Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

INAPPROPRIATE PAYMENTS 

AND QUESTIONABLE BILLING 

FOR MEDICARE PART B 

AMBULANCE TRANSPORTS 

Suzanne Murrin 

Deputy Inspector General 

for Evaluation and Inspections 

September 2015 

OEI-09-12-00351 
 

 

EXECUTIVE SUMMARY: INAPPROPRIATE PAYMENTS AND QUESTIONABLE 

BILLING FOR MEDICARE PART B AMBULANCE TRANSPORTS 

OEI-09-12-00351 

WHY WE DID THIS STUDY 

In 2012, Medicare Part B paid $5.8 billion for ambulance transports, almost double the amount it paid 

in 2003. Historically, Medicare has been vulnerable to fraud involving ambulance transports. In 

2013 and 2014, the Centers for Medicare & Medicaid Services (CMS) imposed temporary moratoria 

on the enrollment of new ambulance suppliers in two metropolitan areas. Medicare billing for 

ambulance transports warrants scrutiny, given its rapid growth and its vulnerability to fraud and 

abuse. 

HOW WE DID THIS STUDY 

To identify inappropriate payments and questionable billing, we analyzed claims data for 7.3 million 

ambulance transports during the first half of 2012. We examined aspects of the transports including, 

but not limited to, transport destinations, transport levels, distance of urban transports, other Medicare 

services that beneficiaries received, and the geographic locations where the beneficiaries who 

received transports resided. 

WHAT WE FOUND 

We identified both improper payments for ambulance transports and questionable billing by 

ambulance suppliers. We found that Medicare paid $24 million in the first half of 2012 for 

ambulance transports that did not meet certain program requirements to justify payment. For 

example, Medicare paid $17 million for transports that were to or from noncovered destinations such 

as physicians’ offices. In addition, Medicare paid $30 million for transports for which the 

beneficiaries did not receive Medicare services at the pick-up or drop-off locations, or anywhere else. 

These claims may have been inappropriate. We also found that about one in five suppliers had 

questionable billing. For example, a supplier may have had an unusually high average mileage for 

the transports that it provided to beneficiaries residing in urban areas. Questionable billing is 

geographically concentrated; more than half of all questionable transports were provided to 

beneficiaries residing in four metropolitan areas. 

WHAT WE RECOMMEND 

Our findings indicate that inappropriate and questionable billing for ambulance transports pose 

vulnerabilities to Medicare program integrity. In response, CMS should enhance existing fraud and 

abuse safeguards. Our report made five recommendations. CMS concurred with our 

recommendations for it to (1) determine whether a temporary moratorium on ambulance supplier 

enrollment in additional geographic areas is warranted, (2) require ambulance suppliers to include the 

National Provider Identifier of the certifying physician on transport claims that require certification, 

(3) increase its monitoring of ambulance billing, and (4) determine the appropriateness of claims 

billed by ambulance suppliers identified in the report and take appropriate action. CMS partially 

concurred with our recommendation for it to implement new claims processing edits or improve 

existing edits to prevent inappropriate payments for ambulance transports. CMS indicated that it will 

review data on claims identified in this report; CMS should use the results of its review to implement 

new, or modify existing, claims processing edits needed to prevent inappropriate payments. 
TABLE OF CONTENTS 

Objectives ....................................................................................................1 

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

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

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

Medicare paid $24 million for ambulance transports that did 

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

Medicare paid $30 million for potentially inappropriate 

ambulance transports for which the beneficiary did not 

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

About one in five ambulance suppliers had questionable 

billing .............................................................................................15 

More than half of questionable ambulance transports 

were provided to beneficiaries who resided in four 

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

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

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

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

Appendix A: Ambulance Transport Levels and Medicare 

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

Appendix B: Detailed Description of Measures of 

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

Appendix C: Questionable and All Ambulance 

Transports That Occurred in Fourteen Additional Areas, 

First Half of 2012...........................................................................31 

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

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

 

 

 

OBJECTIVES 

To determine the extent to which: 

1.	 Medicare paid for ambulance transports that did not meet certain 

Medicare requirements, 

2.	 Medicare paid for ambulance transports for beneficiaries who did not 

receive Medicare services at any origin or destination, 

3.	 ambulance suppliers had questionable billing, and 

4.	 questionable billing for ambulance transports is geographically 

concentrated. 

BACKGROUND 

In 2012, Medicare payments for ground ambulance transports covered 

under Part B totaled $5.8 billion, up from $2.9 billion in 2003.1 Medicare 

beneficiaries received a total of 14.9 million transports in 2012.2 

Investigators have uncovered a variety of fraud schemes involving 

ambulance suppliers. For example, in May 2015, a Florida supplier paid 

$1.25 million to settle allegations that it knowingly upcoded transport 

claims from basic to advanced life support, unnecessarily transported 

patients, and transported patients unnecessarily to their homes at a level of 

care meant for emergencies.3 In June 2014, employees of a supplier 

operating in Philadelphia and other areas of Pennsylvania received prison 

sentences for fraudulently billing Medicare $3.6 million for transports that 

did not meet coverage requirements. The supplier recruited patients who 

could walk and did not require transport by ambulance, and was also 

convicted of falsifying documents to support the transports and paying the 

patients illegal kickbacks.4 In January 2014, owners of a supplier in 

Tennessee received prison sentences for fraudulently billing Medicare and 

____________________________________________________________ 

1

 Medicare also covers ambulance transports by airplane and helicopter. All references in 

this report to ambulance transports apply only to ground transports. 2

 Centers for Medicare & Medicaid Services (CMS), 2003 and 2012 Part B National 

Summary Data Files. Throughout this report, references to Medicare payments represent 

the total amounts allowed by Medicare, which consist of payments made by Medicare 

plus beneficiary cost-sharing payments. Medicare payments we report include the 

amounts paid for the transports’ mileage. 

3 United States Department of Justice, United States Settles False Claims Act Allegations 

Against Multiple Jacksonville Hospitals and an Ambulance Company For $7.5 Million, 

May 8, 2015. Accessed at http://www.justice.gov/usao-mdfl/pr/united-states-settlesfalse-claims-act-allegations-against-multiple-jacksonville on June 9, 2015. 4

 United States Department of Justice, EMT sentenced for role in ambulance fraud 

scheme, June 5, 2014. Accessed at http://www.fbi.gov/philadelphia/pressreleases/2014/emt-sentenced-for-role-in-ambulance-fraud-scheme on June 12, 2014. 

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Medicaid $1.2 million for transports to and from dialysis facilities. 

During these transports patients were seated—sometimes in the front of 

the ambulance—rather than being transported on stretchers. Other 

fraudulent claims reported that the supplier transported patients 

individually when the supplier actually transported the patients together in 

one ambulance. The supplier also used the names and Medicare numbers 

of patients without lawful authority when submitting the claims and 

falsified documents to support the transports.5 

Medicare Coverage of Ambulance Transports 

Medicare covers ambulance transports when a beneficiary’s medical 

condition at the time of transport is such that other means of transportation 

would endanger the beneficiary’s health.6 In addition, the transport must 

be to receive a medically necessary Medicare service or to return from 

such a service.7 For example, Medicare would not cover a transport to a 

hospital if the beneficiary was not treated at the hospital. Transports that 

occur during a beneficiary’s Part A stay at an inpatient hospital, skilled 

nursing facility (SNF), or hospice are generally covered as part of the stay. 

Medicare Part B generally does not make separate payments for transports 

that occur during Part A stays.8 Medicare does not cover other means of 

transport such as wheelchair vans or taxicabs. If the transport meets 

coverage requirements, Medicare also reimburses suppliers for miles 

traveled with the beneficiary on board.9 

Medicare covers seven different levels of ambulance transport.10 

Transport levels vary in terms of the qualifications of the ambulance crew 

and the level of medical care provided.11 The transport level also depends 

on whether the transport is provided in an emergency or nonemergency 

____________________________________________________________ 

5 United States Department of Justice, Former Owners of Murfreesboro Ambulance 

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

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

June 12, 2014.
 6

 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.2.1. 7

 Ibid. 

8

 Ibid., ch. 10 § 10.3.3 and ch. 9 § 40.1.9. Transports of SNF residents to receive dialysis
 

or certain other “high-end” outpatient services are covered under Part B. CMS, Medicare
 

Claims Processing Manual, ch. 15, § 30.2.2. 9

 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.3.
 10 Ibid., ch. 10 § 30.1. 

11 Basic life support transports require an ambulance crew certified at least as basic 

emergency medical technicians. Advanced life support transports require an ambulance 

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

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

such as critical care nursing. 

