Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare non-emergency ambulance services billed on dates of service from January 1, 2018, through December 31, 2018. Below are the review results:

Background

The Office of Inspector General (OIG) report A-09-17-03018, dated July 2018 entitled “Medicare Improperly Paid Providers for Non-Emergency Ambulance Transports to Destinations Not Covered by Medicare,” focused on calendar years (CY) 2014 through 2016 to determine whether Medicare payments to providers for non-emergency ambulance transport complied with Federal requirements. The OIG found that Medicare made improper payments of $8.7 million to providers for non-emergency ambulance transports to destinations not covered by Medicare, including the identified ground mileage associated with the transports. The total improper payment amount of $8.7 million included claim lines outside of the 4-year claim-reopening period. The objective of the report was to determine whether Medicare payments to providers for non-emergency ambulance transports complied with Federal requirements.

Reason for Review

In response to the OIG study, the CMS provided the SMRC a file of national provider identifiers (NPI) specifically identified by the OIG, while conducting the original study. The SMRC will perform medical record review for the specified NPIs to determine if the non-emergency ambulance transports were reasonable and necessary for the level of service billed in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Non-Covered Destination
  • Non-payable origin/destination modifiers billed (scheduled service such as physician office to beneficiary’s residence). CMS Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3 indicates that Medicare covers ambulance transports to only certain destinations.
• Appropriate Origin/Destination
  • Origin/destination related. Documentation did not support the modifiers billed on the claim or the documentation did not support the beneficiary was transported to the nearest appropriate facility. CMS Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3 states that “An ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) as well as the return transport.”
• Transports to Hospice
  • The ambulance service may be covered by the Hospice provider. Please submit to the Hospice provider. CMS Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 40.1.9 states “Ambulance transports of a hospice patient, which are related to the terminal illness and which occur after the effective date of election, are the responsibility of the hospice.”
• Insufficient Documentation
  • The documentation submitted was incomplete and/or insufficient. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. In addition, the Code of Federal Regulations, Title 42, Section 424.5(a)(6) indicates sufficient information must be furnished to the intermediary to determine whether payment is due and amount of payment.
• Medical Necessity
  • Medical necessity. The documentation submitted did not support the beneficiary met medical necessity criteria for a non-emergency ambulance transport. CMS Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2 states “Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated.”

References/Resources

• Social Security Act (SSA) Title XVIII, Section §1833(e). Payment of Benefits
• Social Security Act (SSA) Title XVIII, Section §1861(s)(7). Medical and Other Health Services; Ambulance
• Social Security Act (SSA) Title XVIII, Sections §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
• Social Security Act (SSA) Title XVIII, Sections §1879(879(a)(1), (g)(2). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• Social Security Act (SSA) Title XVIII, Section 1893 (b). Medicare Integrity Program.
• Code of Federal Regulations Title 42, Section 410.40(a-f). Coverage of Ambulance Services
• Code of Federal Regulations Title 42, Section 424.36(b) (1-4). Signature Requirements
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.1. Necessity for the Service
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.2. Reasonableness of the Ambulance Trip
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.3. Medicare Policy Concerning Bed-Confinement
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.4. Documentation Requirements
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.6. Effect of Beneficiary Death on Medicare Payment for Ground Ambulance Transports
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.3. The Destination
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.3.6. Appropriate Facilities
• Medicare Benefit Policy Manual Publication 100-02, chapter 10, Section 10.3.8. Ambulance Service to Physician’s Office
• Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 30.1.1. Ground Ambulance Services
• Medicare Claims Processing Manual, Publication 100-04, Chapter 15. Ambulance
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.2.3.8. No response of Insufficient Response to Additional Documentation Requests
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.3.2.4. Signature requirements
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.3.2.8. MAC Articles
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.6.2.2. Reasonable and necessary criteria
• Local Coverage Determination (LCD) L34549. Ambulance Services. Effective 10/01/2015-present.
• Local Coverage Determination (LCD) L35162. Ambulance Services. Effective 10/01/2015-present.
• Local Coverage Determination (LCD) L37697. Transportation Services: Ambulance. Effective 06/28/2018-present.
• Local Coverage Article (LCA) A52588: Billing for Ground Ambulance Services When the Beneficiary is Pronounced Deceased. Effective 10/01/2015-present.
• Local Coverage Article (LCA) A52594: Emergency and Non-Emergency ground Ambulance services New Part A and Part B. Effective 10/01/2015-present.
• Local Coverage Article (LCA) A54574: Ambulance Services (Ground Ambulance). Effective 10/01/2015-present.
• Local Coverage Article (LCA) A55096: Reminder Regarding Ambulance Transports- Dual Diagnoses (Provider Bulletin). Effective 6/9/2016-present.
• Local Coverage Article (LCA) A55975: A0425 Non-Emergency ground Ambulance services. Effective 06/28/2018-present.
• Local Coverage Article (LCA) A55976: Response to Comments: Emergency and Non-Emergency Ground Ambulance Services. Effective 6/28/2018-present.
• Local Coverage Article (LCA) A56043: Non-Emergency Ground Ambulance Services retired Part A and Part B LCD. Effective 6/28/2018-present.
• Local Coverage Article (LCA) A56070: Emergency and Non-Emergency ground Ambulance services revision to the Part A and Part B LCD. Effective 07/16/2018-present.
• Local Coverage Article (LCA) A56130: Emergency and Non-Emergency ground Ambulance services revision to the Part A and Part B LCD. Effective 09/09/2018-present.

Last Updated Jan 28, 2022