There are some forms of fraud and abuse that are committed only by ambulance companies. Name and explain three of them. 2. Fa
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
Introduction
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.
7
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
Upcoding
Faulty or incomplete documentation
Restocking
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
Patients
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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