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situation. Medicare beneficiaries most commonly receive basic life 

support transports provided in a nonemergency setting. The next most 

common transport level is advanced life support transports provided 

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

and information about Medicare payments for each level. 

Medicare covers ambulance transports to the nearest appropriate facility to 

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

return transport.12 “Appropriate facility” means that the institution is 

generally equipped to provide the needed hospital care or skilled nursing 

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

following destinations: 14
 

 hospitals,
 

 SNFs, 

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

require dialysis, and 

 beneficiaries’ residences. 

For emergency transports, destinations other than hospitals are presumed 

to be inappropriate.16 For specialty care transports, hospitals and SNFs are 

the only appropriate origins and destinations.17 

Although dialysis facilities are a covered destination, most beneficiaries 

who have ESRD do not need to be transported by ambulance to receive 

dialysis.18 One Medicare Administrative Contractor (MAC) estimated that 

only 10 percent of beneficiaries with ESRD who receive hemodialysis— 

one of the two main types of dialysis—require ambulance transports to 

____________________________________________________________ 

12 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.3.
 13 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.3.6. 14 Ibid., ch. 10 § 10.3. Critical access hospitals are included as a type of covered hospital 

destination. The site of a transfer between ground and air ambulance transports is also a 

covered destination. Ibid., ch. 10 § 10.5. 

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

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

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

dialysis three times per week. 

16 One Medicare contractor expressly states that hospitals are the only appropriate 

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

(Ground) Services L32252. Several appropriate destinations are allowed per 42 CFR
 

§ 410.40(e)(1) and CMS, Medicare Benefit Policy Manual, ch. 10, §§ 10.3 and 10.3.6. 

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

§ 424.101.
 17 CMS, Change Request 5533, March 30, 2007. 71 Fed. Reg. 69624, 69716–69717
 

(Dec. 1, 2006). For specialty care transports, hospitals include hospital-based facilities 

that meet CMS’s requirements for provider-based status. 18 Palmetto GBA, Nonemergency Services. 

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and from hemodialysis treatment.19, 20, 21 

To receive Medicare payment for an ambulance transport, the ambulance 

supplier submits a claim and indicates on it the transport level, the origin, 

the destination, and the total miles for the one-way transport. The supplier 

indicates the transport level using a Health Care Procedure Coding System 

code (procedure code). Suppliers must indicate the transport’s origin and 

destination,22 and do so by using modifier codes. The supplier bills for the 

mileage on the same claim, using a different procedure code. 

Program Integrity Safeguards for Ambulance Transports 

CMS uses a variety of safeguards to prevent and detect fraud, waste, and 

abuse of ambulance transports in the Medicare program. 

Provider Screening. CMS and its contractors screen all providers seeking 

to enroll or reenroll in the Medicare program according to the risk of 

fraud, waste, and abuse that is posed by each provider category.23 CMS 

created three levels of risk: limited, moderate, and high.24 Ambulance 

suppliers are categorized as moderate risk. 

Enrollment Moratoria. CMS has temporarily suspended the enrollment of 

new ambulance suppliers into Medicare, Medicaid, and the Children’s 

Health Insurance Program in two areas of the country.25 The enrollment 

moratoria became effective in the Houston, Texas, area in July 2013 and 

in the Philadelphia, Pennsylvania, area in January 2014.26 The enrollment 

moratoria have been extended three times—most recently, in July 2015.27 

Physician Certification Statements. For those ambulance transports that 

are scheduled ahead of time and for some unscheduled transports, the 

beneficiary’s attending physician, nurse, or discharge planner must 

prepare a written statement (physician certification statement) certifying 

____________________________________________________________ 

19 MACs process claims and pay for services provided to beneficiaries in the Medicare 

fee-for-service program.
 20 Novitas Solutions, Inc., Ambulance (Ground) Services L32252. 21 The other main type of dialysis, peritoneal dialysis, is usually performed at home. 

22 CMS, Medicare Claims Processing Manual, ch. 15 § 30.
 23 42 CFR § 424.518.
 24 Screening for providers categorized as limited risk consists of basic verifications, such
 

as verifying that the provider has a valid medical license. Screening for providers 

categorized as moderate risk consists of the same verifications as for limited-risk
 

providers, as well as unscheduled or unannounced site visits. Screening for providers 

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

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

if there is a significant potential for fraud, waste, or abuse. 42 CFR § 424.570.
 26 78 Fed. Reg. 46339 (July 31, 2013); 79 Fed. Reg. 6475 (Feb. 4, 2014). 

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

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that the transport is medically necessary.28 Transports to and from dialysis 

facilities (dialysis-related transports) are one type of transport that is 

typically scheduled ahead of time. Physician certification statements are 

not required for unscheduled transports provided to beneficiaries who live 

at home or in facilities where they are not under a physician’s direct care. 

Prior-Authorization Demonstration. In December 2014, CMS began a 

prior-authorization demonstration for repetitive, scheduled nonemergency 

ambulance transports in New Jersey, Pennsylvania, and South Carolina.29 

Before providing these transports, ambulance suppliers must submit the 

necessary information to CMS to ensure that the transports meet all 

relevant clinical or medical documentation requirements. The 

demonstration focuses on these transports because nonemergency 

transports, particularly those that are dialysis-related, have increased 

noticeably in recent years. The demonstration is meant to test whether 

prior authorization can help to reduce expenditures while maintaining or 

improving quality of care. 

Claims Processing Edits. Claims processing edits prevent inappropriate 

payments for ambulance transports and other services. These electronic 

edits automatically pay, deny, or suspend for manual review all or part of 

a claim, as necessary. MACs may choose to use local edits to enforce 

their local coverage decisions and reduce payment error.30 For example, 

one MAC uses an edit to deny payment for transport claims with origin 

and destination codes that are unlikely to meet coverage requirements.31 

CMS can also direct MACs to implement shared system edits to enforce 

Medicare coverage requirements. 

Monitoring of Suppliers’ Billing. CMS conducts data mining to identify 

potentially fraudulent ambulance suppliers and other providers. CMS 

contracts with Zone Program Integrity Contractors to investigate potential 

fraud, waste, and abuse; identify improper payments; and refer cases to 

law enforcement.32 CMS also uses its Fraud Prevention System to run 

predictive analytics against all Medicare fee-for-service claims data.33

 ____________________________________________________________ 

28 42 CFR § 410.40(d). 

29 CMS, Fact Sheets: Prior Authorization Process for Repetitive Scheduled
 

Non-Emergent Ambulance Transport. 30 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 3, § 3.4.1.5(A). 31 Noridian Healthcare Solutions, which processes Medicare Part B claims in 

Jurisdiction E, implemented the edit in August 2014. Jurisdiction E consists of 

California, Hawaii, Nevada, and the U.S. Pacific territories. 32 CMS, Medicare Program Integrity Manual, Pub. 100-08, ch. 1 § 1.7.B. 33 CMS, Center for Program Integrity: New Strategic Direction and Key Antifraud 

Activities. 

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Related Work 

In September 2013, the Office of the Inspector General (OIG) published a 

report that provides a detailed analysis of the changes in utilization of 

Medicare Part B ambulance transports from 2002 through 2011.34 During 

that time, the number of beneficiaries who received transports increased 

34 percent, compared to an increase of 7 percent in the number of 

beneficiaries enrolled in the Medicare fee-for-service program. In 

particular, the number of transports for beneficiaries with ESRD grew 

during this time period, increasing 269 percent from 2002 to 2011. OIG 

also found that not all transports were to covered destinations. The type of 

noncovered destination to which transports increased the most was 

community mental health centers. 

In June 2013, the Medicare Payment Advisory Commission (MedPAC) 

reported on Medicare’s ambulance fee schedule. MedPAC recommended 

that medical necessity requirements for transports be more precisely 

defined, that a set of national edits based on those requirements be 

developed, and that geographic areas and suppliers that display unusual 

patterns be identified. To support these recommendations, MedPAC cited 

the rapid growth in the enrollment of for-profit suppliers and program 

integrity issues within the Medicare ambulance benefit.35 

METHODOLOGY 

Scope 

This study is based on our analysis of Medicare Part B claims for 

ambulance transports provided by ambulance suppliers from January 1 to 

June 30, 2012.36 Our population includes claims for 7.3 million transports 

and their associated mileage, totaling $2.9 billion in Medicare payments.37 

These claims were submitted by 15,614 unique ambulance suppliers and 

represent transports for 2.9 million Medicare beneficiaries.38 We also 

____________________________________________________________ 

34 OIG, Utilization of Medicare Ambulance Transports, 2002—2011, September 2013 

(OEI-09-12-00350). 

