Emergency Medical Services (EMS) providers face unique compliance challenges that require careful attention and management. Yet for many EMS organizations, it can be challenging to give compliance the immediate attention that it deserves amidst many other pressing concerns — to the point where it ultimately becomes a “set it and forget it” initiative.
Here are the top three myths and facts about EMS compliance, and why establishing a robust compliance program is more important than ever.
Myth: The chances of being audited are low
Fact: The EMS industry faces increased scrutiny
In recent years, the government has stepped up efforts to combat healthcare fraud—with good reason. The healthcare system costs taxpayers trillions of dollars a year, and it loses up to $100 billion to fraud—although investigators say it’s likely much higher¹. The Department of Justice (DOJ) has consistently invested a significant amount to investigating healthcare fraud and crimes against Medicare and Medicaid.
These are actions taken by the DOJ in 2021 alone²:
- 831 new criminal health care fraud investigations
- 462 criminal charges filed against 714 defendants
- 312 defendants convicted
- 805 new civil health care fraud investigations
As a result, the DOJ recovered over $5 billion that year—representing an ROI of $4 for every $1 spent.
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has also stepped up investigations. In 2021, HHS-OIG investigations led to:
- 504 criminal actions
- 669 civil actions
- 1,689 individuals and entities excluded from Medicare participation
Myth: As long as we’re not doing anything illegal, we’re fine
Fact: No one is immune from fraud investigations
Many EMS organizations and practitioners have a clear idea of what healthcare fraud is, but most underestimate the full picture. Examples of fraud in EMS include:
|Medically unnecessary transports
|Submitting a claim for a transport that was not life-threatening or otherwise routine
|Exaggerating medical necessity in order to charge a higher fee
|Treatment not rendered
|Billing for services or supplies not provided, such as oxygen during a transport
|Not necessarily of monetary value, and could also include “exclusive” provider arrangements or preferential treatment
However, in reality, the vast majority of investigations deal with finer nuances in the rules. Many investigations and prosecutions don’t stem from blatant intent to commit fraud at all—but are simply the result of errors, omissions, misunderstanding, and lack of knowledge of the rules and regulations governing the filing of healthcare claims³.
Filing a false claim can render you and your EMS organization liable for civil and criminal prosecution. The False Claims Act applies to any individual or business that directly or indirectly contracts with and is paid for services by the United States government. It also protects whistle-blowers who initiate action on behalf of the government.
Penalties under the False Claims Act
Civil Liability: Triple damages and a penalty of up to $27,018 per claim, with the amount set to increase every year with inflationary adjustments
Criminal Liability: Five year imprisonment and a fine of $250,000 (individuals) or
$500,000 (companies) for federal felony convictions, $100,000 (individuals) or
$200,000 (companies) for misdemeanor convictions—per claim
Although the False Claims Act uses the term “knowingly”, as in “knowingly submits, or causes to submit, false claims to the government…”, it doesn’t necessarily mean an intent to defraud. As seen in several highly publicized cases involving EMS providers, it can also encompass deliberate ignorance or disregard of a claim’s accuracy⁴.
Besides steep penalties, EMS providers found guilty of fraud can also face other financial repercussions such as exclusion from federal benefits programs.
Fraud investigations originate from false claims, and any EMS organization can be subject to a fraud investigation at any time. With penalties imposed for each claim, the consequences are dire. To protect your agency, ensure there are no claims—intentional or otherwise—that could be classified as fraudulent. A good place to start is establishing a robust EMS compliance plan.
Myth: We’ve set a compliance plan, so we’re fine
Fact: Compliance is an ongoing, organization-wide effort
To monitor and ensure that claims are clean and filed appropriately, your EMS organization needs an effective compliance program. A robust compliance program not only safeguards your agency, patients, and the communities you serve—it is also a critical aspect in ensuring high-quality patient care.
More importantly, it’s a business investment in your agency and employees, enabling you to prevent, detect, and correct issues that could otherwise lead to catastrophic consequences.
According to the OIG and DOJ, the following are eight crucial elements of an effective compliance program:
- Written policies and procedures
- Compliance program oversight
- Education and training programs
- Internal auditing, monitoring, and risk assessment
- Investigation, response, and prevention
- Open and effective lines of communication
- Well-publicized and enforced disciplinary standards
- Measurable effectiveness
When creating an effective compliance plan, it’s important to keep these eight elements in mind, and work with your legal counsel or utilize any external consultants as needed. It’s important to keep in mind that there is no “one-size-fits-all” template to build an effective compliance plan. Above all, aim for consistent progress and adaptation — compliance isn’t a day’s work, but upholding it in your everyday operations will be sure to protect you and your agency in more ways than one.
Read our eBook Navigating EMS Compliance: The Strategic Guide to Establishing an Effective Compliance Plan for insights into best practices to implement in your agency’s compliance program.
How EMS|MC Can Help
While navigating the challenges of EMS compliance can be difficult, EMS|MC is here to help. EMS|MC operates with our own compliance program and provides the essential element of auditing and monitoring your billing and your claims. This means that EMS|MC can fulfil certain elements of your compliance program, filling in the blanks for you wherever you need us to.
The EMScholar program, EMS|MC’s proprietary education portal, is designed for employees to complete their training online and provides comprehension testing after each module. We also provide your Compliance Officer with the appropriate reporting from these modules to show you your employees’ levels of completion and understanding.
PWW Advisory Group (PWW|AG), the gold standard in the industry, is also part of the EMS|MC family. Through their advisory services, we can help your agency design and document an effective compliance program, or audit your current program’s effectiveness and make recommendations for improvement. PWW|AG also offers insight into current and future regulatory changes that may impact you, with decades of expertise to help you confidently navigate and solidify your agency’s regulatory compliance.
Ready to get started? Request a consultation with us here.
- Inside the mind of criminals: How to brazenly steal $100 billion from Medicare and Medicaid. CNBC.
- The Health Care Fraud and Abuse Control Program Annual Report for the Fiscal Year 2021, published July 2022 by the Department of Health and Human Services (HHS) Office of Inspector General (OIG).
- How to Prevent EMS Fraud. Journal of Emergency Medical Services.
- Pinnacle: How the Feds Foil Fraud. EMS World.