Medicare requiring pre-approval on ambulance rides to combat fraud in N.J. and Pennsylvania

In an effort to crack down on ambulance fraud, the federal government is beginning a pilot program in Pennsylvania and New Jersey to change the way Medicare reimburses rides for non-emergency medical treatment.

The only people who are supposed to qualify for a free ambulance ride to their regular dialysis or cancer treatment appointments are those who really need it: patients who are bed-ridden or have another serious medical problem.

All too often, though, relatively healthy people have been using ambulances, sometimes with the encouragement of a kickback from a transport company. And at $400 for a round-trip, health care consultant Marsha Simon said Medicare’s increasing tab has officials upset.

“We have the absurd situation at present that the cost of the ride is more than the cost of the dialysis treatment,” she said.

By December 15th, ambulance companies in New Jersey, Pennsylvania, and South Carolina will need to get prior authorization before transporting qualified patients who require rides on a regular basis.

Simon said the restriction is likely to cut down on improper billing. But it also may mean patients won’t get the care they need.

“What may look like savings under the line item called ambulance,” she said, “is going to end up being greater cost on the line item called hospital.”

A much better solution, she said, would have been a pilot program that included a Medicare-funded transportation option for people who may not be able to drive or are unable to afford a taxi, but don’t need an ambulance.

Alternative transport is available in New Jersey, but only if a patient is enrolled in Medicaid — and no such service exists in Pennsylvania.

The Philadelphia area has been one of the worst offenders for ambulance fraud in recent years, including several high profile arrests. In January the government also issued a six-month moratorium on approving new operators in the region.

If the program is as effective at stamping out fraud as Simon believes, then it’s possible some local companies will have to close.

“There’s currently 63 non-municipal ambulance providers in Philadelphia alone,” said Karen Kroon, the general manager of the American Medical Response ambulance company in Philadelphia. “It seems to me there’s way too many for the legitimate number of transports that may be out there.”

Her company focuses on transporting patients who are critically ill, and currently is not providing any rides to people who fall under the new regulations, although they have in the past.

“It’s a little bit more paperwork, but we’re fully prepared,” said Kroon. “We have our pre-authorization process in place, and I don’t see this having much of a impact on our business at all.”

That may be less true of the ambulance providers she sees dropping off patients at the dialysis center across the street from her office.

“Patients walk out the back of the ambulance,” she said. “I see it every day.”