Why EMS Compliance Matters Now More Than Ever

When it comes to compliance, “setting it and forgetting it” is no longer the right approach — especially as the EMS industry faces heightened scrutiny, increasingly complex regulatory issues, and heavier penalties associated with non-compliance.

01

Investigations are on the rise

In 2021 alone, the Health Care Fraud and Abuse Control Program (HCFAC) reported the opening of more than 2,000 new health care fraud investigations by the United States Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI), with more than 4,000 investigations and health care fraud matters pending at the end of the fiscal year.

This isn’t just indicative of how likely you are to be investigated — it also shows how committed the authorities will be towards suppressing health care fraud. After all, according to the HCFAC Program Annual Report, the government recovered over $5 billion in health care fraud judgements and settlements for the fiscal year 2021 through the DOJ and other entities, representing an estimated ROI of $4 for every $1 spent.

831 | new criminal health care
fraud investigations
805 | new criminal health care
fraud investigations
1,432 | civil health care fraud
matters pending
593 | new health care
fraud investigations
2,947 | investigations
pending
559 | operational disruptions of
criminal fraud organizations
107 |

health care fraud
enterprises dismantled

02

Criminal charges and convictions are increasing

But it isn’t just the number of investigations that are increasing — the authorities are also cracking down even harder on fraudulent organizations, with the number of criminal charges and convictions growing as well.

462 | criminal
charges filed
312
out of
741
| defendants convicted
for health care
fraud-related crimes
470 | criminal health care
fraud convictions
526 | indictments
281 |

incidents of prosecutor’s information resulting in criminal charges that began court proceedings

Spotlight on Recent Cases:

Office of the Attor­ney Gen­er­al Secures 16-Year Prison Sen­tence for Ambu­lance Com­pa­ny Own­er Run­ning Med­ic­aid Fraud Scheme

August 2, 2023

The owner of ambulance company Union Healthcare Services was sentenced to 16 years of incarceration and ordered to pay $388,648 in restitution for their criminal involvement in a Medicaid fraud scheme

Massachusetts Ambulance Company to pay $2.6M over false service claims

August 1, 2023

A Leominster-based ambulance company agreed to $2.6 million in settlements after the company filed claims with MassHealth for a level of service it did not provide
Ambulance Owner Sentenced to Eight Years in Prison for $3.5 Million Fraud Scheme

May 10, 2023

A Houston ambulance owner was sentenced to eight years in prison after their fraudulent billings resulted in a loss of over $3.5 million to government health care programs and private insurers

03

Heavier penalties for false claims

These charges and convictions often come with heavy civil and criminal penalties. As of January 30, 2023, the DOJ has also announced an increase in penalties related to the False Claims Act due to inflationary adjustments, with the penalties now ranging from $13,508 to $27,018 per claim. The law also requires that the penalty amounts increase to account for inflation each year.

Spotlight on Recent Cases:

Violation After

November 2, 2015

Assessed After

June 19, 2020

December 13, 2021

May 9, 2022

January 30, 2023

Minimum Penalty

$11,665

$11,803

$12,537

$13,508

Maximum Penalty

$23,331

$23,607

$25,076

$27,018

Source: Whistleblower Law Collaborative (2023)

04

Financial and reputational repercussions

Fraudulent organizations usually end up being excluded from federal health care programs, including Medicare and Medicaid. This leads to irreparable reputational damage for your organization within the industry, and within the community it serves.

United States Department of Health and Human Services Office of Inspector General (HHS-OIG)

Regarding individuals or entities that engaged
in crimes related to Medicare and Medicaid:

504 | criminal actions
669 | civil actions

These included civil monetary penalty (CMP)
settlements and false claims.

1,689

individuals and entities excluded from
participation in Medicare, Medicaid, and other
federal health care programs

And that’s why it’s so crucial for your agency to have a strong, airtight compliance program. Considering the risk, it’s clear why compliance can no longer be treated as an afterthought in your day-to-day operations.

Wondering how to create a robust compliance plan? Download and
read our eBook, “Navigating EMS Compliance: The Strategic Guide to Establishing an Effective Compliance Plan”, for our step-by-step guide.