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1. There are some forms of fraud and abuse that are committed only by ambulance companies. Name and explain three of them.

2. Faulty or incomplete documentation is a common risk area for ambulance suppliers. List at least five pieces of information that should be part of that documentation.


Chapter 20

Ambulance Providers and Suppliers

Learning Objectives

Basic services provided by an ambulance supplier

Fraud types committee by ambulance suppliers

Components of compliance program tailored to ambulance suppliers

Risk areas facing ambulance suppliers

Anti-kickback risks with referral sources

Compliance policies and forms

Model ambulance supplier compliance program


Functions performed by an ambulance

Levels of ambulance service

Companies providing ambulance services

Examples of fraud by ambulance companies

OIG Compliance Program Guidance for ambulance suppliers

Elements of a Compliance Program for Ambulance Suppliers

Development of compliance policies and procedures

Designation of a compliance officer

Education and training programs

Internal monitoring and reviews

Responding to detected misconduct

Developing open lines of communication

Enforcing disciplinary standards through well-publicized guidelines

Policies and Procedures

These documents represent the written standards of conduct for daily operations of the ambulance company.

They should be reviewed periodically, at least annually, and updated as needed.

The reviews should compare the standards with the actual practices within the organization.

Training and Education

Cross-training of employees as a means of raising their overall awareness of compliance across job functions.

Interactive training to enhance employee learning by allowing them to ask questions and receive feedback.

Use real life examples of compliance problems presented by personnel who have experienced them.

Review of the Claims Submission Process

Periodic reviews of documentation and information, medical necessity, coding, co-payment collection, and payor reimbursement.

Identify compliance errors, and seek source & causes of the errors.

Review claims before submitted.

Review claims denials for patterns.


Review of Coding & Billing Systems

How transport is documented and by whom

How information is entered into the supplier?s automated system

Coding and medical necessity determination protocols

Billing system processes and controls, including edits or data entry limitations

Claims generation, submission, and subsequent payment tracking processes

Review of Coding & Billing Systems

Stage 2: Contemplation

People engage in cognitive processes about the behavior.

A key concept in Contemplation is decisional balance, defined as a ?mental weighing? of the importance of the pros and cons associated with changing behavior.

Avoiding Sanctioned Employees or Contractors

Query exclusion and debarment lists before hiring or contracting with new people or entities

Check those lists annually regarding current employees or contracted entities

Identification of Risks Unique to Ambulance Suppliers

OIG Compliance Guidance identifies most common compliance risks faced by ambulance suppliers

Other risk areas unique to the ambulance services industry, the local market, or the company itself

Stay up-to-date with risks by regularly checking OIG publications, OEI reports, and OAS reports

Specific Medicare Risk Areas Facing Ambulance Suppliers

The OIG outlined these specific risk areas for ambulance suppliers in its Compliance Program Guidance.

Medical necessity


Faulty or incomplete documentation


Specific Medicaid Risk Areas Facing Ambulance Suppliers

All states that receive federal Medicaid funds are required to make arrangements for transporting Medicaid recipients to and from medical appointments.

This results in the use and coverage of some transport methods not covered by Medicare, such as wheelchair vans, taxi cabs, and ambulettes.

Care must be taken to ensure that Medicare is not also billed for such transport services already covered by Medicaid.

Kickbacks to Induce Referrals for Ambulance Service Requests

Structure referral arrangements to fit within AKS ?safe harbors?

Set prices at FMV, without considering volume of potential referrals

Do not offer gifts or other benefits to referral sources

Do not accept gifts or other benefits from parties seeking referrals from the company

High Risk Referral Arrangements for Ambulance Suppliers

Public EMS sponsors

First responders

Hospitals and nursing facilities


Sample Ambulance Supplier Compliance Plan

Review the sample compliance plan for an ambulance supplier at the designated internet address

Compare the topics it covers and the requirements it makes with the suggestions in this chapter

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