DEPARTMENT OF HEALTH AND HUMAN SERVICES 

OFFICE OF INSPECTOR GENERAL 

WAS HINGTO N, DC 2020! 

SEP 2 4 2013 

TO: 	 Marilyn Tavenner 

Administrator 

Centers for Medicare & Medicaid Services 

FROM: Stuart Wright 

Deputy Inspector General 

for Evaluation and Inspections 

SUBJECT: 	 Memorandum Report: Utilization ofMedicare Ambulance Transports, 

2002-2011, OEI-09-12-00350 

This memorandum report provides an overview of the changes in utilization of Medicare 

Part B ambulance transports from 2002 through 2011. 

SUMMARY 

The number of ambulance transports reimbursed by Medicare Part B increased 69 percent 

from 2002 to 2011. This memorandum report provides information about the patterns of 

this utilization growth. In a forthcoming report, the Office oflnspector General (OIG) 

will identify ambulance suppliers that exhibited characteristics of questionable billing in 

the first half of 2012 and geographic areas with high numbers of these suppliers. 

From 2002 to 2011, the number of Medicare fee-for-service beneficiaries who received 

transports and the number of ambulance suppliers both increased. The number of 

beneficiaries who received transports increased 34 percent, although the total number of 

Medicare fee-for-service beneficiaries increased just 7 percent during the same 

period. The number of ambulance suppliers increased 26 percent. In addition, the 

number of ambulance suppliers that primarily provided basic life support (BLS) 

nonemergency transports nearly doubled. 

The increase in ambulance transports from 2002 to 2011 varied by the origin and 

destination of the transport. The number of transports to or from independent dialysis 

facilities (dialysis-related transports) increased 269 percent. Further, beneficiaries with 

end stage renal disease (ESRD) , a condition that often requires dialysis treatment, used a 
 

 

 

 

 

 

 

 

 

 

Page 2 – Marilyn Tavenner 

growing and disproportionate amount of transports each year.1 Although transports to or 

from hospitals increased at a significantly slower rate from 2002 to 2011 (55 percent) 

than did dialysis-related transports, they represented a larger proportion of all transports 

(79 percent). Outpatient visits to receive partial hospitalization program services at 

community mental health centers by beneficiaries who received transports increased 

829 percent.2 

We also found that although all States experienced increases in transports from 2002 to 

2011, utilization changes varied widely by State. States with particularly high growth in 

ambulance utilization experienced increases in dialysis-related transports that were 

greater than the national increase. These States also experienced increases that were 

greater than the national increase in BLS nonemergency transports and in inpatient 

hospital visits to treat renal failure in beneficiaries who received transports. 

BACKGROUND 

Utilization of Medicare Ambulance Transports 

Medicare Part B payments for ambulance transports continue to grow at a faster rate than 

all Medicare Part B payments. In 1998, OIG reported that Medicare Part B payments for 

ambulance transports “more than tripled between 1987 and 1996—from $602 million to 

almost $2.1 billion,” although during this time all Medicare Part B payments doubled.3, 4 

This trend continued after that period. From 2002 to 2011, Medicare Part B payments for 

ambulance transports increased 130 percent, from $2.0 billion to $4.5 billion.5 During 

this period, all Medicare Part B payments increased 74 percent.6 

Several factors have contributed to the increase in payments for ambulance transports. 

The increase was caused in part by inflation and the transition to the national fee schedule 

for Medicare ambulance transports, which was phased in from 2002 through 2005.7 

1 ESRD is permanent kidney failure that requires a regular course of dialysis or a kidney transplant. 

Centers for Medicare & Medicaid Services (CMS), Medicare Coverage of Kidney Dialysis & Kidney 

Transplant Services. Accessed at http://www.medicare.gov/Pubs/pdf/10128.pdf, p. 53 on July 3, 2013. 2

 Partial hospitalization programs provide intensive psychiatric care and resemble structured, short-term 

hospital inpatient programs. Patients admitted to a partial hospitalization program (1) do not require 

24-hour supervision as provided in an inpatient setting, (2) must have a support system outside the 

program, and (3) must not be an imminent danger to themselves or others. CMS, Medicare Benefit Policy 

Manual, ch. 6 § 70.3. 3

 OIG, Medical Necessity of Medicare Ambulance Services, OEI-09-95-00412, December 1998. 4

 Medicare Part B payments totaled $28.4 billion in 1987 and $59.1 billion in 1996. CMS, Medicare and 

Medicaid Statistical Supplement. 2001 Edition, Table 12. 5

 OIG analysis of CMS Physician/Supplier Part B claims file. Total Medicare-allowed amounts increased 

from $2.5 billion to $5.7 billion. 

6

 Medicare Part B payments totaled $92.4 billion in 2002 and $160.9 billion in 2011. CMS, Medicare and 

Medicaid Statistical Supplement. 2012 Edition, Table 3.3. 7

 Ambulance fee-schedule amounts are adjusted for inflation using the urban consumer price index, which 

increased 25 percent from 2002 to 2011. After taking inflation into account, average allowances are an 

estimated 3 percent higher than they were before the national fee schedule was implemented. United States 

Government Accountability Office (GAO), Ambulance Providers: Costs and Expected Margins Vary 

Greatly, GAO-07-383, p. 6. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

Page 3 – Marilyn Tavenner 

Continued growth in the utilization of transports has also contributed to the increase. 

From 2002 to 2011, the number of Medicare ambulance transports increased 69 percent 

(from 8.7 million to 14.8 million).8 

Findings from past OIG reports indicate that the ambulance benefit is vulnerable to 

abuse. One report found that in 1996, two-thirds of ambulance transports that did not 

result in expected hospital or nursing home admissions or emergency room care were 

medically unnecessary.9 Another report found that 25 percent of ambulance transports in 

2002 did not meet Medicare program requirements, resulting in an estimated 

$402 million in improper payments.10 The report also found that 27 percent of transports 

to and from independent dialysis facilities in 2002 did not meet coverage requirements. 

Recent cases involving ambulance suppliers also indicate that the ambulance benefit is 

vulnerable to fraud. For example, in October 2012, administrators of a Houston-based 

ambulance supplier pleaded guilty to submitting claims for $1.7 million to Medicare for 

transports that were miscoded, not medically necessary, and in some cases, not 

provided.11 In February 2013, an ambulance supplier operating in South Carolina paid 

$800,000 to settle allegations that it fraudulently billed Medicare for routine, 

nonemergency transports that were not medically necessary and that it created fraudulent 

documents to support the transports.12 

Medicare Coverage of Ambulance Transports 

Medicare covers ambulance transports when a beneficiary’s medical condition at the time 

of transport is such that using other means of transportation would endanger the 

beneficiary’s health.13, 14 In addition, the transport must be to receive a Medicare-covered 

service or to return from such a service.15 Medicare does not limit the number of 

ambulance transports per beneficiary.16 Medicare does not cover means of transport other 

than ambulance. 

Covered destinations. A medically necessary ambulance transport may be covered to and 

from the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic 

8

 OIG analysis of 2002 and 2011 Physician/Supplier Part B claims file. 

