The trusted source for
healthcare information and
Less than two weeks after federal fraud investigators spotlighted physician laxity in certifying the medical necessity of home health and DME services, HCFA is imposing more medical necessity regulations, this time with regard to ambulance services. Effective late February, the new regulations require that physicians certify in writing the medical necessity of "nonemergency ambulance transport" of beneficiaries. While the real onus seems to be on ambulance service providers, the regulations may force more physicians to be involved in ambulance transport decisions and better educated as to what types of services qualify as medically necessary.
Medicare only pays for nonemergency ambulance service if "other means of transportation are contraindicated." Service is medically necessary if the patient is "bed-confined," meaning that he or she can't get up without assistance, can't ambulate, and can't sit in a chair. Also, Medicare won't pay unless the ambulance supplier obtains a physician's written order certifying that the beneficiary must be transported in an ambulance. That order must be less than 60 days old.
Responding to complaints that physicians may not be aware of the coverage requirements for ambulance services, HCFA states that "if the decision to use ambulance services is based on the convenience of the beneficiary, the beneficiary's family, the beneficiary's physician, or some other element of personal preference," Medicare coverage isn't available.
The final rule makes no specific mention of the False Claims Act, though false certifications of medical necessity fall within its purview.
Some ambulance companies and providers also complain that the stricter certification requirements might lead to unnecessary delays. HCFA addresses the concern by allowing that in some cases "the written physician certification can be obtained 48 hours after transportation has been furnished."