Sarah L. Mancebo (sarah.mancebo@adventhealth.com) is Director of Compliance at AdventHealth in Orlando, FL.
A recent emergency medical services annual conference highlighted the revolution that is underway for ambulance transport. It is no longer about getting an individual as quickly as possible to a hospital for treatment. Today’s ambulance providers and suppliers are providing more advanced patient care in the field and are becoming more integrated in the healthcare system. The revolution that ambulance transport is undergoing makes it ever so important to bring compliance to the conversation.
Ambulance suppliers and providers that are enrolled in Medicare need to understand that billing and reimbursement requirements are a challenging and risky compliance area for Medicare, because: (1) the laws and regulations are both lengthy and complex, (2) the Office of Inspector General (OIG) has heightened its focus and review of ambulance claims in recent years, and (3) enforcement actions are trending across the ambulance industry. Each of these categories is briefly summarized below.
Laws and regulations
Medicare regulations and related online manuals contain detailed coverage and reimbursement requirements for ambulance services. Ambulance transports are separately payable under Medicare Part B if the following transportation requirements are met:
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The transport is not covered under Medicare Part A;
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The correct level of service is used;
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Origin and destination requirements are met, which generally means the transport is to the nearest appropriate facility; and
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The transport meets medical necessity and reasonableness requirements. [1]
Medicare-covered ambulance services are paid either as separately billed services, in which case the entity furnishing the ambulance service bills Medicare Part B; or as a packaged service, in which case the entity furnishing the ambulance service must seek payment from the provider who is responsible for the beneficiary’s care.[2] Medicare Part A covers medically necessary ambulance transports of inpatients. Additionally, ambulance providers and suppliers must comply with specific vehicle, staff, equipment, and supply requirements.[3]
Levels of service can be billed as specialty care transport, advanced life support (emergency or nonemergency), or basic life support.[4] The ambulance crewmembers must be very familiar with the documentation requirements for each level, because they are the individuals who make determinations based on the patient’s condition, diagnosis, and information gathered at the scene/originating location. Medical necessity means the patient’s medical condition is such that other means of transportation are contraindicated, and the patient is either confined to bed or, regardless of bed confinement, transportation by ambulance is medically required.[5]
These requirements must be met for the transport to be billed to Medicare, and this can be daunting for providers and suppliers. Being in the “business of ambulance transport” is a unique niche in healthcare for both hospital providers and independent ambulance suppliers.