35 MedPAC, Report to the Congress: Medicare and the Health Care Delivery System, 

Mandated report: Medicare payment for ambulance services, pp. 178–179, June 2013. 36 We did not analyze claims from institutional ambulance providers. In 2012, 4 percent 

of ambulance providers were based at institutions, such as hospitals. 

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

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

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

Paramedic intercepts occur when a paramedic meets a basic life support transport and
 

provides advanced life support services. 38 We identified suppliers by using the provider identification number combined with the 

MAC number. 

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analyzed claims for Medicare services that beneficiaries received at the 

facilities they were transported to and from. 

Data Collection 

Our data sources were the 2012 National Claims History Physician/ 

Supplier Part B claims file; the 2012 Inpatient, Outpatient, SNF, and 

Hospice Standard Analytical Files; the 2012 Denominator File from the 

Medicare Enrollment Database; and the Compromised Numbers 

Contractor database.39 The Physician/Supplier Part B claims file contains 

claims submitted by independent ambulance suppliers and other 

noninstitutional providers. These claims detail information such as the 

transport level and the transport origin and destination.40 The Standard 

Analytical Files contain claims submitted by institutions, such as 

hospitals. The Medicare Enrollment Database contains Medicare 

beneficiaries’ enrollment information, such as date of birth. The 

Compromised Numbers Contractor database contains provider and 

beneficiary identification numbers that have been involved in or are 

vulnerable to medical identity theft.41 

Identification of Ambulance Transports That Did Not Meet 

Certain Medicare Requirements 

Noncovered Destinations. We identified transports that were to 

destinations to which Medicare does not cover ambulance transports, and 

the return transports from those destinations. We identified transports that 

suppliers billed using a modifier on the ambulance claim to indicate that 

the beneficiary was transported to a physician’s office or to a diagnostic or 

therapeutic site. We also identified transports that—according to our 

analysis of other Medicare claims for the same beneficiaries—were to 

noncovered destinations or were the return transports from noncovered 

destinations. For these transports, the beneficiaries received Medicare 

services only at noncovered destinations within 1 day of their transports. 

These included transports that (for example) the suppliers indicated were 

to hospitals but for which the beneficiaries instead received services at 

community mental health centers. We calculated the total Medicare 

payments for transports to or from noncovered destinations. We also 

____________________________________________________________ 

39 We also analyzed claims for services provided on December 31, 2011, for beneficiaries 

who received transports on January 1, 2012. 

40 For 99.98 percent of transports in our population, transports’ origins and destinations 

were reported in the first modifier field. For less than one-tenth of 1 percent of 

transports, origins and destinations were reported in two modifier fields on the same 

claim line. For those transports, we analyzed the first modifier field. 41 Medicare beneficiaries’ identification numbers are also known as Health Insurance 

Claim numbers. In this report, we refer to Medicare beneficiary identification numbers 

as “beneficiary numbers.” 

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calculated the Medicare payments associated with transports to each type 

of noncovered destination.42 

Inappropriate Combinations of Destinations and Transport Levels. We 

identified two types of transports billed with inappropriate combinations 

of destinations and transport levels. First, we identified emergency 

transports that suppliers indicated were to a destination other than a 

hospital or the site of a transfer between ground and air transports. We 

also identified specialty care transports that suppliers indicated were to or 

from destinations other than hospitals, SNFs, or transfer sites. We 

calculated the total Medicare payments for transports with inappropriate 

combinations of destinations and transport levels. 

Identification of Ambulance Transports for Beneficiaries Who 

Did Not Receive Medicare Services at Any Origin or Destination 

We identified ambulance transports for which the beneficiaries did not 

receive Medicare services at any origin or destination. We excluded any 

transport claims for which the beneficiary died within 1 day of the 

transport. We determined whether the beneficiary received services within 

1 day of the transport at the origin or destination indicated by the supplier 

on the claim.43 To account for the possibility that the supplier had 

incorrectly indicated the origin or destination, we also determined whether 

the beneficiary received Medicare services at another origin or destination 

within 1 day of the transport. We reviewed the Inpatient, Outpatient, SNF, 

and Hospice Standard Analytical Files and the Physician/Supplier Part B 

claims file to determine whether beneficiaries received such services.44 

We verified that no claims for related services were submitted during the 

year after the transport occurred.45, 46 We calculated the total Medicare

 ____________________________________________________________ 

42 We counted each transport only once when calculating the same totals across 

destination types. However, some beneficiaries received services at more than one type 

of noncovered destination within 1 day of their transports. In these cases, we could not 

determine the destination to which the beneficiary was transported, so we included the 

transport in each type of noncovered destination—for example, counting it as one 

transport to a physician’s office and one transport to a community mental health center— 

when calculating the volume of transports and Medicare payments by destination type. 

43 We checked for Medicare services that occurred 1 day before or after the transports in 

case the transports occurred close to midnight. For example, a beneficiary may have 

been discharged from a hospital just before midnight and transported home. 

44 We limited our review of the Inpatient, SNF, and Hospice files to services that 

occurred within 1 day of the beneficiary’s admission or discharge. Medicare Part B does 

not pay for transports that occur during stays at these facilities. We excluded services 

that were provided in beneficiaries’ residences, such as in-home hospice services. 

45 Medicare Part A and Part B claims must be submitted no later than 1 year after the date 

the service was provided. CMS, Medicare Claims Processing Manual, ch. 1 § 70. 46 For this analysis, we used claims files that include claims processed up to 1 year after 

the first half of 2012. 

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payments for transports for which the beneficiaries did not receive 

Medicare services at any origin or destination. 

Identification of Ambulance Suppliers That Had Questionable 

Billing 

We developed seven measures of questionable billing for ambulance 

services. The measures are based on Medicare coverage and billing 

requirements for ambulance services; the results of past OIG analyses and 

fraud investigations related to ambulance suppliers; and consultations with 

fraud investigators within and outside of OIG. Table 1 describes the seven 

measures. 

Table 1: Measures of Questionable Billing for Ambulance Transports 

1. No Medicare Service at the Origin or Destination: High percentage of a supplier’s 

transports for which the beneficiaries did not receive Medicare services at the origin 

or destination indicated on the transport claim. Such transports may indicate billing 

for transports to noncovered destinations or transports that were not provided. 

2. Excessive Mileage for Urban Transports: High average mileage for transports for 

beneficiaries in urban areas. Such transports may indicate billing for more miles than 

suppliers actually drove or transports to facilities other than the nearest appropriate 

facilities. 

3. High Number of Transports per Beneficiary: Among suppliers that provided 

dialysis-related transports, high average per-beneficiary number of transports. Such 

transports may indicate billing for transports that were medically unnecessary. 

4. Compromised Beneficiary Number: High percentage of a supplier’s transports with 

compromised beneficiary numbers. Such transports may indicate billing for 

transports that were medically unnecessary or were not provided. 

5. Inappropriate or Unlikely Transport Level: High percentage of a supplier’s transports 

with inappropriate or unlikely transport levels given the destinations. Such transports 

may indicate upcoding or transport levels that were medically unnecessary. 

6. Beneficiary Sharing: High average number of suppliers providing dialysis-related 

transports to the beneficiaries transported by a supplier. Such transports may 

indicate misuse of beneficiaries’ numbers or “shopping” by beneficiaries among 

suppliers to receive higher kickbacks. 

7. Transports To or From Partial Hospitalization Programs (PHPs)47: The supplier 

provided transports that were to or from PHPs. Such transports are likely to be 

medically unnecessary because beneficiaries who meet Medicare coverage 

requirements for PHPs generally do not meet the requirements for transports. 

____________________________________________________________ 

47 PHPs provide intensive psychiatric care and resemble structured, short-term hospital 

inpatient programs. They are provided in two settings: community mental health centers 

and hospital outpatient departments. Beneficiaries admitted to a PHP do not require 

24-hour supervision as provided in an inpatient setting. These beneficiaries must have a 

support system outside the PHP, and must not be an imminent danger to themselves or 

others. 

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We calculated suppliers’ levels of each measure. We then identified 

suppliers that had unusually high levels on at least one measure relative to 

other suppliers (i.e., had questionable billing). We considered a supplier’s 

level to be unusually high if it was greater than the threshold for 

questionable billing (i.e., greater than the 75th percentile plus 1.5 times the 

interquartile range for the measure).48 We identified suppliers that 

exceeded the thresholds in comparison to other suppliers to which the 

measures applied. We also calculated the median level of each measure 

among those suppliers to which the measures applied.49 Appendix B 

provides a detailed description of how we calculated each measure. 

