Fraud vs. Government Waste

The other day, I was talking with @WmRandomWard (www.twitter.com/wmrandomward), in regards to his latest blog post (http://randomparamedicine.firstrespondersnetwork.tv/?p=123). Our discussion was about Medicare/Medicaid billing, waste, and fraud.

Further, over on www.EMTLife.com there have been a few discussions lately that allude to EMS "buffing" charts so Medicare will pay.

Take a call from the other night for example. I was held over 5 hours late to deal with transfering a ventilator patient discharge from a Pennsylvania long-term acute care facility to a long term vent unit in New Jersey.

Pennsylvania and New Jersey have very different EMS rules. With Pennsylvania, I can manage a list of IV drugs on pumps, Monitor Cardiac rhythms, and manage advanced airways and ventilator settings. All by protocol and/or written orders. I need a nurse to manage drugs not on my list, TPN, continuous tube feedings, and transport blood.

In New Jersey, there is no provision for a private service to operate ALS interfacility, so all interfacility transports are SCT nurse runs, with a crew that contains at least 2 people who are EMT's as well as an RN (the nurse can also count as an EMT).

So this guy is going from PA into NJ, so I would be covered under PA protocols and rules for the whole transport. It's a simple ALS call - Vent only, not even on telemetry at the sending facility.

Yet I'm told that this run can't just go ALS, and must go with a RN. So now a nurse is coming to meet me and I'm going to jump in with her and do the run, with an EMT to drive us. Why am I there? Because this nurse isn't qualified as a PA ALS provider. So I have to be there, because this call is technically NOT needing a nurse.

So, why is this a nurse call? Punchline: Because NJ Medicaid is the payor, and they don't seem able to pay for ALS interfacility transports. Because they aren't done in NJ. So instead of running the call with myself and an EMT, there are now 2 advanced providers and an EMT, and a significant increase in cost. And guess who's eating the cost?

http://www.courierpostonline.com/article/20110609/NEWS01/106090338/Coalition-criticizes-Medicaid-cuts-N-J-

Yup. NJ Medicaid. The program that is facing huge budget cuts to help NJ's deficit.

We talk about EMS providers and services that commit fraud by billing for services that aren't indicated, but what of the government mandating services that aren't needed?

Jon