Medicare beneficiaries sometimes receive an unpleasant surprise in the mail soon after receiving doctor-ordered or emergency ambulance services: a bill from the ambulance company for the full amount of the services received.  This Alert is the first in a series about Medicare's coverage of ambulance services.  Here, we discuss common problems involving Medicare's "origin and destination" and "medical necessity" requirements.  In two further installments, we will address non-medical transports, Notice of Noncoverage problems, and Paramedic Intercept issues.

Origin and Destination Requirements

Medicare covers ambulance transfers from any point of origin to the nearest hospital or skilled nursing facility:

"that is capable of furnishing the required level and type of care for the beneficiary's illness or injury.  [The hospital or skilled nursing facility] must have available the type of physician or physician specialist needed to treat the beneficiary's condition." [1] 

In other words, Medicare will only cover trips from any point of origin to the "nearest appropriate facility."[2]  It will not pay for a transfer to a medical facility based simply on beneficiary preference.  This standard applies to air ambulance transfers as well. 

Medicare will also cover trips from a hospital to a beneficiary's home or nursing facility, or from a nursing facility to the nearest supplier of medically necessary services not available at the skilled nursing facility (including the return trip), plus trips for dialysis for ESRD patients, provided, always, that the medical necessity requirements are also met.[3]

Problems associated with the origin and destination requirements most often arise when a Medicare beneficiary experiences a medical crisis outside of his or her hometown or state, and wishes to be transported to a local hospital or nursing facility for immediate care or rehabilitation.  For example, a beneficiary may experience a heart attack outside of her home state, and be admitted to a hospital in that state.  If the beneficiary then needs bypass surgery, for instance, and wishes to have the surgery close to home, Medicare will not pay for the ambulance transport, via ground or air, to a hospital in her home state, unless a particular physician or hospital is the closest one able to address her medical needs.  Likewise, if a beneficiary is dissatisfied with aspects of service at a skilled nursing facility and wishes to change facilities, Medicare will generally not pay for her transfer. 

Medical Necessity Requirements

Medicare pays for ambulance transport when a beneficiary's medical condition is such that other means of transportation are contraindicated.[4]  According to its policy, the Centers for Medicare & Medicaid Services ("CMS") will presume that this requirement is met if the beneficiary was transported in an emergency situation or was unconscious, exhibited signs and symptoms of respiratory or cardiac distress, stroke or severe bleeding, or needed to be constrained or remain immobile because of a fracture or possibility of fracture.[5]

For non-emergency situations, federal regulations state:

"transportation by ambulance is appropriate if either: the beneficiary is bed-confined and it is documented that the beneficiary's condition is such that other methods of transportation are contraindicated; or, if his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.  Thus, bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation.  It is one factor that is considered in medical necessity determinations." 42 C.F.R. §410.40(d) (emphasis added).

Despite the clear language of this regulation, many ambulance companies and Medicare contractors interpret it to require that the beneficiary be wholly bed-confined.  Even the CMS policy manual emphasizes that bed-confinement "is simply one element of the beneficiary's condition that may be taken into account in the . . . determination of whether means of transport other than an ambulance were contraindicated."[6]  When ambulance companies or Medicare contractors misinterpret this regulation, beneficiaries receive improper denials. 

For example, Mrs. Green was admitted to a hospital from her home with complaints of chest pain and respiratory distress.  She spent a few days at the hospital undergoing tests.  On the day of her discharge, her doctor wrote an order for her to be taken by ambulance, based on her weak condition and risk for another cardiac episode, to a skilled nursing facility for short term rehabilitation.  When the ambulance personnel came to pick her up, Mrs. Green took a few steps, with the assistance of a nurse, to the stretcher and was secured.  Her transport to the nursing home was uneventful, and once there, she was helped off the stretcher by a nurse and took a few steps to her bed at the facility.

Later, at the ambulance company offices, billing personnel read that the technicians documented that Mrs. Green was able to walk both to and from the stretcher.  The billing agent then submitted the bill to Medicare as a noncovered claim, based on the fact that Mrs. Green was not bed bound.  Mrs. Green will thus be billed the full amount of the ambulance service, despite the fact that her doctor ordered the service and the transport was medically necessary.  This is an improper denial of Medicare coverage for the ambulance service, and should be appealed.  Again, it is the beneficiary's overall medical condition which must be the focus of the inquiry, not the beneficiary's bed bound status.

Conclusion

Ambulance services for Medicare beneficiaries are an important component of Medicare coverage.  Medicare covers transport in both emergency and non-emergency situations to facilities that are capable of treating the beneficiary's illness or injury, when a beneficiary's medical condition is such that other means of transportation are contraindicated. 

If a beneficiary receives a bill from an ambulance company, determine whether the trip met both Medicare's origin and destination requirements, and medical necessity standard.  If so, challenge the billing via the Medicare appeals process if appropriate.

Coming Soon: Non-Medical Transports and the Notice of Non-Coverage Problem.