9

 OIG, Medical Necessity of Medicare Ambulance Services, OEI-09-95-00412, December 1998. 10 OIG, Medicare Payments for Ambulance Transports, OEI-05-02-00590, January 2006. 11 United States Department of Justice, Houston Ambulance Company Administrator Pleads Guilty to 

Fraud. Accessed at http://www.justice.gov/opa/pr/2012/October/12-crm-1242.html on March 1, 2013. 12 United States Department of Justice, South Carolina Ambulance Company to Pay U.S. $800,000 to
 

Resolve False Claims Allegations. Accessed at http://www.justice.gov/opa/pr/2013/February/13-civ232.html on March 1, 2013. 13 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.2.1. 14 Although they are not required to do so, suppliers may include on a transport claim a diagnosis code that 

characterizes the beneficiary’s medical condition at the time of transport. This diagnosis code is used by
 

suppliers to communicate the beneficiary’s condition as reported by the dispatch center and as observed by
 

the ambulance crew.
 15 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.2.1. 16 Social Security Act § 1861(s)(7). 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

 

 

 

Page 4 – Marilyn Tavenner 

services.17 Medicare covers ambulance transports only to hospitals (including critical 

access hospitals), skilled nursing facilities, the beneficiary’s home, and (for beneficiaries 

with ESRD who require dialysis) dialysis facilities.18 

Although dialysis facilities are a covered destination, transports to them do not usually 

meet coverage requirements under Medicare.19 One Medicare Administrative Contractor 

estimated that 10 percent of beneficiaries who receive hemodialysis—one of the two 

main types of dialysis—require ambulance transportation to receive treatment.20 

Beneficiaries who receive dialysis typically have three dialysis sessions per week.21 

Therefore, beneficiaries who require transportation by ambulance to dialysis facilities 

would typically receive six transports per week. 

Transport levels. Medicare covers seven levels of ground ambulance transports 

(transport levels).22 Each transport level is billed using a Health Care Procedure Coding 

System code (procedure code). Table 1 lists each procedure code, transport level, the 

corresponding total amount allowed by Medicare, the total number of transports, and the 

average allowed amount per transport by Medicare in 2011. 

Table 1: Medicare Allowances in 2011 for Ambulance Transports and 

Corresponding Mileage, by Procedure Code 

Procedure 

Code Transport Level Total Allowed Amount* 

Number of 

Transports 

Average Allowed 

Amount per Transport* 

A0426 

A0427 

A0428 

A0429 

A0432 

A0433 

A0434 

Advanced life support 

(ALS) nonemergency

ALS emergency 

BLS nonemergency 

BLS emergency 

Paramedic ALS intercept 

ALS2 

Specialty care transport

 $153,146,601 

 $2,336,057,963 

 $1,938,054,934 

 $1,084,838,255 

$1,137,377 

$76,074,065 

$91,540,103 

318,886

4,859,616

6,714,246

2,643,313

13,079

112,038

103,641

 $480 

$481 

$289 

$410 

$87 

$679 

$883 

*Includes amounts allowed for corresponding mileage for these transports. Mileage, billed using procedure code A0425, is billed 

together with the transport procedure code. Mileage does not apply to paramedic ALS intercepts transports. Dollar amounts have been 

rounded to the nearest whole number. 

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

The transport levels are distinguished by the qualifications of the ambulance crew and the 

medical care provided.23 All BLS transports require an ambulance crew certified at least 

17 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.3. “Appropriate facility” means that the institution is 

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

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

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%201%20Part%20B~
 

Browse%20by%20Specialty~Ambulance~8EEMHW2614?open&navmenu=Browse^by^Specialty|||| on 

May 1, 2012. 

20 Novitas Solutions, Inc., Ambulance (Grounds) Services L32252. 21 CMS, Medicare Benefit Policy Manual, ch. 11 § 30.1.
 22 Medicare also covers air ambulance transports by airplane and helicopter. 23 CMS, Medicare Benefit Policy Manual, ch. 10 § 30.1.1. This chapter defines the transport levels. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

Page 5 – Marilyn Tavenner 

as basic emergency medical technicians.24 All ALS transports require an ambulance crew 

certified at least as intermediate or paramedic emergency medical technicians. For the 

ambulance transport to be covered as an ALS transport, the beneficiary’s condition must 

require an assessment or a service that can be provided only by an ALS crew. Paramedic 

ALS intercept transports and ALS2 transports are variations of ALS transports.25 

Specialty care transports are interfacility transports for critically injured or ill 

beneficiaries and require that the ambulance crew include a health professional specialist 

(e.g., emergency nurse) or a paramedic emergency medical technician with additional 

training. 

The transport level depends not only on the level of service, but also on whether the 

transport is provided in an emergency or nonemergency situation.26 Emergency 

transports are provided according to the protocol of the local 911 or equivalent dispatch.27 

Lack of immediate medical attention in these cases could reasonably be expected to place 

the beneficiary’s health in jeopardy, result in serious impairment of bodily functions, or 

result in serious dysfunction of any bodily organ. Symptoms or conditions that may 

warrant an emergency transport include, but are not limited to, severe pain, bleeding, or 

unconsciousness.28 Nonemergency transports are provided in the absence of an 

emergency to beneficiaries who are bed-confined before and after transportation, or when 

transportation by ambulance is medically required.29, 30 Nonemergency transports may be 

scheduled or unscheduled and may be one-time or recurring. 

Medicare covers mileage to and from the nearest appropriate facility when the ambulance 

transport is covered.31 Only miles traveled with the beneficiary onboard are covered. 

Related Work 

Both GAO and the Medicare Payment Advisory Commission (MedPAC) have reported 

on the growth in ambulance utilization as part of their work on Medicare Part B payments 

for ambulance transports. In October 2012, GAO reported on the effect of the ambulance 

24 State and local laws that establish qualifications for emergency medical technicians vary. For example, 

only in some jurisdictions are basic emergency medical technicians permitted to establish a peripheral 

intravenous line. 

25 Paramedic intercept transports are provided when a BLS ambulance is dispatched, but the beneficiary 

needs ALS service. For these transports, a paramedic emergency medical technician meets the BLS 

ambulance at the scene or once the ambulance is on the way to the hospital. ALS2 transports include the 

provision of at least three separate administrations of one or more medications or the provision of at least 

one ALS2 procedure (e.g., central venous line, chest decompression).

26 CMS, Medicare Benefit Policy Manual, ch. 10 § 30.1.1. 27 Ibid. 

28 CMS, Medicare Coverage of Ambulance Services, pp. 5–6. Accessed at 

http://www.medicare.gov/Publications/Pubs/pdf/11021.pdf on May 25, 2012. 

29 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.2.3. To be considered bed-confined, the beneficiary 

must be unable to get up from bed without assistance, ambulate, or sit in a chair or wheelchair. 30 While bed-confinement is important in determining the appropriateness of nonemergency ambulance 

transports, bed-confinement alone is neither sufficient nor necessary to determine coverage for Medicare’s 

ambulance benefit. 

31 CMS, Medicare Benefit Policy Manual, ch. 10 § 10.3. Mileage is billed on the same claim as the 

transport using procedure code A0425. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

Page 6 – Marilyn Tavenner 

fee schedule on beneficiaries’ access to care. GAO noted that the increase in utilization 

from 2004 to 2010 was due primarily to an increase in BLS nonemergency transports, 

and that the increase was the greatest in super-rural areas.32 In addition to fraud and 

abuse, the GAO report cites the following as potential reasons for utilization increases: 

(1) new or increased billing by local governments under budgetary pressures that 

previously refrained from billing Medicare for transports and (2) the introduction of the 

national fee schedule for ambulance transports.33 In June 2013, MedPAC reported on the 

ambulance fee schedule. MedPAC also noted that the utilization of BLS nonemergency 

transports, particularly those that were dialysis-related, grew faster than the utilization of 

other transport levels from 2007 to 2011.34 

OIG is conducting additional analysis of national Medicare ambulance claims data. This 

analysis will identify ambulance suppliers that exhibited characteristics of questionable 

billing in the first half of 2012, as well as geographic areas with high numbers of these 

suppliers. 

