OIG developing guidance for ambulance services
OIG developing guidance for ambulance services
The Department of Health and Human Services’ Office of Inspector General (OIG) is seeking input and recommendations from interested parties as it develops a compliance risk guidance for ambulance service providers, especially those serving Medicare, Medicaid, and other federal health care program beneficiaries.
The guidance is likely to be among the last issued by the OIG.
The guidance was prompted by numerous instances of ambulance provider and supplier fraud and abuse, according to the OIG, which adds that many in the industry expressed interest in its development. "We strongly favor it because we think it will clear up a lot of gray areas for our members," says Steve Haracznak, executive vice president of the American Ambulance Association (AAA) in Washington, DC.
According to AAA’s attorney, Darrel Grinstead of Hogan & Hartson in Washington, DC, two primary problems plaguing the industry are ambulance providers that transfer patients who don’t require ambulance transportation and providers that claim they are providing ambulance transportation when what they are really providing a mobile van. "Those are the most common bad-actor types of problems that exist out there," he reports.
Grinstead says the more common problem for legitimate ambulance providers is constantly having disputes with carriers over the question of medical necessity.
"The problems that our providers are having now are really not compliance problems after the fact," he asserts. Rather, many carriers are clamping down on denials in the first place. Increasingly, that means they seek payment through the appeals process.
David Werfel, AAA’s Medicare specialist, says the problem has become acute in a number of states.
"The biggest problem right now is companies being paid correctly, because there are massive denials being issued, and they are way off base," he asserts. "In this frenzy for compliance, the pendulum has swung so far off the charts that some carriers are making major mistakes right now."
According to Werfel, some carriers are even denying payment for heart attacks. He says the situation varies dramatically from state to state. For example, in South Carolina, 90% of the ambulance claims submitted are being denied. "That is the complete opposite of what it was in the past," he asserts.
But South Carolina is not alone. In Maryland, all high-volume ambulance providers are on pre-paid reviews. While carriers have the right to do that, Werfel says, it slows the process down enormously.
"There is a purpose for prepayment review, but you should not throw somebody on that unless you think they are really doing something wrong," he argues. "If this keeps up, you will not have any ambulance providers left."
Comments on the guidance must be delivered to the OIG no later than Oct. 16.
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