Nine Florida hospitals have agreed to pay $6.2 million to settle allegations that they led ambulance companies to bill federal health programs for medically unnecessary rides, the U.S. Attorney's Office for the Middle District of Florida announced Friday.
It's a case government officials say could have implications for hospitals across the country.
Andrea Treese Berlin, senior counsel with the office of counsel to the HHS Inspector General, said the settlement should put hospitals on alert when it comes to making sure they're properly signing Certificates of Medical Necessity and Physician Certification Statements. “Hospitals need to educate their employees and contractors in regard to the documents they sign,” she said. “They need to make sure they understand the criteria to which they're certifying every time they sign one of these documents.”
The certificates, she said, outline why a service is reasonable and medically necessary and are a first step toward determining whether the government should cover an expense.
Baptist Health, which owns four of the hospitals in Jacksonville, said in a statement it did nothing wrong and disagreed with the allegations.
“The Government suggests that hospitals should be ‘gatekeepers’ for ambulance reimbursement, but there are no laws or regulations that place such a burden on hospitals,” according to the Baptist statement. “The Government’s position essentially forces hospitals to become knowledgeable about complicated federal regulations applicable to ambulance companies. It puts the focus on reimbursement, not patient care.”
Baptist also said, “The appropriate mode of transport should be determined by the attending physician, based on a professional assessment of the patient's clinical needs.”
HCA Healthcare, which owns Memorial Hospital, Specialty Hospital, Lake City Medical Center and Orange Park Medical Center, did not return requests for comment by deadline for this article, but told the Florida Times-Union it also did nothing wrong.
UF Health Jacksonville also said in a written statement that it did not admit to any wrongdoing as part of the settlement and did not receive any money for the ambulance services. “UF Health Jacksonville only makes requests for transportation services,” according to the statement.
The government had alleged that between 2009 and 2014, the hospitals provided Certificates of Medical Necessity showing the need for ambulance transportation even when ambulance services were not medically necessary.
Jason Mehta, an assistant U.S. attorney, said many of the non-emergency rides were from the hospitals to nursing homes and patients' homes, according to the Times-Union. The ambulance companies, not the hospitals, received payment from Medicare or Medicaid for the rides, but the hospitals benefitted indirectly by quickly removing patients who no longer needed treatment, freeing up space for new patients, he said.
In its statement, however, Baptist says, “It is often faster to transport a patient by family, friend or taxi, but most patients would prefer to wait and be transported by ambulance if their physician felt it was clinically necessary.”
U.S. Attorney A. Lee Bentley said medically unnecessary billing by ambulance companies is a nationwide issue that could leave hospitals liable for billions of dollars, according to The Florida Times-Union.
UF Health Jacksonville said in its statement that as part of the settlement it has “agreed to provide additional guidance and education to employees involved in requesting ambulance services.”
Patricia Hofstra, a partner with Duane Morris in Chicago who represents hospitals and physician groups, said people shouldn't blindly sign forms. Still, she said, it's important to remember that determining medical necessity isn't always a clearcut decision.
“It's really hard for hospitals and physician groups, when the patient doesn't have any way to get transported from one place to another, to determine whether there's medical necessity or not,” Hofstra said. “The government is trying to send a message about medical necessity and I think that providers should be carefully looking at whether services are medically necessary and document why they think they are but also take into account the decision about medical necessity is also a very subjective decision.”
Century Ambulance Service, which was also part of the settlement, did not provide comment for this article by deadline. But Century's CEO, John Glover, told the Times-Union: “Healthcare fraud is a serious matter and it is not tolerated by Century, period. We do business the right way.”
Century agreed to pay $1.25 million, on top of the $6.2 paid by the hospitals, as part of the settlement.
The settlement came out of a False Claims Act case filed by whistle-blower Shawn Pelletier, a former Century employee. Under the False Claims Act, whistle-blowers are entitled to a portion of any money the government is able to recover. Pelletier will receive more than $1.2 million.