We calculated Medicare payments for ambulance transports associated 

with suppliers’ questionable billing (i.e., questionable transports). For 

four of the measures, we identified transports that exhibited the 

characteristic described in the measure (for example, a compromised 

beneficiary number) and were billed for by suppliers that had unusually 

high levels of the measure. Because the other three measures of 

questionable billing were calculated as averages across transports, we 

could not identify individual transports with the characteristics described 

in these measures. Therefore, we considered all urban transports billed by 

suppliers that had questionable billing for the measure “excessive mileage 

for urban transports” to be questionable. Similarly, we considered all 

dialysis-related transports billed by suppliers with questionable billing for 

the measures “high number of transports per beneficiary” and “beneficiary 

sharing” to be questionable. 

Geographical Analysis of Questionable Ambulance Transports 

We analyzed the geographic locations of questionable ambulance 

transports. We assigned each transport claim to a Core Based Statistical 

Area (area) using the location of the beneficiary’s residence.50 We 

identified the areas (on the basis of where beneficiaries resided) that 

accounted for the most questionable transports. We compared the top 

areas, which were metropolitan areas, with other metropolitan areas with 

____________________________________________________________ 

48 This is a standard exploratory method for identifying members of a population with 

unusually high values on a given statistic compared to the rest of the population when no 

established benchmarks exist. See J.W. Tukey, Exploratory Data Analysis. 

Addison-Wesley, 1977. 

49 For purposes of this report, we use the phrase “typical supplier” to describe suppliers 

that billed the median levels of the measures. Half of the suppliers to which the measure 

applies had levels that fell below the level of the typical supplier. 

50 Core Based Statistical Areas are associated with at least one core urban area with a 

population of at least 10,000. Core Based Statistical Areas with populations of at least 

50,000 are metropolitan areas. In the first half of 2012, there were 955 Core Based 

Statistical Areas in the United States and Puerto Rico, including 373 metropolitan areas. 

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regard to the average Medicare payments per supplier and the average 

number of beneficiaries per supplier. 

Limitations 

We relied on claims data to identify ambulance transports for which the 

beneficiaries received services only at noncovered destinations. We also 

relied on claims data to identify transports for which the beneficiaries did 

not receive Medicare services at any origin or destination. We did not 

review medical or other records from facilities to verify whether the 

beneficiaries received Medicare services at the facilities. When 

beneficiaries received Medicare services associated with their transports, 

we did not determine whether the services were provided at the nearest 

appropriate facilities. These limitations could result in either 

overestimating or underestimating inappropriate or potentially 

inappropriate billing. 

The seven measures of questionable billing used in this study do not 

provide conclusive evidence of fraudulent billing. Rather, the measures 

are intended to identify scenarios that, on the basis of claims data, are 

questionable. We identify ambulance suppliers that, relative to other 

ambulance suppliers, had unusually high levels of questionable billing 

during the first half of 2012. Further investigation would be required to 

determine whether these suppliers have, in fact, submitted fraudulent or 

inappropriate Medicare claims for ambulance transports. We did not 

review beneficiaries’ medical records or the physician certification 

statements to determine whether the transports met coverage requirements. 

We identified urban ambulance transports and analyzed the location of 

questionable transports on the basis of beneficiaries’ primary residences, 

as recorded in their enrollment data. Not all transports may have occurred 

in the same area as the beneficiary’s primary residence. This limitation 

may result in either overestimating or underestimating inappropriate or 

potentially inappropriate billing. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 11 
 

 

 

FINDINGS 

Medicare paid $24 million for ambulance transports

that did not meet certain Medicare requirements 

justifying payment 

In the first half of 2012, Medicare paid $24.2 million for ambulance 

transports that did not meet Medicare requirements regarding the 

transport’s destination. These transports were either to a destination not 

covered by Medicare or to a destination that was inappropriate given the 

transport level.51 

Medicare paid $17 million for transports to noncovered 

destinations and return transports 

Medicare inappropriately paid $17.4 million for ambulance transports to 

destinations to which Medicare does not cover transports and for the 

return transports. For these transports, the beneficiaries did not receive 

Medicare services at covered destinations (that is, at a hospital, dialysis 

facility, or SNF). Rather, the beneficiaries received services at 

noncovered destinations. Transports to or from noncovered destinations 

represented 0.6 percent of total Medicare ambulance payments in the first 

half of 2012. 

Physicians’ offices were the most common type of noncovered destination 

where beneficiaries received services. In the first half of 2012, Medicare 

paid $8.7 million for transports provided to beneficiaries who received 

services at physicians’ offices but not at covered destinations. Medicare 

also paid $5.8 million for transports provided to beneficiaries who 

received services at community mental health centers or psychiatric 

facilities but not at covered destinations. Table 2 presents the numbers of 

transports and Medicare payments, by the type of noncovered destination, 

for transports provided to beneficiaries who received services at 

noncovered destinations instead of at covered destinations.

 ____________________________________________________________ 

51 Transports that met neither requirement accounted for $266,963 of this total. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 12 
 

 

 

 

Table 2: Ambulance Transports Provided to Beneficiaries Who Received Services at 

Noncovered Destinations, First Half of 2012 

Noncovered Destination 

Number of Transports for 

Which the Beneficiary 

Received a Service at the 

Noncovered Destination 

Medicare 

Payments 

Physician’s office 

Community mental health center or 

psychiatric facility 

Independent laboratory or other diagnostic or 

therapeutic site 

Nursing facility (non-SNF) or long-term-care 

facility 

Other noncovered destination* 

Hospice facility 

Total** 

25,829 

18,097

12,019 

6,220

1,779 

1,203 

52,421 

$8,724,161 

 $5,816,778 

$4,090,113 

 $1,971,327 

$641,293 

$391,012 

$17,440,431 

* Other noncovered destinations include, for example, rural health centers and federally qualified health centers. 

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

1 day of their transport. In these cases, we included the transport in each type of noncovered destination. 

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

Medicare paid $7 million for transports with inappropriate 

combinations of destinations and transport levels 

Medicare paid $7.1 million for ambulance transports for which suppliers 

used destination modifiers that were inappropriate for the transport levels 

billed. These included specialty care transports that suppliers indicated 

were between origins and destinations other than hospitals or SNFs, and 

emergency transports that suppliers indicated were to nonhospital 

destinations.52 If suppliers indicated the correct origins and destinations 

on these transport claims, they either billed Medicare for more expensive 

transports levels than they actually provided, or provided transport levels 

that did not meet Medicare coverage requirements. Transports with 

inappropriate combinations of destinations and transport levels 

represented 0.2 percent of total Medicare ambulance payments in the first 

half of 2012. 

Specialty care transports. During the first half of 2012, Medicare paid 

$4.3 million for specialty care transports that ambulance suppliers 

indicated were between origins and destinations other than hospitals or 

SNFs. The most common inappropriate destination for these specialty 

care transports was independent (i.e., nonhospital) dialysis facilities. 

Medicare paid $2.6 million for specialty care transports between SNFs and 

____________________________________________________________ 

52 Emergency transports to nonhospital destinations are presumed to be inappropriate. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 13 
 

 

 

independent dialysis facilities and $0.9 million for specialty care 

transports between independent dialysis facilities and beneficiary 

residences. Medicare paid an additional $0.4 million for specialty care 

transports between beneficiary residences and hospitals. 

Emergency transports. During the first half of 2012, Medicare paid 

$2.7 million for emergency transports that ambulance suppliers indicated 

were to nonhospital destinations. The most common inappropriate 

destination for these emergency transports was SNFs. Medicare paid 

$1.6 million for emergency transports to SNFs. Medicare paid an 

additional $0.7 million for emergency transports to beneficiary residences. 

Medicare paid $30 million for potentially inappropriate 

ambulance transports for which the beneficiary did 

not receive Medicare services at any origin or 

destination 

To be covered by Medicare, ambulance transports must be for the purpose 

of receiving or returning from a Medicare-covered service.53 In the first 

half of 2012, Medicare paid $30.2 million for transports for which the 

beneficiaries did not receive Medicare services at any origin or 

destination. These beneficiaries did not receive Medicare services within 

1 day of their transports at the origin or destination indicated by 

suppliers. In addition to not receiving services at the origin or destination 

indicated by suppliers, these beneficiaries did not receive Medicare 

services at other facility types within 1 day of their transports.54 These 

transports represented 1.1 percent of total Medicare payments in the first 

half of 2012. 

In these instances, Medicare likely inappropriately paid for the ambulance 

transports. The transports may not have occurred or, if they occurred, the 

beneficiaries may not have received Medicare-covered services that would 

justify the need for the transports. It is also possible that the transports 

occurred during an inpatient hospital or SNF stay and should have been 

billed for as part of the stay. 

