Massachusetts Attorney General Andrea Joy Campbell announced on August 4 a $6 million settlement with two Weymouth-based ambulance companies and their current owners. The settlement resolves allegations that the companies and owners submitted false claims to MassHealth for more expensive services than were provided, violated MassHealth medical necessity requirements, and failed to disclose relevant information during their applications to serve as MassHealth providers.
As part of the settlement, the companies and their owners will pay $6 million to the Commonwealth and implement a three-year independent compliance monitoring program at their own expense. The program will include updated policies and procedures, training requirements, and annual site and records audits, with results reported to the Attorney General’s Office (AGO).
The companies, which provide ambulance and wheelchair transportation services to MassHealth patients across Greater Boston and the South Shore, are collectively the largest medical transportation provider in Massachusetts.
According to the AGO’s investigation, the companies fraudulently “upcoded” claims to MassHealth by billing for higher levels of service than were actually provided or required — including billing for emergency transport when only non-emergency service was needed. The companies also allegedly billed MassHealth for medically unnecessary or nonemergency transportation services without maintaining the required documentation to justify those claims.
In addition, the AGO alleges the companies obtained medical authorization signatures from providers without presenting completed and relevant medical necessity documentation, as required by MassHealth regulations. The investigation also found that the companies failed to disclose relevant information about their owners, managers, and employees when submitting provider applications to MassHealth.
The Attorney General’s Office asserted that this conduct violated several state laws, including the Massachusetts False Claims Act.
Compliance Perspective
Issue
Facilities that coordinate non-emergency medical transportation for their residents or participants must ensure that transportation providers comply with Medicaid requirements, including medical necessity standards, appropriate billing practices, and documentation protocols. Even when services are outsourced, facilities share responsibility for ensuring that claims submitted on their behalf are accurate and properly supported. Inadequate oversight can result in significant legal and financial consequences, including potential liability for fraudulent billing.
Discussion Points
- Ensure your facility has clear, written policies for selecting and managing transportation vendors. These policies should cover verifying provider eligibility, documenting medical necessity, and meeting Medicaid billing requirements. Regularly reviewing and updating these policies—sometimes with input from an external consultant—can help keep your facility aligned with current regulations and best practices.
- Provide training for staff responsible for arranging or overseeing transportation services. Staff should understand the criteria for medical necessity, know how to verify the appropriate level of service, and ensure that all required documentation is complete before services are rendered or billed. Med-Net Academy offers the course, Fraud Series Module 10 – Vendor Contracts and Services, which covers vendor contracting policies, key elements of Medicare Part B consolidated billing, and federal contracting standards.
- Conduct routine audits of transportation records, billing submissions, and related documentation to check for accuracy and compliance. Working with a consultant can provide additional support in designing audits that catch potential issues early and help implement effective follow-up actions.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*