PORTLAND — Maine Medical Center and Scarborough-based North East Mobile Health Services will pay more than $1.4 million to settle federal complaints about false Medicare claims.
The fines were announced Feb. 23 by U.S. Attorney Halsey B. Frank. NEMHS will pay $825,000. Maine Medical Center will pay $600,000.
NEMHS settled allegations the company violated the federal False Claims Act by billing Medicare for ambulance services that were not medically necessary for patients discharged from the hospital. In settling, Frank said, the company also acknowledged it knowingly kept Medicare over-payments.
“Although NEMHS Mobile Health Services continues to deny that all the transports were not medically necessary, NEMHS Mobile Health Services has agreed to repay the claims, the cost of which is less than defending a lawsuit,” a NEMHS statement said Monday.
The four-count complaint against NEMHS sought triple the amount of damages sustained by the government because of the alleged false billing, in accordance with the False Claims Act.
Maine Medical Center settled allegations its staff gave inaccurate or incomplete information regarding the need for ambulance services for discharged passengers.
“Maine Medical Center’s settlement agreement with the U.S. Attorney’s Office is the unfortunate result of a legal process that at times penalizes hospitals for prioritizing safe patient care,” hospital spokesman Clay Holtzman said in a Feb. 23 press release.
In a 30-page civil complaint filed in U.S. District Court, the government said NEMHS provided MMC with an “Ambulance Certification Statement” template to allow discharged patients to leave the hospital by ambulance.
NEMHS has a “preferred provider” contract with the hospital. This gives the company “initial rights to each MMC transport,” according to the complaint.
The complaint said patients who did not meet the criteria for “bed confinement” were taken home or to assisted living centers by ambulance, as opposed to a private vehicle or by a van built to accommodate wheelchairs. Those methods are not covered by Medicare.
“At issue here, patients transported to and from Maine Medical Center via NEMHS ambulance were often found walking around their homes or hospital rooms, walked themselves to NEMHS ambulances and then sat down on the stretchers, or were able to sit comfortably in chairs or wheelchairs,” the complaint said.
NEMHS then billed Medicare for the transportation and was reimbursed at about 50 percent by the federal program providing health care to senior citizens. Medicare typically covered about 50 percent of the ambulance fee, ranging from $185 to $200 in government-cited examples.
The complaint said of 949 patients discharged from MMC following knee replacements from 2010-2012, 800 were taken to assisted-care facilities or home health care by NEMHS.
“The vast majority of these total knee replacement patients were transported approximately 10 to 20 minutes by NEMHS via ambulance, (and) did not meet the medical necessity requirements for ambulance transfer,” the complaint said, although it did not specify how many cases made up the “vast majority.”
NEMHS, said, “In all instances, all providers were acting in the best medical interest of the patient and the required documentation from medical personnel certified the ambulance transports were medically necessary. As such, reimbursement claims were submitted to Medicare and processed.”
The complaint also said NEMHS staff provided training to MMC staff in 2010 and 2011 in determining medical necessity for ambulance use and how to make sure documentation conformed to Medicare billing standards.
In 2014, MMC staff took part in a training session not attended by NEMHS staff that indicated discharged patients were getting ambulance services that were not medically necessary, according to the complaint.
When hospital staff spoke to NEMHS about the new information, the complaint alleges an unnamed NEMHS vice president said the company instruction was correct.
“Each case examined was based on medical necessity determined by a qualified medical provider. However, as the settlement agreement explicitly states, in order to ‘avoid delay, uncertainty, inconvenience, and expense of protracted litigation’ MMC has agreed to a settlement that is modest relative to the potential legal costs, and one that makes clear the hospital’s position that it did nothing wrong,” Holtzman said.