METHODOLOGY 

Scope 

This evaluation is national in scope and is based on all claims for ground ambulance transports 

from CMS’s Physician/Supplier Part B claims files from 2002 to 2011. We analyzed claims 

billed under the procedure codes A0425–A0429 and A0433–A0434.35 We did not review 

transports billed by institution-based ambulance suppliers.36 We analyzed only transports for 

which mileage was also billed.37 

We did not review the medical records of beneficiaries who received transports. 

Therefore, we did not determine whether the transports were medically necessary or met 

coding and documentation requirements for coverage. Generally, we cannot conclude 

whether fraud, waste, or abuse, or other potential reasons—such as new or increased 

billing by local governments or the introduction of the national ambulance fee 

schedule—caused the changes in ambulance utilization that we report. 

32 Super-rural areas have population densities lower than rural areas. GAO, Costs and Margins Varied 

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

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

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

report: Medicare payment for ambulance services, pp. 178-179, June 2013. 35 We did not analyze claims for paramedic ALS intercept transports, which accounted for less than 

one-tenth of 1 percent of all transports and were provided only in New York. In our analysis, we also
 

included mileage procedure codes A0380 and A0390 and transport procedure codes Q3019 and Q3020,
 

which were phased out as part of the transition to the national fee schedule. 

36 Four percent of ambulance suppliers in 2011 were institution-based suppliers. OIG analysis of CMS’s 

2011 Outpatient 100-percent Standard Analytic File. 

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

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

before it arrived.
 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

Page 7 – Marilyn Tavenner 

Data Sources and Analysis 

We used CMS’s Physician/Supplier Part B claims file, the Denominator file for 

2002 through 2011, and the Medicare Enrollment Database for 2011. We also used 

CMS’s Inpatient and Outpatient 100-percent Standard Analytic Files for 2002 and 2011. 

The Physician/Supplier Part B claims file contains claims submitted by independent 

ambulance suppliers and other noninstitutional providers such as physicians, physician 

assistants, and nurse practitioners. The Denominator file and Medicare Enrollment 

Database both contain enrollment information, such as date of birth and eligibility 

category, about each Medicare beneficiary. The Inpatient and Outpatient Standard 

Analytic Files contain claims submitted by institutions, such as hospitals. We used the 

18-month files, which include claims processed as of June 30th of the year following the 

dates of service. 

We determined the extent to which the utilization of ambulance services changed from 

2002 to 2011. For each year, we analyzed the characteristics of beneficiaries, suppliers, 

and transports and calculated the percentage differences since 2002. We also calculated 

changes in utilization by State. Furthermore, we calculated the change in certain 

transport characteristics in the States with the largest utilization increases that also 

accounted for at least 3 percent of 2011 transports nationally (high-growth States). See 

Appendix A for more details of our data analysis. 

This inspection was conducted in accordance with the Quality Standards for Inspection 

and Evaluation approved by the Council of the Inspectors General on Integrity and 

Efficiency. 

RESULTS 

The Number of Beneficiaries Who Received Transports Increased 34 Percent, 

Compared With the 7-Percent Increase in All Fee-For-Service Medicare 

Beneficiaries, From 2002 to 2011 

Over 1 million more beneficiaries received transports in 2011 than in 2002, an increase of 

34 percent. In 2002, 3.6 million beneficiaries received transports, compared with 

4.8 million beneficiaries in 2011. In contrast, the number of Medicare fee-for-service 

beneficiaries increased just 7 percent from 2002 to 2011. 

On average, beneficiaries received more transports. Among beneficiaries receiving 

transports, the number of transports a beneficiary received each year increased from an 

average of 2.4 in 2002 to an average of 3.1 in 2011. 

Beneficiaries who received transports were younger, on average, and more likely to be 

eligible for Medicare because of a disability in 2011 than in 2002. The average age of 

beneficiaries who received transports decreased from 76.7 years to 75.4 years. This 

change resembled that of the Medicare fee-for-service population, among whom the 

average age decreased from 70.6 years to 69.7 years. The percentage of beneficiaries 

who received transports and were eligible because of a disability increased from 

13 percent in 2002 to 19 percent in 2011. Similarly, the percentage of Medicare 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

 

Page 8 – Marilyn Tavenner 

fee-for-service beneficiaries who were eligible because of a disability increased from 

15 percent in 2002 to 18 percent in 2011. Table 2 presents the percentages of 

beneficiaries who received transports by their Medicare eligibility status from 2002 to 

2011. 

Table 2: Percentage of Beneficiaries Who Received Transports 

From 2002 to 2011, by Medicare Eligibility Status 

Year Aged 65 and Over 

Without ESRD 

Disabled

 (Under 65 and 

Without ESRD) 

Has ESRD 

(Regardless of Age 

or Disability Status) * 

2002 85.1% 13.0% 2.3% 

2003 84.4% 13.6% 2.7% 

2004 83.2% 14.4% 3.0% 

2005 82.6% 15.0% 3.1% 

2006 82.2% 15.2% 3.3% 

2007 81.5% 15.7% 3.4% 

2008 81.1% 16.1% 3.4% 

2009 80.4% 16.7% 3.6% 

2010 80.0% 17.4% 3.3% 

2011 78.3% 18.8% 3.2% 

*There are five Medicare eligibility categories. We combined into a single category the three 

categories of beneficiaries with ESRD. (These three categories distinguish ESRD beneficiaries 

by age and disability status.) 

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

Note: Percentages do not add to 100 percent because transport-receiving beneficiaries whose 

age or ESRD status changed during the course of the year were counted more than once. 

Less than 1 percent of beneficiaries who received transports were counted more than once 

in each year. 

Twenty-Six Percent More Ambulance Suppliers Provided Transports in 2011 Than 

in 2002 

Over 3,500 more ambulance suppliers provided transports in 2011 than in 2002 and, on 

average, suppliers provided more transports. The number of suppliers increased 

26 percent (from 14,087 to 17,776). Additionally, suppliers provided an average of 

34 percent more transports in 2011 than in 2002 (increasing from 619 to 830 transports 

per supplier). 

Ambulance suppliers billed for greater average transport distances. The average trip 

length increased 1.6 miles (from 7.8 to 9.4 miles). Furthermore, suppliers billed for 

longer-mileage transports—i.e., those that were more than 20 miles—111 percent more 

often in 2011 than in 2002. However, Medicare beneficiaries were no more likely to live 

in a rural location in 2011 than in 2002.38 

38 In 2002, 31.2 million Medicare beneficiaries lived in urban locations and 9.3 million in rural
 

locations. In 2011, 39.1 million Medicare beneficiaries lived in urban locations and 9.8 million in rural
 

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

Table 2.3. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

Page 9 – Marilyn Tavenner 

The number of ambulance suppliers that primarily provided BLS nonemergency 

transports nearly doubled.

39 The number of ambulance suppliers that primarily provided 

a single transport level increased from 2002 to 2011. In particular, the number of 

suppliers that primarily provided BLS nonemergency transports increased 92 percent 

during this period. In 2002, these suppliers represented 7 percent of all suppliers and 

billed for 16 percent of all transports. In 2011, they represented 11 percent of suppliers 

and billed for 30 percent of all transports. Table 3 presents the growth in the numbers of 

suppliers that usually provided a single transport level. 