____________________________________________________________ 

53 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.2.1. 54 To account for the possibility that the supplier incorrectly indicated the origin or 

destination on the claim, we also determined whether the beneficiary received Medicare 

services at another type of facility. Other facility types we checked included covered 

destinations (such as SNFs) and noncovered destinations (such as physicians’ offices). 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 14 
 

 

 

About one in five ambulance suppliers had 

questionable billing 

In the first half of 2012, 21 percent of ambulance suppliers had 

questionable billing for at least one of the seven measures of questionable 

billing that we examined. These suppliers received $207 million for 

transports associated with questionable billing during the first half of 

2012. 

Seventeen percent of ambulance suppliers had questionable billing for one 

of the seven measures. Four percent of suppliers had questionable billing 

for two, three, or four measures. No suppliers had questionable billing for 

more than four measures. Table 3 presents the number of measures for 

which suppliers had questionable billing. 

Table 3: Number of Measures for Which Ambulance Suppliers Had 

Questionable Billing, First Half of 2012 

Number of Measures of 

Questionable Billing 

Percentage of 

Suppliers 

(N=15,614) 

Number of 

Suppliers 

1 

2 

3 

4 

Total 

17.1% 

3.2% 

0.9% 

0.1% 

21.3% 

2,668 

501 

140 

11

3,320 

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

The measure of questionable billing associated with the largest percentage 

of suppliers is based on transports for which the beneficiaries did not 

receive Medicare services at the origins or destinations indicated on the 

transport claims. Over three times as many ambulance suppliers had 

questionable billing for this measure as the number of suppliers that had 

questionable billing for the next most common measure. Table 4 presents 

the levels of the measures of questionable billing among all suppliers, the 

thresholds above which suppliers had questionable billing for each 

measure, and the numbers of suppliers that had questionable billing. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 15 
 

 

 

 

Table 4: Questionable Billing Among Ambulance Suppliers, First Half of 2012 

Measure of Questionable Billing 

Median Among 

All Suppliers 

Suppliers That Had Questionable Billing 

Threshold 

Number of 

Suppliers 

No Medicare Service at the Origin or 

Destination 

Excessive Mileage for Urban Transports 

High Number of Transports per 

Beneficiary1 

Compromised Beneficiary Number 

Inappropriate or Unlikely Transport Level 

Beneficiary Sharing1, 2 

Transports to or From PHPs 

0 transports 

10 miles 

4 transports 

1% 

<1% 

1.2 suppliers 

0 transports 

3% 

34 miles 

21 transports 

7% 

3% 

2.3 suppliers 

<<1%3 

2,038 

642 

533 

358 

268 

168 

127 

Note: We identified suppliers that had questionable billing and calculated median levels for each measure among all suppliers to which the 

measures applied. For example, the measure “excessive mileage for urban transports” applies to suppliers with urban transports. Appendix B 

provides a detailed description of how each measure was calculated. 1

 Among suppliers that provide dialysis-related transports. 

2

 As represented by the number of suppliers per beneficiary. 

3 “<<1” means that the number would round to 0, but is above 0. 

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

No Medicare Service at the Origin or Destination. Thirteen percent of 

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

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

receive Medicare services at the origins or destinations indicated on the 

transport claims. Suppliers with questionable billing for this measure may 

have transported the beneficiaries to different destinations than those 

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

transports to noncovered destinations. Alternatively, the transports may 

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

were not provided. Medicare payments for these questionable transports 

totaled $41.2 million in the first half of 2012. 

For a typical supplier, beneficiaries always received Medicare services at 

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

questionable billing for this measure, beneficiaries did not receive Medicare 

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

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

receive Medicare services at the indicated origins or destinations for at 

least 95 percent of the transports they billed. 

Excessive Mileage for Urban Transports. Four percent of ambulance
 

suppliers (642 out of 15,614) had questionable billing in terms of their 

average distances for transports for beneficiaries residing in urban areas. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 16 
 

 

 

Suppliers with questionable billing for this measure may not have 

transported beneficiaries to the nearest appropriate facility, as required, or 

may have billed for more miles than they actually drove. Medicare 

payments for these questionable transports totaled $7.3 million in the first 

half of 2012. 

For a typical supplier providing urban transports, the average urban 

transport distance was 10 miles. For the 642 suppliers that had 

questionable billing for this measure, the average urban transport distance 

was at least 34 miles. The average urban transport distance for 48 of these 

suppliers was over 100 miles. 

High Number of Transports per Beneficiary. Three percent of ambulance 

suppliers (533 out of 15,614) provided dialysis-related transports and had 

questionable billing in terms of the average number of transports per 

beneficiary. These suppliers may have billed for dialysis-related 

transports that were medically unnecessary or were not provided. 

Medicare payments for these questionable transports totaled 

$132.5 million in the first half of 2012. 

Beneficiaries transported by a typical supplier of dialysis-related 

transports received an average of four transports from all suppliers during 

the first half of 2012. Beneficiaries transported by the 533 suppliers that 

had questionable billing for this measure received an average of at least 

21 transports. 

Compromised Beneficiary Number. Two percent of ambulance suppliers 

(358 out of 15,614) had questionable billing in terms of their percentages 

of transports associated with compromised beneficiary numbers. 

Compromised beneficiary numbers are those that have been involved in or 

are vulnerable to medical identity theft. Suppliers with questionable 

billing for this measure may have billed for transports that were medically 

unnecessary or were not provided. Past OIG investigations have 

uncovered schemes in which providers have used stolen beneficiary 

numbers to submit false claims to Medicare.55 Medicare payments for 

these questionable transports totaled $28.8 million in the first half of 2012. 

For a typical supplier that billed for any transports with compromised 

beneficiary numbers, 1 percent of the supplier’s claims for transports had 

compromised beneficiary numbers. For the 358 suppliers that had 

questionable billing for this measure, at least 7 percent of their claims for 

transports had compromised beneficiary numbers. Transports with 

____________________________________________________________ 

55 Testimony of Gerald T. Roy, OIG Deputy Inspector General for Investigations, before 

the U.S. House of Representatives, Committee on Energy & Commerce, Subcommittee 

on Oversight & Investigations, March 2, 2011. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 17 
 

 

 

compromised beneficiary numbers accounted for at least 95 percent of the 

transports billed by 31 of these suppliers. 

Inappropriate or Unlikely Transport Level. Two percent of ambulance 

suppliers (268 out of 15,614) had questionable billing in terms of their 

percentages of transports with inappropriate or unlikely combinations of 

destinations and transport levels. Suppliers with questionable billing for 

this measure may have billed for more expensive transport levels than they 

actually provided or for transports that were medically unnecessary. 

Emergency transports to destinations other than hospitals that were billed 

by these suppliers were inappropriate, as were specialty care transports 

between origins and destinations other than hospitals and SNFs.56 

Advanced life support transports between origins and destinations other 

than hospitals and SNFs were unlikely to be medically necessary, 

according to fraud investigators. Medicare payments for these 

questionable transports totaled $5.6 million in the first half of 2012. 

For a typical supplier that billed any transports with an inappropriate or 

unlikely combination of destination and transport level, less than 1 percent 

of its transports were billed with inappropriate or unlikely combinations. 

For the 268 suppliers that had questionable billing for this measure, at 

least 3 percent of their transports were billed with inappropriate or 

unlikely combinations. For 19 of these suppliers, transports billed with 

inappropriate or unlikely combinations accounted for at least 25 percent of 

their transports. 

Beneficiary Sharing. One percent of ambulance suppliers (168 out of 

15,614) were associated with beneficiaries who, on average, received 

dialysis-related transports from an unusually high number of suppliers. 

When multiple suppliers bill for dialysis-related transports for the same 

beneficiary, the suppliers may have fraudulently shared beneficiaries or 

beneficiaries’ identification numbers with other suppliers. Alternatively, 

beneficiaries transported by these suppliers may have “shopped” among 

suppliers to receive kickbacks. Medicare payments for these questionable 

transports totaled $4.5 million in the first half of 2012. 

For a typical supplier of dialysis-related transports, on average, 

beneficiaries each received these transports from a single supplier during 

the first half of 2012. For the 168 suppliers with questionable billing for 

____________________________________________________________ 

56 Novitas Solutions, Inc., Ambulance (Ground) Services L32252. CMS, Change Request 

5533, March 30, 2007. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 18 
 

 

this measure, beneficiaries received dialysis-related transports from an 

average of at least two suppliers. 

