(Bloomberg) – The patient smoked cigarettes in the passenger seat of the ambulance every week, chatting with the driver while taxpayers foot the $1,000 bill to drive him four blocks for his dialysis treatment.
The routine was part of a $1.5 million scheme to defraud Medicare by Penn Choice Ambulance Inc., according to an indictment against the Philadelphia company. The case helps explain part of why Medicare paid $5 billion to ambulance companies in 2012, more than went to cancer doctors or orthopedic surgeons, according to newly released federal data.
The U.S. Department of Health and Human Services has identified ambulance service as one of the biggest areas of overuse and abuse in Medicare — companies billing millions for trips by patients who can walk, sit, stand or even drive their own cars.
"It's a cash cow," said Assistant U.S. Attorney Beth Leahy, who prosecuted Penn Choice and five other ambulance fraud cases. "It's basically like a taxi service except an extremely expensive one that the taxpayers are financing."
Penn Choice received $833,000 from Medicare in 2012, the year before it was indicted, according to the new data for the U.S. government health program for the elderly and disabled. The company went out of business after the indictment. Founder Anna Mudrova pleaded guilty to fraud charges and is facing more than five years in prison, said Thomas Kenny, her lawyer.
Federal regulators and investigators have ramped up efforts in the past year to fight ambulance fraud and overuse, with rides to dialysis centers one of the problem areas. HHS estimates Medicare overpaid ambulance providers by $314 million last year, a third of it for medically unnecessary claims to the U.S. government health program for the elderly and disabled.
Outsourcing
Once dominated by local fire departments, volunteers, or hospitals, ambulances are increasingly being operated by private companies as local governments outsource the service to cut costs, said Sarah Turk, an analyst with research firm IBISWord Inc.
About a third of ambulances billing Medicare are for-profit suppliers, according to the Medicare Payment Advisory Commission, or Medpac, which counsels Congress.
Cases of fraud seem to be isolated within certain regions, said Leahy. She said most of the companies she has prosecuted were started by Russian or Eastern European immigrants in the Philadelphia area with the intent of being an illegal operation.
The American Ambulance Association "condemns Medicare fraud in any form" and supports preventive measures such as preauthorization for dialysis trips, a review for new providers of dialysis transports, and unannounced site reviews, the trade group said in a statement.
There have been relatively few barriers for those starting an ambulance company, making the industry susceptible to illegal activity, Kenny said. In the case of Penn Choice, Mudrova, a Russian immigrant with no medical training or advanced degree, was doing administrative work at a doctor's office when she got a loan from her family to start the ambulance company, according to Kenny.
"The threshold to get into the system is basically that you have to have a driver's license and take a safety course," Kenny said. "Medicare is letting these ambulances sign up and the threshold is very easy — you or I could do it tomorrow and we don't know a thing about ambulances."
HHS is conducting additional screenings of ambulance operators to step up enforcement, including license and database checks, and announced and surprise site visits, said Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services.
Dialysis trips
A large amount of fraudulent ambulance spending is coming from rides to and from dialysis treatment, according to a Medpac report last year. Dialysis patients must get treatment three days a week for years while they await a kidney transplant, making them a predictable, stable source of revenue for fraudsters, Leahy said.