Table 3: Ambulance Suppliers That Primarily Provided a Single Transport Level 

in 2002 and 2011 

Year 

Suppliers That 

Primarily Provided 

BLS Nonemergency 

Transports 

Suppliers That 

Primarily Provided 

ALS Emergency 

Transports 

Suppliers That 

Primarily Provided 

Another Single 

Transport Level* 

Suppliers That 

Provided a Mix 

of Transport 

Levels 

All 

Suppliers 

2002 981 2,862 2,839 7,405 14,087 

2011 1,881 4,060 3,067 8,768 17,776 

Percentage 

Change 92% 42% 8% 18% 26% 

*Most of these suppliers primarily provided BLS emergency transports (94 percent in 2002 and 97 percent in 2011). 

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

The number of suppliers that primarily provided ALS emergency transports also 

increased at a greater rate than the overall number of suppliers. In 2002, these suppliers 

represented 20 percent of all suppliers and billed for 8 percent of all transports. In 

2011, they represented 23 percent of suppliers and billed for 10 percent of all transports. 

In addition to the growth in the numbers of suppliers that primarily provided BLS 

nonemergency transports or ALS emergency transports, the overall use of these transport 

levels increased more than that of other transport levels. In 2002, beneficiaries received 

3.5 million BLS nonemergency transports, a figure that increased to 6.7 million in 

2011 (a 94-percent increase). Similarly, the total number of ALS emergency transports 

increased from 2.9 million in 2002 to 4.9 million in 2011 (a 68-percent increase). See 

Appendix B for the changes from 2002 to 2011 in the use of each transport level. 

The Number of Dialysis-Related Transports Increased 269 Percent From 2002 to 

2011 

Dialysis-related transports increased the most, compared with transports to or from other 

origins and destinations.40 These transports increased 269 percent (from 753,741 to 

2,780,323). They represented 9 percent of all transports in 2002 and 19 percent of all 

transports in 2011. 

39 For the purpose of this report, we use the term “primarily provided” to mean those suppliers for which a 

single transport level accounted for at least 75 percent of the supplier’s transports. 40 We considered a transport to be dialysis-related if the two-letter modifier on the claim indicated an
 

independent dialysis facility as the origin or destination.
 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

Figure 1: Percentage of Beneficiaries With ESRD Who Received Transports 

and Their Share of All Ambulance Transports From 2002 to 2011 

30% 

25% 

20% 

15% 

10% 

5% 

0%
 

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
 

24% 24% 25% 25% 

19% 

21% 21% 

22% 

14% 

11% 

3% 3% 3% 3% 4% 3% 3% 2% 3% 3% 

Percentage of beneficiaries Percentage of transports 

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

Note: Percentages are rounded to the nearest whole number. 

 

Page 10 – Marilyn Tavenner 

Beneficiaries with ESRD who received transports accounted for an increasing percentage 

of all ambulance transports. Although beneficiaries with ESRD did not make up a large 

percentage of beneficiaries who received transports, this group used a growing and 

disproportionate number of transports. From 2002 to 2011, the percentage of 

beneficiaries with ESRD who received transports varied little. However, the percentage 

of transports associated with these beneficiaries increased from 11 percent to 22 percent. 

Most of these transports were dialysis-related. Figure 1 presents the percentage of 

beneficiaries with ESRD who received transports and their share of all transports from 

2002 through 2011. 

More Medicare fee-for-service beneficiaries with ESRD received transports and, on 

average, received a greater number of transports in 2011 than in 2002. The number of 

transport-receiving Medicare fee-for-service beneficiaries with ESRD increased 

85 percent. In contrast, the number of all Medicare fee-for-service beneficiaries with 

ESRD increased 24 percent during the same period. In addition, the average number of 

transports a beneficiary with ESRD received each year increased from 12 transports to 

21 transports. 

The Number of Transports To or From Hospitals Increased 55 Percent From 2002 

to 2011 

The number of transports to or from hospitals increased significantly less than the 

number of dialysis-related transports but accounted for 79 percent of all transports in 

2011.41 The number of transports to or from hospitals increased 55 percent, from 

7.5 million in 2002 to 11.7 million in 2011. In 2011, over three-quarters of transports to 

or from hospitals had hospitals as their destinations (for example, from the beneficiary’s 

41 We considered a transport to be to or from the hospital if the two-letter modifier indicated a hospital as 

the origin or destination. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

Page 11 – Marilyn Tavenner 

residence to the hospital), and the remainder were from hospitals to other destinations. 

Between 2002 and 2011, there were changes in the origins, transport levels, medical 

conditions of beneficiaries at the time of transport, and destination facilities of transports 

to hospitals. 

The origins of transports to hospitals changed. Notably, transports to hospitals 

originating from the scene of an accident or acute event increased 112 percent from 

2002 to 2011, representing 13 percent of transports to hospitals in 2011. Transports 

originating from a residence increased 51 percent, representing half of all transports to 

hospitals in 2011. 

Suppliers provided certain levels of transports more frequently for transports to hospitals. 

Emergency transports to hospitals increased 65 percent from 2002 to 2011, compared 

with the 14-percent increase in nonemergency transports to hospitals. The type of 

emergency transport level that increased the most was ALS emergency transports, which 

increased 69 percent and represented 55 percent of all transports to hospitals in 2011. 

BLS emergency transports increased 60 percent from 2002 to 2011, and represented 

30 percent of transports to hospitals in 2011. 

For transports to hospitals, the respective prevalences of 15 diagnosis codes that represent 

the beneficiary’s medical condition at the time of transport increased at least 

100 percent.

42 Of all the diagnosis codes used to report the beneficiary’s medical 

condition at the time of transport, 15 codes were reported more than twice as often in 

2011 than in 2002 among transports to hospitals.43 Transports using these 15 codes 

represented a combined 35 percent of transports to hospitals in 2011. See Table 4 for the 

changes from 2002 to 2011 in medical conditions reported at the time of transport among 

transports to hospitals. 

42 This analysis is based on transports to hospitals for which the supplier reported the diagnosis code that 

represents the beneficiary’s medical condition at the time of transport. The diagnosis code was reported on 

92 percent and 100 percent of transport claims in 2002 and 2011, respectively. OIG analysis of 2002 and 

2011 CMS Physician/Supplier Part B claims file. 

43 We report only the diagnosis codes that each represented at least 0.5 percent of transports to hospitals in 

2011. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

Page 12 – Marilyn Tavenner 

Table 4: Most Frequent Medical Conditions Reported at the Time of Transport 

Among Transports to Hospitals by Percentage Change From 2002 to 2011 

Percentage Change, Percentage of 2011 Medical Condition at the Time of Transport 2002–2011 Transports 

