“Upcoding” is the term used in EMS for instances where an individual provider or his employer falsely documents the patient condition in order to increase the amount of money paid for ambulance transport.
A couple of examples of this are obtaining a 12 Lead EKG when one is not necessary. Another is using an ambulance to transport a patient that could be transported in a Chair Car.
Sometimes an IV will be placed where again none is required. Sometimes that is a paramedic who is really not clear on the concept of when a patient needs an IV. Other times they are following company policy, usually unwritten, but enforced none the less. This is known as “a line and a ride.”
This goes on every day in ambulance services across the United States. Typically this is done by private for profit ambulance services, however sometimes municipal services will do it as well.
A lot of people I know were incensed about the amount of fraud and abuse within United States Agency for International Development (USAID), but I’ve long maintained that Medicare and Medicaid fraud are far more prevalent and expensive than USAID.
Both Medicare and Medicaid are funded by the United States government. Medicaid is administered by the individual states, while Medicare is administered and paid for by the federal government.
The states name their versions of Medicaid as they wish. In California it’s “Medical,” in Massachusetts it’s “MassHealth.” Texas just calls it “Medicaid.” And so on.
The states primarily enforce fraud in Medicaid while the federal government enforces fraud for Medicare. Of course the federal government can investigate Medicaid fraud if a state isn’t vigilant enough.
There are both civil and criminal prosecutions for this type of fraud, but civil seems to be more common. At least at the state level.
This is a rather long prologue for this article,
BOSTON — Attorney General Andrea Joy Campbell today announced that her office has reached a $6 million settlement with two Weymouth-based ambulance companies, Brewster Ambulance Service, Inc. (Brewster) and EasCare, LLC (EasCare), and their current owners, Mark Brewster and George Brewster, Jr. The settlement resolves allegations that the companies and owners submitted false claims to MassHealth for more expensive services than were provided, violated MassHealth medical necessity requirements, and failed to disclose relevant information when submitting the companies’ applications to serve as MassHealth providers.
Note that EasCare is a subsidiary of Brewster ambulance.
“When companies violate our laws and defraud the MassHealth program, crucial taxpayer resources are misdirected from paying for health care for those who need it most,” said AG Campbell.
This is true. It means that people are in effect stealing taxpayer money and committing fraud.
Per its investigation, the AGO alleged that Brewster and EasCare fraudulently “upcoded” their claims to MassHealth by billing for more expensive levels of services than they actually provided or required, including billing for emergency services when only non-emergency services were provided or required.
Meets the exact definition of “upcoding”.
Additionally, the AGO alleged that the companies fraudulently billed MassHealth for medically unnecessary services and/or for nonemergency services without maintaining relevant medical necessity documentation, as required by MassHealth.
There is a required form, informally known as a “MedNec” that the crews must get signed by a medical provider.
A little bit more about this settlement.
Mass. ambulance companies to pay $6M to the state for overcharging MassHealth, AG says
Brewster Ambulance CEO Mark Brewster said in a statement to MassLive that the company was “pleased” to have settled the lawsuit.
“To be clear, the trips at issue were completed and this settlement reflects concerns about paperwork,” the statement reads. “We stand ready to work with state leaders and regulators to help clarify and strengthen documentation requirements so that this type of litigation doesn’t continue to impact our industry and our health care system.”
Yes, I’ll bet he’s pleased that they got away this cheap and no criminal charges were filed. He should just remember that the government doesn’t consider this to be “about paperwork,” they consider it fraud.
From the Attorney General’s press release,
The AGO asserted that this conduct constituted violations of various state laws, including the Massachusetts False Claims Act. These allegations were first uncovered through a whistleblower lawsuit filed in the District of Massachusetts.
A long time ago I was at dinner while attending an EMS conference. One of the other people was a FBI Agent who specialized in health care fraud investigations, including EMS services. The issue of Medicare and Medicaid fraud came up and he told me that “Disgruntled ex employees are an excellent source of information.”
In this case it’s likely that the whistleblower filed a Qi Tam law suit under which if successful the whistleblower gets some percentage of the judgement. The suit was filed in federal court in Boston, which may mean that the US Attorney for Eastern Massachusetts might want to have a chat with the management of Brewster and Eascare.
Such are the wages of upcoding.