Current EMS news is littered with stories of fraud and abuse cases involving ambulance companies and insurance carriers. Some ambulance companies have actually been guilty of shady business practices and others may have been guilty by ignorance of the law. Either way, verifying medical necessity plays a large role in these negative allegations. The Centers for Medicare and Medicaid Services (CMS) has indicated that $350 million a year is paid to ambulance companies due to fraud or abuse.
Medicare and Medicaid payers will only reimburse for the ambulance transport if the services is "Medically Necessary." In which it would have been unsafe or would have caused harm to the patient if they would have been transported by any other means of transportation. So, if the patient is able to ambulate, sit up in bed or sit in a wheelchair these types of patients are normally found to be not "Medically Necessary."
Ambulance companies must not develop key terms for their providers to use such as "bed-ridden" or "stretcher-bound" to attempt to justify medical necessity. The patient assessment must be detailed and completely describe the patient's medical condition to meet the requirements of "Medical Necessity" at the time of transport. Include the medical care that was required at the time of transport to make to assure the patient arrived at the receiving facility safely.
Other vague terms that should be avoided in the patient care report include, "Weakness", "ESRD", "Dialysis Transport", "Unknown" and even "other". The documentation of the detailed assessment within the patient care report should describe the body systems affected by the weakness and its limitations. The detailed assessment of the patient should describe what is occurring at the time of transport and why the patient needs the ambulance to transport them to the dialysis center for their treatment.
Unfortunately, some ambulance companies have had their employees remove any terms that might indicate the patient could have been transported by another means of transportation. Each patient care report must be factual and specific in regards to the patient's condition at the time of transport.
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