Gastritis and duodenitis 3,090% 0.7% 

Crushing injury or internal injury 939% 0.8% 

Diabetes mellitus without complication 606% 0.7% 

Other fractures 468% 1.1% 

Other nervous system disorders 239% 1.4% 

Schizophrenia and other psychotic disorders 193% 1.5% 

Residual codes, unclassified 176% 13.1% 

Other circulatory disease 143% 1.8% 

Other injuries and conditions due to external causes 143% 5.8% 

Headache, including migraine 136% 1.0% 

Complication of device, implant, or graft 135% 0.7% 

Delirium, dementia, and amnestic and other cognitive 133% 0.7% disorders 

Nausea and vomiting 128% 2.6% 

Open wounds of extremities 123% 0.5% 

Other connective tissue disease 101% 2.1% 

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

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

Not all transports that were billed using the destination modifier code for hospitals were 

to hospitals; the number of transports to nonhospital facilities increased. Transports to 

hospitals resulted in outpatient visits at hospitals and nonhospital facilities more often 

than inpatient hospital visits. Beneficiaries who received transports made 40 percent 

more outpatient hospital visits in 2011 than in 2002 (from 3.6 million visits in 2002 to 

5.0 million in 2011). In contrast, all Medicare fee-for-service beneficiaries made 

20 percent more outpatient hospital visits. Beneficiaries who received transports made 

37 percent more outpatient visits at nonhospital facilities (from 373,734 visits in 2002 to 

512,963 visits in 2011).44 In contrast, all Medicare fee-for-service beneficiaries made 

27 percent more outpatient visits at nonhospital facilities. The number of inpatient 

hospital visits made by beneficiaries who received transports increased 13 percent (from 

3.3 to 3.7 million), mirroring the increase in inpatient hospital admissions from 2002 to 

2011. 

The number of outpatient visits to certain nonhospital facilities made by beneficiaries 

who received transports increased greatly. In particular, between 2002 and 

2011 there was an 829-percent increase in visits by beneficiaries who received transports 

to receive partial hospitalization program services at community mental health 

44 Although beneficiaries who received transports visited nonhospital facilities such as community mental 

health centers and dialysis facilities, the associated transports were billed by the supplier as though they 

involved a visit to a hospital. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

Page 13 – Marilyn Tavenner 

centers.45 In contrast, all outpatient visits to receive partial hospitalization program 

services at community mental health centers increased only 157 percent during this 

period. See Table 5 for the types of visits and facilities associated with transports to 

hospitals. 

Table 5: Types of Visits and Facilities Associated With Ambulance 

Transports to Hospitals by Percentage Change From 2002 to 2011 

Types of Visits and Facilities Percentage Change, 

2002–2011 

Percentage of Visits 

Associated With Transports 

to Hospitals in 2011 

Inpatient visits at hospitals 

Outpatient visits at hospitals* 

Outpatient visits at nonhospital facilities** 

 Community mental health centers 

 Federally qualified health centers 

 Independent dialysis facilities 

 Rural health clinics 

13% 

40% 

37% 

829% 

142% 

62% 

67% 

40.3% 

54.2% 

5.5% 

0.1%

0.7%

1.9%

0.9% 

*Includes critical access hospitals and Medicare Part B services provided to inpatient beneficiaries without Part A coverage. 

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

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

Beneficiaries were transported to hospitals for inpatient visits to treat certain conditions 

more frequently in 2011 than in 2002.46 Visits to treat septicemia increased 164 percent, 

visits to treat renal failure increased 158 percent, and visits related to rehabilitation 

increased 99 percent. 

Increases in Ambulance Utilization From 2002 to 2011 Varied Widely by State 

Although all States experienced increases in transports from 2002 to 2011, utilization 

changes varied widely by State. High-growth States experienced increases that were 

greater than the national increase in dialysis-related transports, BLS nonemergency 

transports, and inpatient hospital visits to treat renal failure in beneficiaries who received 

transports. 

Among the States, the change in ambulance utilization varied from an increase of 

8 percent in Utah to an increase of 289 percent in California. Ten States experienced 

increases of greater than 100 percent and six States experienced increases of 25 percent 

or less. Figure 2 illustrates the percentage change from 2002 to 2011 in ambulance 

utilization by State. 

45 Ambulance transports to partial hospitalization programs generally do not meet Medicare coverage 

requirements. Most beneficiaries do not meet the coverage criteria for both partial hospitalization programs 

and ambulance transports. For example, under a now-retired policy from Trailblazer Health Enterprises 

LLC, if a beneficiary was transported via ambulance because he was a danger to himself and/or others, he 

would not have been eligible for the partial hospitalization program. Trailblazer Health Enterprises, LLC, 

Ambulance, June 2012, pp. 61–62. (This policy is retired because Trailblazer Health Enterprises, LLC, is 

no longer a MAC.)

46 We identified claims for inpatient hospital visits that were associated with beneficiaries’ transports to 

hospitals. We report the conditions that represent at least 1 percent of all conditions that were treated 

during beneficiaries’ inpatient visits. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

Page 14 – Marilyn Tavenner 

Figure 2: Percentage Change From 2002 to 2011 in Ambulance 

Utilization by State 

Percentage Change 8%–26% 28%–42% 42%–51%

 53%–64% 66%–118% 124%–301% 

Note: Two territories experienced significant increases in ambulance utilization, and another territory experienced the only decrease in 

utilization. (Ambulance utilization increased 34,092 percent in Guam and 31,613 percent in the Northern Marianas, and decreased 

71 percent in Puerto Rico.) However, these three territories together accounted for less than 1 percent of all transports in 2011. 

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

In addition to the overall increase in the number of transports, changes in beneficiaries 

who received transports and supplier utilization also varied widely by State: 

	 Nationally, the number of beneficiaries who received transports increased 34 percent. 

Among the States, the change in the number of beneficiaries who received transports 

varied from an increase of 1 percent in Pennsylvania to an increase of 110 percent in 

California. 

	 Nationally, the average number of transports per beneficiary increased 26 percent. 

Among the States, the change in the average number of transports per beneficiary 

varied from a decrease of 1 percent in Vermont to an increase of 85 percent in 

California. 

	 Nationally, the number of suppliers increased 26 percent. Among the States, the 

change in the number of suppliers varied from a decrease of 25 percent in Mississippi 

to an increase of 207 percent in Virginia. 

	 Nationally, the average number of transports per supplier increased 34 percent. 

Among the States, the change in the average number of transports per supplier varied 

from a decrease of 20 percent in Virginia to an increase of 274 percent in California. 

See Appendix C for the changes in these utilization measures for all States and territories. 

Appendix C also presents, for all States and territories, changes in the number of 

transports for each transport level and changes in the number of transports between 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

Page 15 – Marilyn Tavenner 

various origins and destinations. 

After California, the other high-growth States were Virginia, South Carolina, Georgia, 

and New Jersey.47 Ambulance utilization in these four States increased between 

126 percent and 145 percent. Virginia, South Carolina, and Georgia each accounted for 

3 percent of transports in 2011, and New Jersey accounted for 5 percent. The number of 

beneficiaries who received transports increased between 39 and 110 percent in the 

high-growth States. In contrast, the number of all Medicare fee-for-service beneficiaries 

increased between 8 and 24 percent in those same States. 

The increase in dialysis-related transports in the high-growth States was much greater 

than the national increase. Beneficiaries who received transports in the high-growth 

States received between 329 percent and 6,920 percent more dialysis-related transports in 

2011 than in 2002. Nationally, dialysis-related transports increased 269 percent. The 

greatest increase in dialysis-related transports occurred in South Carolina. In 

2002, 2 percent of South Carolina’s transports were dialysis-related, a share that grew to 

48 percent in 2011. Additionally, the numbers of beneficiaries with ESRD who received 

transports in the high-growth States increased between 83 and 166 percent.48 In four of 

the five high-growth States, this increase exceeded the national increase of 85 percent. 

