OIG Issues Final Compliance Program Guidance for Ambulance Suppliers

Ambulance suppliers now have access to another tool to assist them in combating fraud, waste and abuse in their dealings with federal health care programs. The Office of Inspector General for the Department of Health and Human Services today issued a final compliance program guidance to assist ambulance suppliers in establishing compliance programs.

This program guidance also serves as a useful resource for those ambulance suppliers with existing compliance programs. One of the factors that was taken into account when developing the guidance was the great variation among ambulance industry suppliers. Factors such as the size of the company, whether for-profit or not-for-profit, affiliated with a hospital or independent, and run by municipalities/counties or commercially owned will determine the applicability of the information provided in the program guidance.

“This guidance provides a blueprint for ambulance suppliers to design a compliance program that best fits the needs of their own particular organization. This is not a one size fits all document,” Inspector General Janet Rehnquist said.

The guidance, entitled OIG Compliance Program Guidance for Ambulance Suppliers, is published as a notice in the March 24 Federal Register. It is also available on the OIG Web site at http://oig.hhs.gov/fraud/docs/complianceguidance/032403ambulancecpgfr.pdf.

The OIG acknowledges in the program guidance that the ambulance industry is already familiar with compliance fundamentals (e.g., the role of the compliance officer). Accordingly, the focus of this program guidance is on risk areas relevant to the ambulance industry and recommends ways ambulance suppliers can address these and other compliance risks.

For example, to address the potential for abuse in the area of non-emergency transports, the guidance urges suppliers to follow the Medicare program’s criteria for the coverage of scheduled and unscheduled non-emergency transports, including the requirement that suppliers obtain physician certification statements (PCS) to verify that the transport was medically necessary.

The PCS should provide adequate information for each individual beneficiary and be signed by the appropriate physician or other health care professional.

Additionally, the guidance reviews some of the fraudulent and abusive practices that have occurred in the ambulance industry, including:

• improper transport of individuals with other acceptable means of transportation;
• medically unnecessary trips;
• trips claimed but not rendered;
• misrepresentation of the transport destination to make it appear as if the transport was covered by a federal health care program;
• false documentation;
• billing for each patient transported in a group as if he/she were transported separately;
• upcoding from basic life support to advanced life support services; and
• payment of kickbacks

The final compliance program guidance released today has been modified from the draft guidance to more fully address the Centers for Medicare and Medicaid Services’s new ambulance fee schedule and those comments received from the ambulance industry.

This is the 10th compliance program guidance document released by the OIG. Other compliance guidance documents cover sectors ranging from clinical laboratories, hospitals, home health agencies, third-party medical billing companies, durable medical equipment suppliers, hospices, Medicare+Choice Organizations, nursing facilities, and individual and small group physician practices. In addition, the final compliance guidance for the pharmaceutical industry is expected to be released by early summer.