By Michael Hill
It’s a multi-billion dollar business — transporting dialysis patients to treatment. A government audit found a big chunk of that bill is fraud — of patients being transported who lack the medical necessity for going on a stretcher in an ambulance three times a week.
“There was some fraud going on there that they probably should not have been committing,” said John Bush.
Bush owns On Time Ambulance in Roselle. He’s seen a lot of his competitors, 10 of them, disappear from the market since December.
One former worker at a company that went out of business at the end of March says she knew it was coming. She worked in the billing department and she said she knew the company was not following the rules.
“They waited til Dec. 15 to start getting all the pre-approvals and all that stuff going. Did take a lot of time. As we were preceding through that process we realized that many of the dialysis patients they were transporting were not supposed to be going by stretcher,” said Stephanie Dojer.
In December, the Centers for Medicare and Medicaid Services changed the rules, requiring ambulance companies “pre-approve” a patient’s medical necessity for transport.
“It’s almost like a prescription,” Bush said.
The government says “prior authorization” does not create new clinical documentation requirements. Instead, it requires the same information necessary to support Medicare payment, just earlier in the process.
“It was very, very easy to get approval. The only thing you had to worry about was an audit down the road which many companies didn’t worry too much about. I personally did. Fast forward to where we are now, they’ve swung the pendulum much further where it’s very difficult to get medical necessity, almost too difficult. You need to have substantial doctors’ notes, they need to be legible,” Bush explained.
Bush says despite the extra steps, it’s better now because previously too many competitors did not follow the rules of pre-approving.
“Many times when we said no to a patient because we felt the medical necessity wasn’t there, another company would pick up that patient,” he said.
Now, some patients must wait longer than usual for transport to treatment. Or families pay out of pocket and hope for reimbursement.
Bush says his company always had a policy of checks and balances.
“We encouraged our EMTs, after they had been transporting to let us know if they felt like maybe something wasn’t right,” said Susan Delsandro.
The government audit found a lot of “something wasn’t right” in New Jersey, South Carolina and Pennsylvania — such as companies coming on the scene with little experience but collecting millions of dollars per patient in the lucrative business of dialysis transport. But in the quest to rid the industry of fraud and waste, the government has charged some companies and collected millions of dollars in settlements.