PHP Transports. One percent of ambulance suppliers (127 out of 15,614) 

had questionable billing for PHP transports. Suppliers with questionable 

billing for this measure may have billed for transports to or from PHPs for 

beneficiaries who do not qualify to receive the transports. Beneficiaries 

who meet Medicare coverage requirements for PHPs generally do not 

meet the requirements for transports.57 For example, a beneficiary who is 

being transported because he is a danger to himself would not qualify to 

receive PHP services. Medicare payments for these questionable 

transports totaled $10.7 million in the first half of 2012. 

For a typical supplier, no transports were to or from PHPs. For the 

127 suppliers that had questionable billing for this measure, at least one 

transport was to or from a PHP. For 59 of these suppliers, transports to or 

from PHPs accounted for at least 75 percent of their transports. 

Suppliers that had questionable billing provided 

nonemergency basic life support transports more often than 

other suppliers 

Ambulance suppliers that had questionable billing differed from other 

ambulance suppliers in terms of transport levels they commonly billed. 

Sixty-five percent of the transports billed by suppliers that had 

questionable billing were basic life support transports provided in 

nonemergency settings. In comparison, basic life support transports 

provided in nonemergency settings accounted for only 36 percent of the 

transports billed by all other suppliers. This difference between suppliers 

that had questionable billing and those that did not—a higher proportion 

of nonemergency basic life support transports—could assist efforts to 

monitor questionable billing. 

____________________________________________________________ 

57 Trailblazer Health Enterprises, LLC, Ambulance, June 2012, pp. 61–62. (Trailblazer’s 

MAC contract ended later in 2012, and its Ambulance publication was retired.) 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 19 
 

 

 

 

 

More than half of questionable ambulance transports 

were provided to beneficiaries who resided in four 

metropolitan areas 

Questionable billing for ambulance transports was concentrated in the 

metropolitan areas that include the cities of Philadelphia, Los Angeles, 

New York, and Houston.58 These four areas accounted for 52 percent of 

questionable transports but only 18 percent of all transports during the first 

half of 2012.59 Table 5 presents the percentages of national totals and the 

Medicare payments for questionable transports and all transports provided 

to beneficiaries who resided in the four metropolitan areas during the first 

half of 2012. 

Table 5: Questionable Ambulance Transports and All Ambulance Transports That 

Were Provided to Beneficiaries Who Resided in Four Metropolitan Areas, First Half 

of 2012 

Area 

Percentage of National Total Medicare Payments 

Questionable 

Transports All Transports 

Questionable 

Transports All Transports 

Philadelphia, Pennsylvania 

Los Angeles, California 

New York, New York 

Houston, Texas 

Total in All Four Areas 

All Other Areas 

15.2% 

15.2% 

13.4% 

8.3% 

52.0% 

48.0% 

3.8% 

4.7% 

7.7% 

1.8% 

18.0% 

82.0% 

$27.0 million 

$32.3 million 

$26.2 million 

$18.0 million 

$103.5 million 

$103.9 million 

$88.1 million 

$118.6 million 

$194.6 million 

$46.6 million 

$447.9 million 

$2,407.6 million 

Notes: Columns may not sum to totals because of rounding. Of the 951 other areas, 133 did not have any questionable transports. 

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

Together, the four metropolitan areas with the most questionable 

transports accounted for $104 million of the $207 million in Medicare 

payments for questionable transports provided during the first half of 

2012. The following examples illustrate the extent to which questionable 

billing for ambulance transports is concentrated in these four areas: 

____________________________________________________________ 

58 Specifically, the areas include: (1) Philadelphia–Camden–Wilmington, Pennsylvania– 

New Jersey–Delaware–Maryland; (2) Los Angeles–Long Beach–Santa Ana, California; 

(3) New York–Northern New Jersey–Long Island, New York–New Jersey–Pennsylvania; 

and (4) Houston-Sugar Land–Baytown, Texas. 

59 An additional 22 percent of questionable transports—but only 12 percent of all 

transports—were provided to beneficiaries who resided in 14 other metropolitan areas. 

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

questionable billing in each area. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 20 
 

	 Although 4 percent of all transports were for beneficiaries who resided 

in the Philadelphia area, 21 percent of questionable dialysis-related 

transports associated with high numbers of transports per beneficiary 

were for beneficiaries who resided in that area. The Philadelphia area 

accounted for $25.6 million of the $132.5 million in Medicare 

payments for these questionable transports. 

	 Although 5 percent of all transports were for beneficiaries who resided 

in the Los Angeles area, 45 percent of questionable transports billed 

with compromised beneficiary numbers were for beneficiaries who 

resided in that area. The Los Angeles area accounted for $12.7 million 

of the $28.8 million in Medicare payments for these questionable 

transports. 

	 Although 8 percent of all transports were for beneficiaries who resided 

in the New York area, 17 percent of questionable transports for which 

the beneficiary did not receive a Medicare service at the origin or 

destination indicated on the transport claim were for beneficiaries who 

resided in that area. The New York area accounted for $6.5 million of 

the $41.2 million in Medicare payments for these questionable 

transports. 

	 Although 2 percent of all transports were for beneficiaries who resided 

in the Houston area, 97 percent of questionable transports to or from 

PHPs and 39 percent of questionable transports billed with 

compromised beneficiary numbers were for beneficiaries who resided 

in that area. The Houston area accounted for $10.4 million of the 

$10.7 million and $11.0 million of the $28.8 million, respectively, in 

Medicare payments for these types of questionable transports. 

Suppliers that provided transports to beneficiaries who 

resided in the four metropolitan areas received more Medicare 

payments on average than suppliers that provided transports 

to beneficiaries who resided in other metropolitan areas 

On average, ambulance suppliers that provided transports to beneficiaries 

who resided in each of the four metropolitan areas received more 

Medicare payments for the transports than suppliers that provided 

transports to beneficiaries in other metropolitan areas.60 For transports 

provided to beneficiaries who resided in the four metropolitan areas, 

suppliers transported an average of 24 to 69 beneficiaries and beneficiaries 

each accounted for an average of $1,264 to $1,525 during the first half of 

____________________________________________________________ 

60 Among the 955 CBSAs in the Nation, the 373 with the largest populations are 

classified as metropolitan areas. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 21 
 

 

 

 

2012. In all other metropolitan areas, suppliers transported an average of 

18 beneficiaries and beneficiaries each accounted for an average of $880.61 

Suppliers each received Medicare payments of $105,696, on average, for 

transporting Los Angeles beneficiaries during the first half of 2012—more 

than six times the average supplier payment of $16,137 for transporting 

beneficiaries who resided in metropolitan areas other than the four areas. 

Table 6 compares the four metropolitan areas with all other metropolitan 

areas in terms of the average number of beneficiaries per supplier, 

Medicare payments per beneficiary, and Medicare payments per supplier. 

Table 6: Medicare Payments for Transports Provided to Beneficiaries Who 

Resided in Metropolitan Areas, First Half of 2012 

Metropolitan Area 

Average Number 

of Beneficiaries 

per Supplier 

Average Medicare 

Payments per 

Beneficiary 

Average Medicare 

Payments per 

Supplier 

Los Angeles, California 

New York, New York 

Philadelphia, Pennsylvania 

Houston, Texas 

All Other Metropolitan 

Areas* 

69 

68 

38 

24 

18 

$1,525 

$1,264 

$1,507 

$1,432 

$880 

$105,696 

$85,606 

$56,667 

$34,951 

$16,137

 * Suppliers’ averages are based on the transports that they provided to the beneficiaries who resided in each 

metropolitan area. 

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

____________________________________________________________ 

61 The average number of transports per beneficiary was also higher in the four 

metropolitan areas than in other metropolitan areas. Beneficiaries who resided in the four 

metropolitan areas each received between 3.7 and 4.8 transports on average during the 

first half of 2012. Beneficiaries who resided in other metropolitan areas each received an 

average of 2.3 transports. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 22 
 

 

 

CONCLUSION AND RECOMMENDATIONS 

Medicare payments for ambulance transports have increased in recent 

years, and investigators have uncovered a variety of fraud schemes 

involving ambulance suppliers. Our findings suggest that inappropriate 

and questionable billing for ambulance transports continues to pose 

vulnerabilities to Medicare program integrity. 

Medicare paid for ambulance transports that did not meet certain Medicare 

requirements to justify payment. Medicare also paid for transports that 

may have been billed inappropriately, because our analysis of claims data 

indicates that the beneficiaries did not receive Medicare services at the 

pick up or drop off locations, or anywhere else. Further, about one in five 

ambulance suppliers had questionable billing, which was geographically 

concentrated among beneficiaries who resided in four metropolitan areas. 

