Review of Ambulance Claims Submitted by Eastern Shore Ambulance Service Incorporated

EXECUTIVE SUMMARY:

The objective of the review was to determine the allowability and reasonableness of ambulance claims submitted for Medicare reimbursement by Eastern Shore Ambulance Service Incorporated (ESAI). Our review showed that Medicare reimbursed ESAI at least $110,417 for unallowable ambulance services. Based on the results of a statistical sample, we found that at least $108,439 of the non-emergency Basic Life Support (BLS) and Advanced Life Support (ALS) transports and related paid claims were unallowable. Of the 100 sample items reviewed: a) 38 sampled items were not medically necessary, and b) 22 sampled items were billed as ALS services, a level of service that ESAI was not equipped to provide. We also determined that all 15 emergency ALS and 5 emergency BLS paid claims totaling $1,978 were not allowable. We recommended that the Carrier: (1) recover overpayments totaling $110,417; (2) provide increased training to ESAI regarding billing for ambulance services; and (3) consider placing ESAI on prepayment monitoring to ensure claims billed to Medicare are properly documented.