.  One  would  expect, 

Medicare  to  pay  more  for  ambulance  services  in States  such  as California,  Illinois,  New 

York  and  other  States  where  the  cost  of  doing  business  is higher.  Conversely,  one  would 

expect  that  Medicare  would  pay  less  in  Louisiana,  Mississippi  and  other  States  where  the 

cost  of  doing  business  is lower. 

Using  average  hourly  wage,  housing  costs,  fuels  costs  and  other  measures  indicative  of 

the  cost  of  doing  business,  we  found  that  Medicares  allowed  charge  has  little  or  no 

relationship  to  the  cost  of  doing  business  in  an  area.  For  example,  Mississippi 

consistently  ranks  in  the  top  10 States  for  base  rate  reimbursement;  yet,  the  average 
 hourly  wage  paid  in  Mississippi  ranks  47 out  the  50 States.  Montana  ranks  in  the  top  20 

States  for  these  same  services,  while  it ranks  46 out  of  the  50 States  in  per  capita 

personal  income  for  1996. 

We  asked  the  carriers  what  they  believed  ~1s  included  in Medicares  reimbursement  for 

mileage.  In  24 States,  the  carrier  responsible  for  processing  claims  believed  the  payment 

was  intended  to  cover  only  the  cost  of  replacing  fuel  during  a covered  transport  by 

ambulance.  In  10 States,  the  carrier  believed  mileage  reimbursement  was  intended  to 

cover  vehicle  depreciation  as well  as  fuel  replacement  costs.  An  equal  number  believed 

the  amount  was  intended  to  cover  insurance  cost,  fuel  replacement  and  depreciation. 

As  with  base  rates,  Medicares  allowed  charge  for  mileage  is derived  from  charges 

submitted  by  the  providers.  This  encourages  providers  to  raise  charges  each  year.  The 

actual  cost  to  secure  fuel  is not  currently  taken  into  account  when  determining  Medicare 

allowable  reimbursement. 

11  RECOMMENDATIONS 

The  HCFAs  well-intentioned  efforts  to  limit  ambulance  companies  to  four  billing 
methods  using  37 procedure  codes  has  been  circumvented  by  idiosyncrasies  of  the  current 
fee-for-service  payment  system.  At  a time  when  most  Medicare  Part  B services  are  being 
paid  on  a fee  schedule,  ambulance  services  are  among  the  few  services  the  Medicare 
program  still  reimburses  on  a reasonable  charge  basis. 
Tremendous  variation  in payments  indicates  that  Medicare  reimbursement  in  many  areas 
may  be  too  high.  The  reasonable  charge  payment  mechanism  has  resulted  in  inflated 
charges  for  ambulance  services  and  does  not  accurately  reflect  the  real  cost  of  doing 
business  in  an  area.  More  importantly,  the  fee-for-service  system  provides  little  or  no 
incentive  for  providers  to  control  costs.  Efforts  to  control  expenditure  levels  in  the  fee-
for-service  system  result  in fragmentation  of  services  and  increased  utilization.  Extensive 
carrier  reviews  of  ambulance  claims  adds  to  program  costs.  Fraud  and  abuse  in  this  area 
has  also  been  well  documented. 
We  believe  that  the  vulnerabilities  we  found  need  to  be  addressed  as  soon  as possible. 
We  recommend  that  HCFA: 
seek  legislative  authority  to  develop  a fee  schedule  for  ambulance  transportation. 
b 
In  doing  so,  HCFA  should  take  into  consideration  the  competitive  prices  available  in  an 
area  including  the  negotiated  rate  that  exist  between  managed  care  entities/hospitals  and 
ambulance  providers.  A  fee  schedule  could  also  take  into  account  the  cost  of  doing 
business  in  an  area,  economies  of  scale  available  to  some  providers,  adjustments  for  local 
subsidies  and  other  consideration  that  may  affect  the  cost  of  doing  business. 
The  following  interim  teps  should  be  taken  to  help  develop  the  fee  schedule: 
Instruct  carriers  to  examine  the  inherent  reasonableness  of  current  allowable 
b 	
charges  and  adjust  them  as  necessary. 
Work  with  the  ambulance  industry  to  develop  clearer  guidelines  as to  what  is or  is 
b 	
not  included  in  the  base  rate  and  what  mileage  is intended  to  cover. 
b 	 Eliminate  separate  payments  for  oxygen,  supplies,  injectables  and  other  services 
such  as  EKGs.  These  items  should  be  included  in  the  base  rate. 
Limit  the  number  of  procedure  codes  available  to  ambulance  suppliers  for  billing. 
b 	
At  a minimum,  restrict  use  of  procedure  codes  to  the  37 specific  codes  designated 
for  ambulance  transportation. 
We  believe  that  Medicare  ambulance  policies  could  be  simplified  and  unreasonable  base 
rate  and  mileage  payment  levels  reduced.  Consistent  coverage  policies  should  be 
12  developed  and the number  of billing  methods  and procedure  codes  currently  in use 

reduced.  Elimination  of many  procedure  codes  would  discourage  unbundling  and the 

routine  use of some  supplies  and services  designed  simply  to enhance  payment.  Items 

considered  essential  for  life  support  should  be included  in base rate  reimbursement  and 

should  not  be paid  as separate  items  or services. 

