OIG Investigates Payments for Ambulance Transports of SNF Patients

Medicare’s Office of Inspector General (OIG) has issued a sixteen-question survey to many ambulance service suppliers. The survey is focused on SNF patients, and specifically why the ambulance service has billed Medicare Part B for transports while patients were in a Part A stay. During Part A stays, the nursing home receives Medicare payments that include funds for most transports for the patient. This makes the SNF the responsible party for payment to any third party transporting the patient. However, claims for these transports often go to Medicare Part B because the ambulance service providing the transport did not know that the patient was in a Part A stay. 

The sixteen questions asked in the OIG survey mainly focus on what the ambulance service did or didn’t do to prevent an improper Part B claim. One question asks, “How do you determine whether the beneficiary is a Part A SNF resident?” while another asks, “Do you obtain any written communication or notification from the SNF or outpatient hospital as to the beneficiaries’ Part A or Part B status or the services the beneficiary received at the destination?” An associated question asks, “Do you ever contact hospitals to determine the nature of the outpatient service rendered? If not, how does your company determine whether the patient received services that allow you to bill Medicare?”

Another asks, “Do you have specific policies and procedures for processing claims that are rendered in conjunction with a Medicare beneficiary in a Part A stay?” Finally, one that cuts right to the heart of the matter: “Can you tell us why you submitted the ambulance charges to the Medicare Contractor instead of to the skilled nursing facility where the patient was an inpatient in a Part A stay?”

From just a few of the survey questions, you can clearly see that the OIG feels that the burden of keeping up with the Part A status of a patient should be on the ambulance service supplier, not on the SNF who is requesting the transport. Whether or not that is reasonable, it is the ambulance service which ends up receiving any improper payment; therefore, the ambulance service is where the focus will be and from where any repayment will be requested. In fact, according to the OIG’s office of Audit Services, the results of this survey may be turned over to the Medicare Administrative Contractors for collection of money due to be paid back to the Medicare program by the ambulance suppliers. 

Several years ago, Medicare issued a massive number of recoupment demands based on this same issue. After that, however, changes in the Medicare Common Working File (where both Part A and Part B patient information is kept) were supposed to catch these claims before they resulted in improper Part B payments. For the most part, I think that Medicare does try to prevent these claims from being paid on the front end, but some may slip through the cracks.

The moral of the story is that ambulance service suppliers should not rely on either Medicare or the SNF to catch the issue on the front end. The ambulance service should have policies in place for dealing with Part A patients. They should also be collecting and documenting verification of patient status from the SNF prior to the transport and services rendered to the patient from the destination facility after the transport. If you have these safeguards in place, there should not be any improperly-paid Part B claims. If you do not have these safeguards, then you may be getting a bill from your local MAC!

G. Christopher Kelly is an attorney who focuses on federal laws and regulations as they relate to the healthcare providers and specifically to the ambulance industry. Chris lectures and advises EMS service clients across the U.S. This article is not intended to be legal advice. For more information or specific questions, Chris can be reached at ckelly@emscltd.com.