Given the growth of ambulance payments and the findings of this report, 

CMS should enhance existing fraud and abuse safeguards. Therefore, we 

recommend that CMS: 

Determine whether a temporary moratorium on ambulance 

supplier enrollment in additional geographic areas is 

warranted 

CMS should determine whether to place a temporary moratorium on 

ambulance supplier enrollment in areas where questionable transports are 

concentrated. CMS imposed moratoria in the Houston area in July 2013 

and in the Philadelphia area in January 2014. However, questionable 

transports were also concentrated in two other metropolitan areas. The 

Los Angeles area accounted for 15 percent of questionable transports and 

only 5 percent of all transports during the first half of 2012. The 

New York area accounted for 13 percent of questionable transports and 

only 8 percent of all transports. 

Require ambulance suppliers to include the National Provider 

Identifier of the certifying physician on transport claims that 

require certification 

For ambulance transports that require physician certification, CMS should 

require that the supplier include the National Provider Identifier of the 

physician or other certifying provider on the transport claim.62 Suppliers 

that had questionable billing provided nonemergency basic life support 

____________________________________________________________ 

62 CMS requires that the National Provider Identifier of the ordering provider be included 

on claims for covered imaging and clinical laboratory services and items of durable 

medical equipment, prosthetics, orthotics, and supplies, and that the National Provider 

Identifier of the ordering/certifying provider be included on claims for home health 

services. 42 CFR § 424.507. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 23 
 

transports, which typically require certification, more often than other 

suppliers. The physicians who certified the medical necessity of 

questionable transports cannot be identified in the claims data. Without 

this identifying information, CMS and other oversight entities are unable 

to conduct certain program integrity activities to ensure that these 

transports meet Medicare coverage requirements. If necessary, CMS 

should seek legislative authority to make this regulatory change. The 

National Provider Identifier should also be included on the physician 

certification statement. 

Implement new claims processing edits or improve existing 

edits to prevent inappropriate payments for ambulance 

transports 

CMS should implement claims processing edits in its shared system to 

prevent inappropriate payments for ambulance transports that did not meet 

the requirements that we examined. These edits should identify claims 

and reject payments for transports that are to or from noncovered 

destinations and transports with inappropriate combinations of 

destinations and transport levels. 

Increase its monitoring of ambulance billing 

CMS should monitor the billing of ambulance transports by using 

measures of questionable billing similar to those that we examined. 

Zone Program Integrity Contractors should identify suppliers that bill at 

unusually high levels for transports with the characteristics described in 

these measures. CMS’s Fraud Prevention System should also be used to 

identify suppliers that have questionable billing for these measures. As 

appropriate, CMS and its contractors should refer these suppliers to law 

enforcement for investigation. It may be prudent for CMS to focus its 

monitoring of suppliers’ billing patterns in geographic areas where 

questionable billing is concentrated. 

Determine the appropriateness of claims billed by ambulance 

suppliers identified in the report and take appropriate action 

In a separate memorandum, we will refer to CMS the claims that did not 

meet certain Medicare requirements and the ambulance suppliers that had 

questionable billing in the first half of 2012. CMS or its contractors 

should further assess these suppliers’ claims—for example, by reviewing 

medical records or performing unannounced site visits. CMS should then 

determine what appropriate actions, if any, are needed. Appropriate 

actions could include recouping any inappropriate payments; suspending 

payments to the supplier; educating the supplier on how to properly bill 

for transports; revoking the supplier’s Medicare billing privileges; or 

referring the supplier to law enforcement for criminal investigation. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 24 
 

 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with our recommendation to determine whether a 

temporary moratorium on ambulance supplier enrollment in additional 

geographic areas is warranted. CMS stated that it will continue to monitor 

geographic areas for a significant potential for fraud, waste, or abuse, and 

will impose additional temporary moratoria if warranted. 

CMS concurred with our recommendation to require ambulance suppliers 

to include the National Provider Identifier of the certifying physician on 

transport claims that require certification. CMS stated that it will explore 

the best way to implement our recommendation to require ambulance 

suppliers to include the National Provider Identifier of the certifying 

physician on transport claims that require certification. 

CMS concurred with our recommendation to determine the 

appropriateness of claims billed by ambulance suppliers identified in the 

report and take appropriate action. CMS stated that it will conduct an 

analysis of the claims identified in this report and determine the 

appropriate number of claims to review. 

Although CMS concurred with our recommendation to increase its 

monitoring of ambulance billing, the actions that it described do not 

appear to fully address the recommendation. CMS stated that it would 

continue its current monitoring of ambulance billing, whereas we 

recommended that it increase monitoring by using measures similar to 

those outlined in this report to identify ambulance suppliers with patterns 

of questionable billing. In its final management decision, CMS should 

indicate whether and how it plans to increase monitoring. 

CMS partially concurred with our recommendation to implement new 

claims processing edits or improve existing edits to prevent inappropriate 

payments for ambulance transports. CMS indicated that it will review 

data on claims identified in this report and will consider whether to 

enhance current claims processing edits. CMS should use the results of its 

review to implement new, or modify existing, claims processing edits 

needed to prevent inappropriate payments. 

We withdrew two recommendations from our draft report. 

For the full text of CMS’s comments, see Appendix D.63

 ____________________________________________________________ 

63 In August 2015, we offered CMS the opportunity to update its comments on the draft 

report. CMS provided updated technical comments, which we incorporated into the final 

report as appropriate. CMS did not update its formal comments. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 25 
Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 26 

APPENDIX A Ambulance Transport Levels and Medicare Payments in 2012 by Level 

Transport Level Procedure Code Total Medicare Payments Number of Transports Average Payment Amount per Transport Advanced life support—nonemergency Advanced life support—emergency Basic life support—nonemergency Basic life support—emergency Paramedic intercept* Advanced life support (level 2)**Specialty care transport 

A0426 A0427A0428 A0429A0432 

 A0433 

A0434 

$82,036,627 

 $2,061,259,816 

$1,481,128,407 

 $953,912,406 

$1,145,651 

$66,828,516 

$75,733,041 

315,322 

4,984,105 

6,685,824 

2,687,644 

3,067 

111,723 

103,315 

$260 

$414 

$222 

$355 

$374 

$598 

$733 

* Paramedic intercept transports are provided when a basic life support ambulance is dispatched but the beneficiary needs advanced life support. 

For these transports, a paramedic emergency medical technician meets the basic life support ambulance at the scene or once the ambulance is on 

the way to the hospital. The paramedic intercept benefit is limited to certain rural areas, a list of which is published periodically in the Federal 

Register. ** Advanced life support (level 2) transports include the provision of at least three separate administrations of one or more medications or the

provision of at least one level 2 procedure (e.g., central venous line, chest decompression). Notes: Medicare pays for mileage under procedure code A0425. Medicare payments for mileage in 2012 totaled $1,079,084,350. Dollar amounts 

have been rounded to the nearest whole number. Source: CMS, 2012 Part B National Summary Data File. 
 

APPENDIX B 

Detailed Description of Measures of Questionable Billing for 

Ambulance Transports 

We calculated the seven measures of questionable billing as follows: 

1.	 No Medicare Service at the Origin or Destination. This measure 

represents the percentage of a supplier’s transports to destinations and 

from origins where the beneficiary did not receive Medicare services. 

We identified transports for which the beneficiaries did not receive 

Medicare services within 1 day of their transports at the facilities 

where we expected, on the basis of the origins and destinations 

indicated on the transport claims, that the beneficiaries received 

services. For transports that the supplier indicated were to a covered 

facility (i.e., hospital, dialysis facility, or SNF), we determined 

whether the beneficiaries received services at the destinations.64 For 

transports that the supplier indicated were from a covered facility to a 

residence, we determined whether the beneficiaries received services 

at the origin.65 We did not determine whether beneficiaries received 

services at noncovered facilities. We identified suppliers with 

unusually high levels of this measure among all 15,614 suppliers. At a 

minimum, these suppliers incorrectly indicated on their claims the 

transport’s origin or destination. Alternatively, suppliers that had 

questionable billing for this measure may have billed for transports 

that were to or from a noncovered destination; transports for which the 

beneficiary did not receive a Medicare service; or transports that were 

not provided. 

Our identification of transports for the first measure of questionable 

billing resembles our identification of (1) ambulance transports for 

which beneficiaries received services only at noncovered destinations 

(see page 7) and (2) transports for which the beneficiaries did not 

receive Medicare services at any origin or destination (see 

page 7). The first measure includes both sets of transports as well as 

transports for which the beneficiaries received services at different 

covered origins or destinations than those indicated on the transport 

____________________________________________________________ 

64 For transports that the supplier indicated were between a hospital and dialysis facility, 

we determined whether the beneficiary received a service at either a hospital or dialysis 

facility. 

