Healthcare fraud is a rampant problem in the United States. Each year, the False Claims Act proves integral in recovering billions of dollars from wayward hospitals, management corporations and physicians. Under the False Claims Act, individuals known as whistleblowers (or relators) can file their own lawsuit on behalf of the United States. These cases allege knowing submission of false claims to the government, resulting in abuses of taxpayer funds. Often, these cases settle because defendants want to avoid the time and expense of protracted litigation without admitting any liability.
Whistleblowers in healthcare fraud cases often recount stories of medical professionals billing for services that either did not take place at all or were not medically necessary at the time of the procedure. In today’s case, we examine a recent settlement involving a Kentucky-based ambulance company that was allegedly unnecessarily transporting patients for services when a less costly measure could have been chosen.
The case was instigated by a former owner of a competing ambulance company who noticed an excessive and unnecessary pattern of patient transport when no emergency situation appeared to exist. The relator will receive $186,000 in exchange for their willingness to come forward with the allegations.
Details of the case against Trans-Star Ambulance Services
Like many jurisdictions, Floyd County, Kentucky, relies on ambulance services from private independent contractors. One such provider, Trans-Star Ambulance Services, provides emergency transport to patients in need of immediate transfer to the nearest medical facility.
Under relevant Medicare guidelines, a service provider like Trans-Star can only lawfully request reimbursement on behalf of Medicare enrollees if the ambulance service was medically necessary at the time. In other words, the patient must have been in need of immediate medical attention and other transport options would not have adequately met the patient’s needs. More specifically, Medicare guidelines address ambulance service as follows:
[Medicare] covers ambulance services to or from a hospital, critical access hospital (CAH), or a skilled nursing facility (SNF) only when other transportation could endanger [the patient’s] health….In some cases, Medicare may also cover ambulance services [for patients with] End-Stage Renal Disease (ESRD), need dialysis, and need ambulance transportation to or from a dialysis facility.
According to the whistleblower, Trans-America was in the practice of routinely offering ambulance transport services to patients in need of dialysis. As explained above, ambulance transport to a dialysis center or hospital is covered only for those with end-stage renal disease. However, it is not covered when a less expensive transport option is viable. The misconduct occurred between 2006 through 2012 when the ambulance company provided services when other forms of transportation would not have posed any medical risk for the patient.
The U.S. Attorney’s Office said in a statement, “It is vitally important that the resources available to federally funded healthcare programs be used only to pay for medically necessary services… Our office and our agency partners are committed to protecting the integrity of these important programs on which so many of our citizens depend.”
Contact Berger Montague
If you are aware of healthcare fraud and would like to speak to a knowledgeable and confidential whistleblower attorney, please contact Berger Montague right away for more information.