Table 6 presents the changes in dialysis-related transports, the percentage of 

2011 transports that were dialysis-related, and changes in the number of beneficiaries 

with ESRD who received transports within each of the five States and nationally. 

Table 6: Percentage Change in Dialysis-Related Ambulance Transports 

and Beneficiaries with ESRD Who Received Transports From 2002 to 2011 

State 

Percentage Change in 

Dialysis-Related 

Ambulance Transports 

Percentage of 

2011 Transports That 

Were Dialysis Related 

Percentage Change in 

Beneficiaries With ESRD 

Who Received Transports 

National

South Carolina 

California 

Georgia 

Virginia 

New Jersey 

 269% 

6,920% 

2,727% 

1,138% 

329% 

857% 

19% 

48% 

28% 

33% 

26% 

29% 

85% 

83% 

166% 

102% 

133% 

127% 

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

The increase in BLS nonemergency transports in the high-growth States was greater than 

the national increase. The high-growth States experienced increases in BLS 

nonemergency transports ranging from 126 percent to 554 percent. Nationally, BLS 

nonemergency transports increased 94 percent. The greatest increase in BLS 

nonemergency transports occurred in California. In 2002, 31 percent of California’s 

transports were BLS nonemergency transports, a share that grew to 53 percent in 2011. 

47 Ambulance utilization in Maryland and Alaska increased 138 percent and 136 percent, respectively, but
 

accounted for 1 percent and less than 1 percent of all 2011 transports, respectively. 48 In contrast, the numbers of all Medicare fee-for-service beneficiaries with ESRD in these States 

increased between 18 and 36 percent. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

Page 16 – Marilyn Tavenner 

Table 7 presents the changes in BLS nonemergency transports within each of the five 

States and nationally. 

Table 7: Percentage Change in BLS Nonemergency 

Ambulance Transports From 2002 to 2011 

State Percentage Change, 

2002–2011 

Percentage of 

2011 Transports 

National 94% 46% 

California 554% 53% 

Georgia 301% 51% 

South Carolina 218% 68% 

New Jersey 144% 71% 

Virginia 126% 51% 

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

In the high-growth States, the increase in the number of inpatient hospital visits to treat 

renal failure in beneficiaries who received transports was greater than the national 

increase. High-growth States experienced increases in the numbers of inpatient hospital 

visits to treat renal failure in beneficiaries who received transports. These increases 

ranged from 184 percent to 403 percent. Nationally, the number of inpatient hospital 

visits to treat renal failure in beneficiaries who received transports increased 158 percent. 

The greatest increase occurred in Virginia. In 2002, 1 percent of Virginia’s inpatient 

visits associated with transports to hospitals were to treat renal failure, a share that grew 

to 3 percent in 2011. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

Page 17 – Marilyn Tavenner 

CONCLUSION 

Payments for ambulance transports from 2002 to 2011 increased 130 percent, compared 

to the 74-percent increase in overall Medicare Part B payments. Increases in the 

utilization of ambulance transports are disproportionate in relation to increases in the 

population of Medicare fee-for-service beneficiaries. 

We found that—among many significant changes from 2002 to 2011—dialysis-related 

transports were much more common in 2011 than in 2002, increasing 269 percent. In 

addition, beneficiaries with ESRD who received transports used a growing and 

disproportionate amount of transports each year. Further, the number of Medicare 

fee-for-service beneficiaries with ESRD who received transports increased 85 percent 

from 2002 to 2011. In contrast, the number of all Medicare fee-for-service beneficiaries 

with ESRD increased only 24 percent during that period. We found that high-growth 

States experienced increases in dialysis-related transports greater than the national 

increase. Although dialysis facilities are a covered destination, transports to them do not 

usually meet coverage requirements under Medicare.49 

We did not determine whether the utilization changes described in this memorandum 

report were appropriate, that is, whether transports met Medicare coverage requirements. 

In a forthcoming report, OIG will identify ambulance suppliers that exhibited 

questionable billing characteristics in the first half of 2012 and geographic areas with 

high numbers of these suppliers. 

This report is being issued directly in final form because it contains no recommendations. 

If you have comments or questions about this report, please provide them within 60 days. 

Please refer to report number OEI-09-12-00350 in all correspondence. 

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

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

APPENDIX A 

Detailed Data Analysis Methodology 

We calculated the change in beneficiary, supplier, and transport characteristics from 

2002 to 2011. 

Beneficiary characteristics. We used the 2002 to 2011 Denominator files to determine 

the percentage of Medicare fee-for-service beneficiaries who received ambulance 

transports. We calculated the total number of beneficiaries who received transports. We 

calculated the average number of transports per beneficiary. We calculated beneficiaries’ 

average age and the percentage of beneficiaries in each Medicare eligibility category 

using the date of birth and eligibility category reported on each claim.50 As another 

measure of beneficiaries’ utilization, we also calculated the percentage of transports 

received by beneficiaries in each Medicare eligibility category.51 

Supplier characteristics. We calculated the total number of ambulance suppliers. We 

defined an ambulance supplier as each unique provider identification number, combined 

with a Medicare Administrative Contractor identification number, in our population of 

ambulance claims.52 We calculated the average number of transports per supplier. In 

addition, we calculated the percentages of each supplier’s transports that were billed with 

each procedure code, that is, the supplier’s breakdown of transport levels. We identified 

suppliers for which at least 75 percent of the supplier’s transports were billed with the 

procedure code for a single transport level. 

Transport characteristics. Using CMS’s Physician/Supplier Part B claims file, we 

calculated the frequency of the different transport levels, the frequency of transport origins 

and destinations, the average transport length in miles, and the beneficiary’s medical 

condition at the time of transport. We determined the origin and destination using the 

two-letter modifier on the claim. We calculated the average transport length in miles. We 

determined the beneficiary’s medical condition at the time of transport by analyzing the 

International Classification of Diseases code on each ambulance claim. 

50 For 2011 only, we used the Enrollment Database file to identify the beneficiary’s eligibility category. 

51 People can become eligible for Medicare if they are 65 years or older. People under 65 years old can 

become eligible for Medicare if they are disabled and/or have ESRD. 52 We did not use the National Provider Identifier because it was not required before May 2008 and 

therefore could not have been used to identify unique suppliers in all the years included in our scope. The 

provider identification number is unique only within each Medicare Administrative Contractor’s 

jurisdiction; combining the provider identification number and the Medicare Administrative Contractor 

identification number allowed us to identify unique suppliers. 
 

 

 

 

Page 19 – Marilyn Tavenner 

Detailed Data Analysis Methodology, continued

We analyzed the type of visits (inpatient or outpatient) made by beneficiaries who 

received transports to hospitals. We identified claims from CMS’s Inpatient and 

Outpatient 100-percent Standard Analytic Files that were associated with transports to 

hospitals. We considered an inpatient claim to be associated with the transport if the 

beneficiary health insurance claim number matched the number on the transport claim 

and the inpatient admission date was within 2 days of the transport. If the transport did 

not have an associated inpatient claim, we determined whether the transport had an 

associated outpatient claim. We considered an outpatient claim to be associated with the 

transport if the beneficiary health insurance claim number matched the number on the 

transport claim and the date of service was within 31 days of the transport. We allowed 

the additional days for associated outpatient claims because transports may be provided 

during an outpatient billing period (for example, during a skilled nursing facility stay). If 

the transport had multiple associated outpatient claims, we chose the outpatient claim 

with the date of service that was closest to the date of the transport. For associated 

outpatient claims, we analyzed the type of bill to determine the most common type of 

outpatient facility that provided medical services to the beneficiary. For associated 

inpatient claims, we determined the most common Medicare severity diagnosis related 

groups (condition) of the inpatient stays. 

