NJ-EMS

Medicare fraud crackdown in New Jersey ensnaring more patients and ambulance companies

The federal government's four-month crackdown on ambulance companies that fraudulently bill Medicare to take patients to non-emergency dialysis, chemotherapy and wound care is continuing to have a dual impact:  reducing the number of ambulance carriers and confounding patients and their families.
The New Jersey Department of Health this week reported that 11 ambulance providers have given up their licenses since the beginning of the year, although surviving operators say the actual number of shuttered businesses may be twice that or more.
"What I keep hearing is it's 20 to 25 that are closed," said John Bush, owner of On Time Ambulance in Roselle. "I think there's a few more that are on their heels right now."
Still, even 11 closures are well above levels from recent years, when health department officials said at the most three closures a year would be the norm.
Ambulance companies and patients complain that the sweep of the program entangles legitimate operators and patients who truly need their services, as well as those gaming the system.
The decision to shut down can happen abruptly to patients and caregivers.
Holy Name Medical Center in Teaneck heard one day in late March that Aaron Ambulance in Hackensack would not make its scheduled runs the following day. That following day, it called to say it was closing for good, spokeswoman Katherine Emmanouilidis said.
She said the hospital worked with another company out of Hackensack to cover Aaron's former patients.
Phone numbers for Aaron have been disconnected.
Health department spokeswoman Dawn Thomas said the 11 companies that have closed since Jan. 1 reported that Medicare's pre-authorization requirements, instituted in New Jersey in mid-December, are the primary reason for the closures.
Medicare began the crackdown after a government audit of New Jersey revealed that from 2002 to 2011 the growth in ambulance transports was nearly twice the national average and the number of trips per patient was up about 60 percent.
Overall, Medicare during that period saw billing for non-emergency transportation increase 130 percent to $4.5 billion a year nationally.
Medicare pays for non-emergency transportation only when a patient must be carried on a stretcher. If the patient can be moved in a wheelchair or can walk, Medicare does not pay.
The pre-authorization program has clamped down, according to patients and ambulance companies. Throughout 2015, patients and ambulance companies have said that people whose doctors determined that they qualified for stretcher service found the Medicare program administrator for New Jersey, Novitas Solutions, routinely denying authorization.
Applications continue to be denied for any number of reasons, including illegible doctor's notes, ambulance companies say.
"We have found that one of the hardest things is the notes that are required now to substantiate medical necessity are poorly written or you can't read them," Bush said. "Legibility is a huge one."
Without authorization, patients and ambulance companies are left with a choice: Find another way to get to life-sustaining treatment, use the same provider and hope to gain authorization on appeal or pay out of pocket.
Watchung resident Eunice Aridi said Medicare has declared that her father qualifies for Medicare-covered transport to get to his thrice-weekly dialysis, but still has been denied because his documentation lacks details.
"It has gone unbelievably terrible," she said. "I have all kinds of doctor certification statements, therapist notes, hospital records describing the reason my father needs a stretcher transport and Medicare has not given the approval."
She said she's paying $300 a week to transport him while she waits on appeals. Without dialysis, Aridi said, "he will surely die within weeks."
Bush said that he has hired a nurse full-time to educate patients and doctors about the requirements for authorization.
The goal of pre-authorization is not to put companies out of business, said William Polglase of the office of communications at the U.S. Centers for Medicare and Medicaid Services. It's to tighten oversight, he said.
He also said CMS has no plans at this point to expand the program past New Jersey and the other two states that had excessive billing, Pennsylvania and South Carolina.
Another ambulance operator, who did not want NJ Advance Media to use his name because he fears retribution, said most of his Medicare authorization requests have been denied and eventually end up before an administrative law judge, who he said approves them.
"I have a ton of claims that have to go through this process," he said. "We're basically hanging on by a thread."