Source: https://bergermontague.com/medically-necessary-ambulance-services-under-the-false-claims-act/
Timestamp: 2019-02-23 20:47:19
Document Index: 421086261

Matched Legal Cases: ['§ 1395', '§ 1395', '§ 410', 'art:\n42', '§ 410', '§ 410', '§ 10']

"Medically Necessary" Ambulance Services Under the False Claims Act | Berger Montague
“Medically Necessary” Ambulance Services Under the False Claims Act
A non-intervened False Claims Act case filed against Medstar, an ambulance company, settled for $12.7 million on January 17, 2017. The qui tam case was filed on October 4, 2013 in the Federal District Court of Massachusetts under the caption United States ex rel. Dale Meehan v. MedStar et als, Civil Action No. 13-12495-IT.
Many whistleblower cases brought under the False Claims Act (“FCA”) against ambulance companies involve determining if the ambulance transports were “medically necessary.”
Ambulance Services and Medicare
Medicare does not pay for any and all services furnished to beneficiaries, but only those which are “reasonable and necessary for the diagnosis or treatment of illness or injury . . . .” 42 U.S.C. § 1395y(a)(1)(A). With respect to ambulance services in particular, Medicare covers such services only “where the use of other methods of transportation is contraindicated by the individual’s condition, but only to the extent provided in regulations.” 42 U.S.C. § 1395x(s)(7).
The Medicare regulations regarding ambulance transport are set forth in 42 C.F.R. § 410.40, which is entitled “Coverage of ambulance services.” Accordingly, the regulations in effect for ambulance transportation services for the entire period of time covered by this Complaint provide, in relevant part:
42 C.F.R. § 410.40(d)(1).
In addition, CMS established a requirement that “nonemergency, scheduled ambulance services,” such as maintenance dialysis, are covered if “the ambulance provider or supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying that the medical necessity requirements of paragraph (d)(1) of this section are met.” 42 C.F.R. § 410.40(d)(2).
The Medicare Benefit Policy Manual (“MBPM”), which sets forth the rules and regulations for Medicare reimbursement, further describes the requirements for coverage of ambulance transport. For example, the MBPM states:
Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.
MBPM at § 10.2.1.
By Kate Nolen| 2018-03-25T09:50:04+00:00 February 22nd, 2017|Healthcare Fraud|