Characteristics of utilization growth in States with the highest growth. We assigned each 

transport to a State based on the beneficiary’s residence ZIP Code reported on the claim. 

We assigned each ambulance supplier to a State based on the majority of its transports. 

For each State, we calculated the change from 2002 to 2011 in the number of transports, 

number of beneficiaries who received transports, average number of transports per 

beneficiary, number of suppliers, and average number of transports per supplier. We also 

calculated the change during this period by State in the frequency of transports of 

different levels and transport origins and destinations. 

We identified the States with the largest utilization increases that also accounted for at 

least 3 percent of 2011 transports nationally (high-growth States). We determined the 

extent to which these high-growth States experienced changes from 2002 to 2011 that 

differed from the national changes in transport destinations, transport levels, and medical 

services received by beneficiaries who received transports to hospitals. 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

Page 20 – Marilyn Tavenner 

APPENDIX B 

Number of Ambulance Transports From 2002 to 2011 for Selected Transport Levels 

0

1

2

3

4

5

6

7

8

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 

Millions 

Basic life support 

nonemergency 

Advanced life support 

emergency 

Basic life support 

emergency 

Advanced life support 

nonemergency 

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

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

transport) are not shown in this figure because collectively they represented less than 2 percent of all transports each year.
 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 21 – Marilyn Tavenner 

APPENDIX C 

Table C-1: Percentage Changes From 2002 to 2011 in Utilization Measures by 

State 

State 

Number of 

Ambulance 

Transports 

Number of 

Beneficiaries 

Who Received 

Transports 

Average 

Number of 

Transports per 

Beneficiary 

Number of 

Ambulance 

Suppliers 

Average Number 

of Transports per 

Ambulance 

Supplier 

National 69% 34% 26% 26% 34% 

Alabama 49% 26% 18% -13% 71% 

Alaska 136% 108% 13% 93% 22% 

Arizona 42% 33% 6% -4% 48% 

Arkansas 63% 48% 10% -1% 65% 

California 289% 110% 85% 4% 274% 

Colorado 77% 52% 16% 6% 66% 

Connecticut 70% 37% 24% 21% 40% 

Delaware 118% 74% 25% 19% 83% 

District of Columbia 301% 239% 18% -50% 702% 

Florida 46% 23% 18% 7% 36% 

Georgia 133% 44% 61% 13% 107% 

Guam 34,092% 693% 4,214% * * 

Hawaii 95% 77% 10% 0% 95% 

Idaho 46% 34% 10% 77% -17% 

Illinois 64% 45% 13% 41% 16% 

Indiana 118% 36% 60% 31% 66% 

Iowa 42% 31% 8% 12% 26% 

Kansas 42% 30% 9% 4% 37% 

Kentucky 41% 22% 15% 37% 3% 

Louisiana 20% 11% 7% 4% 15% 

Maine 26% 14% 10% 1% 25% 

Maryland 138% 103% 17% 24% 91% 

Massachusetts 41% 30% 9% 1% 39% 

Michigan 41% 12% 25% 16% 22% 

Minnesota 25% 13% 10% -16% 48% 

Mississippi 53% 36% 12% -25% 104% 

Missouri 50% 42% 6% 11% 35% 

Montana 33% 23% 8% 6% 26% 

Nebraska 61% 42% 14% 37% 18% 

Nevada 71% 53% 12% 10% 55% 

New Hampshire 53% 35% 13% 5% 46% 

New Jersey 126% 42% 59% 75% 29% 

*We assigned each ambulance supplier to a State based on the majority of the supplier’s claims. Using this method, the State had 

zero suppliers in 2002 and/or 2011. 

continued on next page 

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Table C-1: Percentage Changes From 2002 to 2011 in Utilization Measures by 

State, continued

State 

Number of 

Ambulance 

Transports 

Number of 

Beneficiaries 

Who Received 

Transports 

Average 

Number of 

Transports per 

Beneficiary 

Number of 

Ambulance 

Suppliers 

Average Number 

of Transports per 

Ambulance 

Supplier 

New Mexico 54% 38% 12% 1% 53% 

New York 31% 9% 20% 23% 6% 

North Carolina 83% 56% 17% 87% -2% 

North Dakota 24% 10% 13% -1% 25% 

Northern Marianas 31,613% 413% 6,088% * * 

Ohio 54% 27% 21% 60% -4% 

Oklahoma 51% 42% 7% -19% 87% 

Oregon 38% 23% 12% 41% -3% 

Pennsylvania 66% 1% 64% 1% 64% 

Puerto Rico -71% -58% -33% 72% -83% 

Rhode Island 124% 83% 23% 41% 60% 

South Carolina 140% 39% 73% 93% 24% 

South Dakota 40% 29% 8% 5% 34% 

Tennessee 64% 35% 22% 24% 32% 

Texas 51% 31% 15% 46% 3% 

Utah 8% 2% 5% 11% -3% 

Vermont 28% 29% -1% 9% 18% 

Virgin Islands 83% 29% 42% -33% 174% 

Virginia 145% 96% 25% 207% -20% 

Washington 60% 43% 12% 86% -14% 

West Virginia 22% 7% 14% -1% 23% 

Wisconsin 24% 7% 15% 3% 20% 

Wyoming 51% 39% 9% 2% 48% 

*We assigned each ambulance supplier to a State based on the majority of the supplier’s claims. Using this method, the State had
 

zero suppliers in 2002 and/or 2011. 

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

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 23 – Marilyn Tavenner 

Table C-2: Percentage Changes From 2002 to 2011 in the Number of Transports in 

Each Transport Level by State 

State 

ALS 

Nonemergency 

(A0426) 

ALS 

Emergency 

(A0427) 

BLS 

Nonemergency 

(A0428) 

BLS 

Emergency 

(A0429) 

ALS2 

(A0433) 

Specialty 

Care 

Transport 

(A0434) 

National -40% 68% 94% 57% 18% 114% 

Alabama -29% 38% 74% 45% 132% 196% 

Alaska 22% 206% 124% 101% 8% 57% 

Arizona 25% 50% 20% 39% -31% 21% 

Arkansas -16% 95% 58% 67% 46% 205% 

California 15% 180% 554% 157% 82% 371% 

Colorado -46% 96% 83% 87% 29% -37% 

Connecticut 1% 93% 65% 73% -69% 58% 

Delaware -34% 85% 109% 134% 100% 22% 

District of Columbia 137% 2,898% 53% 1,598% 3,333% 500% 

Florida -60% 58% 69% 34% 4% 229% 

Georgia -18% 58% 301% 97% 2% 394% 

Guam 0% 274% 143,200% 117% * * 

Hawaii 210% 134% 117% 18% 32% 329% 

Idaho 35% 53% 65% 33% 128% -12% 

Illinois 5% 99% 44% 62% 122% 72% 

Indiana 32% 91% 183% 36% -24% 283% 

Iowa -36% 56% 31% 61% 21% 61% 

Kansas -23% 53% 9% 64% 10% 71% 

Kentucky -4% 46% 49% 28% 25% -22% 

Louisiana -47% 18% 27% 39% 77% 612% 

Maine -26% 37% 20% 30% -56% 124% 

Maryland 21% 201% 108% 235% 91% 5% 

Massachusetts 14% 84% 29% 33% -8% 151% 

Michigan -24% 32% 70% 28% 17% 309% 

Minnesota -13% 28% -3% 47% -21% -51% 

Mississippi -20% 38% 69% 322% 25% 367% 

Missouri -46% 71% 36% 89% 70% 7% 

Montana -40% 55% -7% 28% 149% 92% 

Nebraska 12% 52% 39% 89% 399% -71% 

Nevada -21% 106% 8% 21% 63% 54% 

*The State had zero transports billed under that particular transport level in 2002 and/or 2011. 