65 For transports that the supplier indicated were between a hospital or dialysis facility 

and a SNF, we treated the SNF as though it were the beneficiary’s residence and 

determined whether the beneficiary received a service at either a hospital or dialysis 

facility. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 27 
 

claims. For example, this measure would include a transport that the 

supplier indicated was to a hospital, but for which the beneficiary did 

not receive a hospital service. 

2.	 Excessive Mileage for Urban Transports. This measure represents a 

supplier’s average mileage for transports for beneficiaries in urban 

areas. We used census data and beneficiary addresses to identify 

beneficiaries residing in urban areas.66 We identified suppliers with 

unusually high levels of this measure among the 13,352 suppliers with 

urban transports. Suppliers that had questionable billing for this 

measure may have billed for more miles than they actually drove or 

may not have transported beneficiaries to the nearest appropriate 

facility. 

3.	 High Number of Transports per Beneficiary. This measure represents 

the extent to which a supplier that provides dialysis-related transports 

is associated with beneficiaries who receive unusually high numbers of 

transports. We determined the total number of transports that each 

beneficiary received from any supplier. For each supplier of 

dialysis-related transports, we calculated the average number of 

transports per beneficiary. We identified suppliers with unusually high 

levels of this measure among the 3,265 suppliers with dialysis-related 

transports. Suppliers that had questionable billing for this measure 

may have billed for dialysis-related transports that are medically 

unnecessary or were not provided. 

4.	 Compromised Beneficiary Number. This measure represents 

the percentage of a supplier’s transports that were billed using 

compromised beneficiary numbers. Using the Compromised Numbers 

Contractor database, we identified transports that were billed with 

beneficiary numbers that were compromised at any time before 

June 30, 2012. Because a supplier may have mistakenly billed for 

transports with compromised beneficiary numbers, we identified 

suppliers with unusually high levels of this measure among the 

2,218 suppliers with at least one of these transports. This allowed us 

to identify suppliers that were outliers compared to other suppliers 

exhibiting the behavior. Suppliers that had questionable billing for 

this measure may have billed for transports that are medically 

unnecessary or were not provided. 

5.	 Inappropriate or Unlikely Transport Level. This measure represents 

the percentage of a supplier’s transports with inappropriate or unlikely 

____________________________________________________________ 

66 We used census data from 2010. We defined “urban” as a metropolitan area, that is, an 

area with a population of at least 50,000. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 28 
 

combinations of destinations and transport levels. We identified 

emergency transports to nonhospital destinations and specialty care 

transports between facilities other than hospitals or SNFs, which are 

inappropriate combinations.67 We also identified advanced life support 

transports between destinations other than hospitals or SNFs which, 

according to fraud investigators, are unlikely to be medically 

necessary. We identified the origins and destinations using the 

modifiers reported by suppliers on their claims. Because a supplier 

may have mistakenly billed for transports with an unlikely 

combination of destination and transport level, we identified suppliers 

with unusually high levels of this measure among the 2,036 suppliers 

with at least one transport with an inappropriate or unlikely 

combination. This allowed us to identify suppliers that were outliers 

compared to other suppliers exhibiting the behavior. Suppliers that 

had questionable billing for this measure may have billed for more 

expensive transport levels than they actually provided or for transports 

that were medically unnecessary. 

Our identification of transports for the fifth measure of questionable 

billing resembles our identification of transports with inappropriate 

combinations of destinations and transport levels (see page 7). The 

fifth measure includes an additional combination—advanced life 

support transports between destinations other than hospitals or SNFs— 

that is unlikely to be medically necessary but is not necessarily 

inappropriate. 

6.	 Beneficiary Sharing. This measure represents the number of suppliers 

providing dialysis-related transports to the beneficiaries transported by 

a given supplier. We determined the total number of suppliers from 

which each beneficiary received at least one dialysis-related 

transport. For each supplier, we calculated the average number of 

suppliers per beneficiary. For example, if the beneficiaries transported 

by a supplier did not receive transports from any other suppliers, this 

supplier’s average number of suppliers per beneficiary would be 1. If 

the supplier’s beneficiaries also received transports from other 

suppliers, the supplier’s average number of suppliers per beneficiary 

would be greater than 1. We identified suppliers with unusually high 

levels of this measure among the 3,265 suppliers with dialysis-related 

transports. Suppliers that had questionable billing for this measure 

may have fraudulently shared beneficiaries, or beneficiaries’ 

identification numbers, with other suppliers. Alternatively, these 

____________________________________________________________ 

67 Novitas Solutions, Inc., Ambulance (Ground) Services L32252. CMS, Change Request 

5533, March 30, 2007. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 29 
 

 

suppliers may have been involved with beneficiaries who were 

“shopping” among suppliers to receive kickbacks. 

7.	 Transports To or From PHPs. This measure represents the percentage 

of a supplier’s transports that were to or from PHPs. We identified 

transports for beneficiaries who received PHP services within 1 day of 

their transports. These beneficiaries received PHP services and did not 

receive services at a covered destination. We identified suppliers with 

unusually high levels of this measure among all 15,614 suppliers. 

Beneficiaries who meet Medicare coverage requirements for PHPs 

generally do not meet the requirements for transports.68 Suppliers that 

had questionable billing for this measure may have billed for 

transports to or from PHPs for beneficiaries who do not qualify for the 

transports. 

____________________________________________________________ 

68 Trailblazer Health Enterprises, LLC, Ambulance, June 2012, pp. 61–62. (Trailblazer’s 

MAC contract ended later in 2012, and its Ambulance publication was retired.) 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 30 
APPENDIX C 

Questionable and All Ambulance Transports That Occurred in 14 Additional Areas, First 

of 2012 

Area 

Percentage of National Total Total Medicare Paymen

Questionable 

Transports All Transports 

Questionable 

Transports All T

AtlantaSandy SpringsMarietta, Georgia 6.7% 1.8% $13.1 million $4

ChicagoNapervilleJoliet, IllinoisIndianaWisconsin 2.6% 3.8% $4.7 million $9

Memphis, Tennessee-Mississippi-Arkansas 1.6% 0.8% $2.9 million $1

Virginia BeachNorfolkNewport News, VirginiaNorth Carolina 1.5% 1.0% $2.8 million $2

GreenvilleMauldinEasley, South Carolina 1.5% 0.5% $2.6 million $1

Columbia, South Carolina 1.2% 0.5% $2.2 million $1

Macon, Georgia 1.1% 0.2% $2.2 million $

MiamiFort LauderdalePompano Beach, Florida 1.0% 1.4% $2.5 million $3

San JuanCaguasGuaynabo, Puerto Rico 0.9% 0.2% $1.6 million $

Florence, South Carolina 0.8% 0.3% $1.6 million $

IndianapolisCarmel, Indiana 0.8% 0.6% $1.5 million $1

CincinnatiMiddletown, OhioKentuckyIndiana 0.8% 0.8% $1.5 million $2

Gainesville, Georgia 0.8% 0.1% $1.5 million $

Flint, Michigan 0.8% 0.3% $1.3 million $

 Subtotal in the 14 Additional Areas 22.2% 12.3% $42.0 million $309

 Subtotal in the 4 Areas With the Most Questionable Transports 52.0% 18.0% $103.5 million $447

 Subtotal in Other Areas With Questionable Transports* 25.8% 67.8% $62.0 million $2,035

 Subtotal in Areas Without Questionable Transports -- 1.8% -- $62 Total 100% 100% $207.5 million $2,855

* Includes transports that did not occur in a Core Based Statistical Area, i.e., transports that occurred in areas with populations of less than 10,000. 

Note: Columns may not sum to totals because of rounding. Source: OIG analysis of Part B data for Medicare ambulance services, 2013. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 31 
 

APPENDIX D 

Agency Comments 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 32 
 

APPENDIX D 

Agency Comments (continued) 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 33 
 

APPENDIX D 

Agency Comments (continued) 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 34 
 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Blaine Collins, Regional 

Inspector General for Evaluation and Inspections in the San Francisco 

regional office, and Michael Henry, Deputy Regional Inspector General. 

Sarah Ambrose served as the team leader for this study, and 

Veronica Gonzalez served as the lead analyst. Other Office of Evaluation 

and Inspections staff from the San Francisco regional office who 

conducted the study include Timothy Brady, Joyce Greenleaf, and 

Bi Nguyen. Central office staff who provided support include 

Berivan Demir Neubert, Evan Godfrey, Althea Hosein, Scott Manley, and 

Christine Moritz. 

Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports (OEI-09-12-00351) 35 
Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of individuals served by those programs. 

This statutory mission is carried out through a nationwide network of audits, investigations, 

and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and individuals. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.