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Chasing ambulance compliance

Patrick K. Kennedy ( is Executive System Director Hospital Compliance, UNC Healthcare, Chapel Hill, NC.

Identifying and retaining subject matter experts in the compliance profession can be challenging. They face researching, investigating, and opining on very unique topics within healthcare. One such topic is compliance with ambulance transport documentation and billing. Nurses, paramedics, and flight crews focus every day—and during every transport trip—on providing high-quality care in a complex environment and safely delivering patients to their destinations. Ambulance services are a unique compliance subject within the healthcare system that can result in negative compliance outcomes without expertise, solid policies and procedures, and regular attention.

In July 2018, the Department of Health and Human Services Office of Inspector General (OIG) issued an audit report on nonemergency ambulance transports to destinations not covered by Medicare[1] (i.e., from a skilled nursing facility to an outpatient hospital). OIG identified improper payments totaling $8.7 million for nonemergency transports during calendar years 2014 through 2016—$5.5 million for base rate payments and $3.2 million for mileage associated with the noncovered transports. Not only do ambulance service providers have to consider if the patient’s originating and destination locations are covered by Medicare, but they must also consider other regulatory factors such as loaded mileage, physician certification for medical necessity, provider or patient/family choice, locality rules, and level of care. As such, Centers for Medicare & Medicaid Services (CMS) has provided a Medicare Learning Network (MLN) booklet[2] that outlines regulatory factors that ambulance providers must be knowledge of to ensure compliant billing and payment under Medicare fee-for-service. The MLN booklet provides covered and noncovered scenarios as well as billing guidelines that depend on the patient’s location (origination and destination) and type of transport (ground or air).

This article will focus on two key areas of ambulance compliance that are important for ensuring positive compliance outcomes: (1) accurate charging and billing, including zip codes, mileage, and modifiers; and (2) determining appropriate locality for the transport.

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