Actual  savings  from  simplification  and more  uniform  policies  would  depend  on how  base 

rate  and mileage  are defined  and the  fee schedule  allowances  for these  services.  If 

implemented  as we have  suggested  we project  that  Medicare  could  save  at least  $242 

million  annually.  Fifty  million  dollars  of these  projected  savings  could  be derived  solely 

from  elimination  of separate  payments  for  oxygen,  supplies,  injectables  and  other  services 

such  as EKGs.  At  least  $192 million  could  be saved  annually  by  limiting  the  allowed 

charge  for  mileage  to the  lower  of actual  charge  or $1 per mile. 

Our  savings  projections  are predicated  on the  current  base rate  levels  remaining 

unchanged  except  for  increases  due to the  inflation  index  charge  or changes  in customary 

and prevailing  charges.  Actual  savings  could  be higher  if the base  rate  allowed  charge 

for non-emergency  transportation  is adjusted  to ensure  that  Medicare  pays  the  same  or 

less  for this  service  than  it does  for the base rate  for  emergency  transportation. 

Structuring  payments  to take  into  account  average  miles  per  gallon,  bulk  purchasing 

discounts,  State  and  local  taxes  and other  factors  could  also  impact  projected  savings. 

Savings  may  be lower  if some base rates  are increased  or policies  developed  that  permit 

unbundling  of some  services. 

AGENCY  COMMENTS 
Since  issuing  our  draft  report,  Congress  passed  the  Balanced  Budget  Act  of  1997.  This 
legislation  implements  our recommendation  and requires  that  HCFA  establish  a fee 
schedule  for Medicare  ambulance  payments.  We look  forward  to HCFAs  regulation 
that  will  carry  out the  legislation. 
13  APPENDIX  A 

Examples  of  Ambulance  Cases  Investigated  By 
The  Office  of  Inspector  General 
A- 1 
 Three  related  ambulance  companies  in Connecticut  submitted  false  claims  to  the 
0 	
Medicare  program  from  1991  to  1994.  The  companies  falsified  claims  to  obtain 
payments  for  noncovered  services.  The  false  claims  concealed  routine 
transportation  of  ambulatory  patients  from  their  residences  or  nonskilled  nursing 
homes  to  renal  dialysis  clinics  in order  to  obtain  Medicare  payments. 
An  ambulance  provider  convicted  and  sanctioned  for  Medicaid  Fraud  in  1986  used 
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front  men  to  form  transportation  companies  so  she  could  get  Medicare  payments 
for  ambulance  service  without  anyone  detecting  she  was  a sanctioned  provider. 
Using  the  fronts,  the  provider  obtained  various  vehicle  licenses  for  special  need 
transportation  and  then  billed  Medicare  and  Medicaid  for  individual  services  when 
multiple  patients  were  transported  in  unlicensed  personal  vehicles. 
 	 A St.  Paul,  MN  based  company  billed  Medicaid  and  Medicare  for  basic  life 
support  ambulance  transportation,  claiming  the  rides  were  medically  necessary, 
when  a lesser  form  of  transportation  would  have  been  appropriate.  Consumers, 
too,  lost  money  when  they  were  billed  for  copayments  on  the  unnecessary 
ambulance  rides  when  a simple  van  ride  would  have  been  appropriate. 
a 	 In  Illinois,  an  ambulance  company  was  convicted  of  targeting  nursing  home 
patients  and  billing  for  ambulance  services  when  the  patients  did  not  need  an 
ambulance.  The  defendants  falsified  medical  and  trip  records  and  back  dated 
them  in  an  effort  to  establish  the  medical  necessity  of  the  ambulance  transports. 
A  case  in  Indiana  found  an  ambulance  provider  guilty  of  transporting  nursing 
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home  residents  to  scheduled  medical  appointments  at  doctors  offices,  clinics  and 
hospitals.  Most  ,)f the  patients  transported  were  ambulatory  or  in wheelchairs  but 
the  provider  indicated  on  claims  submitted  for  payment  that  the  patients  were  bed 
confined.  The  provider  also  routinely  billed  for  oxygen  which  was  not 
administered. 
 	 In  Ohio,  an  ambulance  provider  falsified  destinations,  medical  necessity 
information  and  ordering  physician  information.  For  7 years  the  owner  altered 
trip  tickets  submitted  by  his  drivers  to  reflect  that  patients  were  transported  to 
covered  destinations  when  in fact  patients  were  transported  to  doctors  offices. 
The  owner  would  also  change  the  trip  tickets  to  show  that  patients  were 
bedridden  when  in  fact  the  patients  were  in wheelchairs  and  in  some  instances 
could  walk.  There  were  occasions  when  the  company  billed  for  ambulance 
transports  when  the  patients  were  transported  in a company  station  wagon. 
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