continued on next page 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 24 – Marilyn Tavenner 

Table C-2: Percentage Changes From 2002 to 2011 in the Number of Transports in 

Each Transport Level by State, continued

State 

ALS 

Nonemergency 

(A0426) 

ALS 

Emergency 

(A0427) 

BLS 

Nonemergency 

(A0428) 

BLS 

Emergency 

(A0429) 

ALS2 

(A0433) 

Specialty 

Care 

Transport 

(A0434) 

New Hampshire 12% 61% 48% 59% 10% 38% 

New Jersey -69% 359% 144% 79% 525% 75% 

New Mexico -31% 72% 36% 45% 239% 63% 

New York -41% 39% 35% 27% 6% 69% 

North Carolina -33% 99% 75% 105% 161% 41% 

North Dakota -8% 32% 22% 24% -38% -71% 

Northern Marianas 200% 900% 251,600% 40% * * 

Ohio -14% 89% 48% 37% -33% 84% 

Oklahoma -32% 82% 16% 49% 97% 282% 

Oregon -35% 41% 26% 68% 29% 69% 

Pennsylvania -14% 17% 159% 16% -19% 127% 

Puerto Rico -90% 6% -74% -51% 231% -12% 

Rhode Island -90% 222% 92% 325% 214% 141% 

South Carolina -21% 57% 218% 87% -5% 243% 

South Dakota -45% 76% -10% 42% -5% 32% 

Tennessee -46% 95% 65% 93% -13% 712% 

Texas -83% 41% 106% 122% 19% 226% 

Utah -15% 27% -26% 4% -39% -55% 

Vermont 16% 77% 2% 9% 24% 41% 

Virgin Islands 30% 1,347% 219% -91% * 17% 

Virginia -22% 238% 126% 165% 175% 4% 

Washington 11% 82% 30% 81% 33% 3% 

West Virginia -3% 10% 26% 37% -60% 111% 

Wisconsin 12% 55% 29% 0% 40% -17% 

Wyoming -42% 92% 53% 42% 140% 84% 

*The State had zero transports billed under that particular transport level in 2002 and/or 2011. 

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

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 25 – Marilyn Tavenner 

Table C-3: Percentage Changes From 2002 to 2011 in the Number of Transports Between 

Various Origins and Destinations by State 

State 

Between a 

Hospital and 

Private 

Residence 

Between a 

Hospital and 

SNF or 

Residential 

Facility** 

Between 

Hospitals 

From an 

Accident to 

a Hospital 

Between an 

Independent 

Dialysis Facility 

and Private 

Residence 

Between an 

Independent 

Dialysis Facility 

and SNF or 

Residential 

Facility 

National 51% 49% 53% 112% 264% 285% 

Alabama 25% 23% 32% 142% 297% 328% 

Alaska 142% 138% 133% 289% * * 

Arizona 29% 36% 102% 118% 2,665% 116% 

Arkansas 48% 46% 44% 319% 288% 646% 

California 173% 277% 164% 146% 3,255% 2,652% 

Colorado 74% 62% 58% 136% 1,670% 826% 

Connecticut 77% 61% 35% 114% 184% 86% 

Delaware 144% 41% 112% 121% 604% 228% 

District of Columbia 993% 41% 242% 3,709% 21,300% 432% 

Florida 22% 48% 33% 114% 416% 407% 

Georgia 51% 68% 27% 245% 2,125% 657% 

Guam 7,655% 778% 220% 850% * * 

Hawaii 125% 51% -6% 137% -13% 400% 

Idaho 37% 96% 15% 31% * * 

Illinois 87% 38% 51% 111% 291% 72% 

Indiana 76% 67% 76% 65% 658% 458% 

Iowa 45% 31% 57% 59% * -97% 

Kansas 50% 25% 31% 65% 457% -78% 

Kentucky 12% 24% 65% 242% 189% 146% 

Louisiana 28% -2% 260% 41% 88% 107% 

Maine 19% 16% 34% 78% 251% 77% 

Maryland 179% 83% 91% 570% 3,824% 225% 

Massachusetts 38% 14% 25% 159% 121% 178% 

Michigan 24% 28% 19% 59% 949% 426% 

Minnesota 33% -1% 29% 58% 291% 102% 

Mississippi 48% 34% 90% 67% 114% 168% 

Missouri 53% 35% 76% 97% 502% -16% 

Montana 28% 60% 23% 44% -39% -99% 

Nebraska 52% 94% 45% 47% * -47% 

Nevada 69% 76% 104% 98% -67% 551% 

New Hampshire 43% 35% 58% 123% 1,840% 280% 

New Jersey 122% 35% 26% 267% 1,129% 607% 

*The State had zero transports billed with that particular origin and destination in 2002 and/or 2011. 

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

continued on next page 

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350) 
 

 

 

 

 

 

 

 

 

 

 

 

 

Page 26 – Marilyn Tavenner 

Table C-3: Percentage Changes From 2002 to 2011 in the Number of Transports Between 

Various Origins and Destinations by State, continued

State 

Between a 

Hospital and 

Private 

Residence 

Between a 

Hospital and 

SNF or 

Residential 

Facility** 

Between 

Hospitals 

From an 

Accident to 

a Hospital 

Between an 

Independent 

Dialysis 

Facility and 

Private 

Residence 

Between an 

Independent 

Dialysis Facility 

and SNF or 

Residential 

Facility 

New Mexico 42% 23% 42% 149% 7,640% 444% 

New York 23% 17% -5% 83% 399% 281% 

North Carolina 67% 94% 57% 116% 173% 59% 

North Dakota -6% 18% 23% 222% * * 

Northern Marianas 8,600% * * 0% * * 

Ohio 73% 17% 66% 132% 272% 156% 

Oklahoma 70% 25% 79% 58% 260% 42% 

Oregon 14% 107% 28% 45% 3,650% 214% 

Pennsylvania 16% 19% 41% 36% 1,436% 422% 

Puerto Rico -51% 20% -63% 20% -67% 9% 

Rhode Island 313% 60% 22% 478% 132% 78% 

South Carolina 59% 83% 45% 48% 9,659% 4,535% 

South Dakota 47% 28% 17% 38% 1,500% * 

Tennessee 41% 35% 80% 126% 186% 162% 

Texas 56% 95% 72% 35% -33% 108% 

Utah -1% -5% 74% 27% * 5,350% 

Vermont 27% 27% 73% 92% * 579% 

Virgin Islands 37% 77% 108% -27% * * 

Virginia 170% 83% 63% 362% 427% 253% 

Washington 43% 71% 86% 109% 192% 137% 

West Virginia 1% 17% 47% 104% 103% 79% 

Wisconsin 15% 27% 50% 20% 226% 298% 

Wyoming 46% 35% 67% 91% * 500% 

*The State had zero transports billed with that particular origin and destination in 2002 and/or 2011. 

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

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

Utilization of Medicare Ambulance Transports, 20022011 (OEI-09-12-00350)