Maine Medical Center in Portland and the state’s largest ambulance provider have agreed to pay $1.4 million to the federal government to settle allegations that the ambulance provider submitted reimbursement claims for ambulance rides that were not medically necessary, a violation of the federal False Claims Act.
North East Mobile Health Services of Scarborough will pay $825,000 to resolve allegations that between 2007 and 2015, it improperly billed Medicare for transporting an unspecified number of patients who it claimed were “bed-confined” or who were otherwise medically required to be transported by ambulance, the office of U.S. Attorney Halsey B. Frank said Friday.
Maine Medical Center, which has contracted with North East since 2007 as its favored provider for medical transport services, agreed to pay $600,000 to resolve allegations that hospital personnel provided North East with paperwork containing incomplete or inaccurate information about the medical necessity of an ambulance ride, Frank’s office said.
That paperwork was then used by North East to bill Medicare, according to federal prosecutors.
Both groups cooperated with the investigation, and because of the settlement, neither admits wrongdoing, according to court records. Prosecutors did not specify in their complaint the number of ambulance rides that may have been affected. North East is also accused of keeping money that Medicare had overpaid to the company – an allegation it also denies. North East’s alleged improper conduct spanned from October 2007 to December 2017, according to a settlement agreement with Frank’s office. Maine Medical Center’s alleged improper conduct occurred between October 2007 and March 2015, the agreement said.
LESS COSTLY THAN A LAWSUIT
A call to Butch Russell, the CEO at North East, was not returned Friday, but the company released a statement through a public relations firm reasserting that North East did nothing wrong. The ambulance company also contended that all transports it provided were requested by medical professionals who were “acting in the best medical interest of the patient.”
Both groups said repaying the claims is less costly than defending a lawsuit.
“At the request of medical personnel, North East Mobile Health Services transported Maine Medical Center patients via ambulance to hospitals, skilled nursing facilities and other locations,” the North East statement said. “In all instances, all providers were acting in the best medical interest of the patient and the required documentation from medical personnel certified the ambulance transports were medically necessary. As such, reimbursement claims were submitted to Medicare and processed. However, the medical necessity of some of these ambulance transports was subsequently contested.”
Maine Medical Center, in a statement, also reiterated that it admitted no fault or liability, and called the settlement “an unfortunate result of a legal process that at times penalizes hospitals for prioritizing patient care,” and said the settlement heads off protracted and costly litigation.
The hospital said an “independent reviewer” found that Maine Medical Center saw no financial gain or incentive from the result of the disputed Medicare charges, but the statement did not identify the reviewer.
“Each case examined was based on medical necessity determined by a qualified medical provider,” the hospital said. “At all times, MMC acted with the best interests of patients in mind, making sure they had safe and reliable transportation following their treatment. We will continue to prioritize safe patient care and ensure that patients who have medical necessity receive access to ambulance services in a way that fully complies with legal and regulatory standards.”
The allegations by the government include details about the ambulance company’s relationship with the hospital. Since 2007, North East has held a “preferred provider” contract with Maine Medical Center to transport routine and critical care patients 24 hours a day, seven days a week. North East would often transport patients being discharged from the hospital to a skilled nursing facility or other rehabilitation center.
STAFFERS SIGNED OFF
For Medicare to pay a portion of the ambulance cost, the patient must be bed-confined or otherwise medically required to be transported by ambulance. Medicare will not cover the cost of an ambulance if a patient is able to walk around or sit in a wheelchair, meaning he or she could be transported by car or wheelchair van – modes of transport that Medicare does not pay for.
For North East to be reimbursed, the company is required to submit paperwork to Medicare showing that the ride was medically necessary. That documentation included a template certification form that North East provided and that hospital staff filled out.
Although North East’s own records showed that numerous patients could sit upright, move around and were not confined to a hospital bed or otherwise required to be transported by ambulance, the paperwork that Maine Medical staffers signed off on showed the ambulance ride as medically necessary, prosecutors alleged.
“These certifications are contradicted not only by the contemporaneous narratives of (North East Mobile Health Services) personnel, but also by (Maine Medical Center’s) medical records,” prosecutors alleged in a complaint.
According to Maine Medical Center’s settlement agreement, the hospital began conducting an internal audit in March 2015 of every nonemergency ambulance transport to ensure the information it submitted was accurate and complete.
As part of the agreement, Maine Medical Center agreed to continue conducting the self-audit for 18 months after the agreement was signed, until August 2019, and that it would notify North East of any suspected error in the paperwork within a reasonable time frame.
Although there is no specific number of allegedly improper ambulance rides, prosecutors allege that the vast majority of 949 patients who underwent total knee replacement surgery between 2010 and 2012 did not meet the requirements for ambulance rides, and could have been taken by car or wheelchair van.
LISTED AS ‘BED-CONFINED’
In one case from July 2010, a woman who had a knee replaced at Maine Medical Center was able to walk the roughly 10 feet from her hospital chair to a stretcher.
A Maine Medical Center nurse said the patient was fine to walk, but she was nonetheless transferred by stretcher to an ambulance that took her to St. Joseph’s Manor in Portland, according to prosecutors. The certification offered by Maine Medical Center for her transport showed she was “bed-confined,” according to prosecutors, and North East was paid $201.56 by Medicare on a $424 claim.
A week later, North East was dispatched to pick up the same woman to transport her to Maine Medical Center to have her other knee replaced. When EMTs arrived, the woman was sitting on the edge of her bed and denied having any pain or discomfort. She was able to walk with a walker to the ambulance stretcher and then to her hospital bed, prosecutors alleged.
The woman was listed again as “bed-confined” when North East billed Medicare for the $389 trip, of which it was paid $185.06.
But North East had indicated in the forms that the service was “medically indicated and necessary for the health of the patient,” prosecutors wrote.
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