Trouble Plenty

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I came across this via an EMS newsfeed. These things are never good for EMS in general and even worse for the particular service involved.

AG Healey Sues Somerville Ambulance Company for Overbilling MassHealth More Than $600,000

BOSTONA Somerville-based ambulance services provider has been sued for allegedly overbilling the state’s Medicaid program (MassHealth) for more than $600,000 in ambulance services that reflected a higher level of care than was actually provided, Attorney General Maura Healey announced today. 

The complaint against Cataldo Ambulance Service, Inc. (Cataldo), filed on Thursday in Suffolk Superior Court, alleges that from 2005 to November 2015, Cataldo billed MassHealth for Emergency Advanced Life Support (ALS) services when, in fact, the patient’s condition at the scene only required, and the patient only received, Emergency Basic Life Support (BLS) services. Cataldo provides a variety of transportation services, including emergency ambulance services, throughout the Greater Boston area. 

“Upcoding” as the practice is known, seems to be an issue for ambulance services in both the private and public sectors.

MassHealth reimburses ambulance providers at a greater rate for ALS codes than BLS codes. The AG’s Office alleges that over 40 percent of Cataldo’s submissions at the Emergency ALS Level 1 rate were false and should have been billed at the lower and less costly BLS level.

If that allegation is proved, it represents a significant pattern of upcoding. At least one would think so.

Cataldo also allegedly ignored concerns raised by its own employees, as well as other insurance payors, that claims for ALS services were submitted when documentation by Cataldo’s responding personnel clearly indicated the patient only needed and received BLS care.

Yeah, that’s going to be a problem.

Finally,

This matter was initiated after a referral from the Insurance Fraud Bureau and Federal Bureau of Investigation.

Since Medicaid is administered by the states (MassHealth in this case) it makes sense that the case was referred by the FBI. What the press release doesn’t say is if the FBI is investigating Medicare fraud. Which will be ambulance load of trouble for Cataldo.

Other services should carefully check their billing practices to make sure that they don’t get an unwelcome visit from government agents who want to have a little chat about billing.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.