STAMFORD, CT – Nelson Ambulance, which provides non-emergency patient transport services for hospitals and medical facilities throughout Fairfield County, is the subject of an investigation by state health officials, Hearst Connecticut Newspapers has learned.
A former supervisor of the company said he has told the FBI that Nelson Ambulance is falsifying bills submitted to Medicaid and Medicare for payments. The ex-employee said the FBI also is investigating the company, which provides services to patients at a number of hospitals in the region, including in Danbury, Bridgeport, Stamford and Greenwich.
In an undated memo from a manager to ambulance crews, obtained by Hearst, a Nelson supervisor told employees that “we are not able to bill some of our medicare and Medicaid patients due to poor documentation.”
“Medicare WILL NOT pay for ambulatory patients or DOCTORS appointments,” wrote Denise Markavich, Nelson’s director of operations. “As this effect a good portion of our ambulance patients we ask the following. Please document that ALL patients were moved by sheet lift to our stretcher, even if the patient was ambulatory writing such will make medicare denie the claim. Also for doctors appointments please document it as a Procedure, not a follow up or Doctor appointment. This will secure billing rights for these calls.”
A Nelson official Friday said the company does not believe the memo is authentic. Phil Onofrio, a Nelson vice president who became operations director a few weeks ago, said company officials had never seen the memo and that there have been previous issues with a former aggrieved employee who was forging documents. Onofrio did not name the former employee.
“We need to do our own internal investigation on this (to authenticate the document),” he said.
Onofrio added that the billing practices outlined in the memo, “are not in line with the company’s billing practices, both past and present.”
Bill Garrish, a spokesman for the state Department of Public Health, confirmed last week that the department is investigating Nelson Ambulance, whose main office is in North Haven.
He declined, however, to specify the nature of the probe.
Onofrio said Friday that Nelson has been contacted by state health officials about an inquiry and “we complied with all the information they requested.”
“They did not advise us of the nature of the inquiry, but we have no reason to believe at this time that it’s a patient-care issue,” he said.
The non-emergency medical transport business in southwestern Connecticut is a fiercely competitive, multimillion-dollar industry. Reimbursements by Medicare and Medicaid — for taking patients to a nursing home or for a dialysis appointment, for instance — are a substantial part of that business.
George Previs, a former supervisor with Nelson, told Hearst he reached out to the FBI last fall after he was fired from the company. Previs said he was fired for refusing to tell employees to lie on patient “run forms” so that the company could get Medicare reimbursements to which it wasn’t entitled.
“Medicare and Medicaid have very strict rules about what they’ll pay for,” Previs said.
Medicare won’t, for example, pay for patient transports if individuals are not ambulatory — capable of walking to the ambulance under their own power. In such instances, an ambulance isn’t considered a medical necessity.
Previs said company officials would routinely tell employees to lie on patient run forms indicating that patients were “non-ambulatory,” even if they could walk under their own power, so that the company would get paid by Medicare for the calls.
“If you didn’t follow suit and do what the company wanted, you’d be disciplined for it,” he said. “They use strong-arm tactics to keep their employees in line.”
Onofrio denied the allegations, stating that billing paperwork goes through a great deal of “internal scrutiny” before the company bills Medicare for services and that a doctor has to sign off on the claim.
A spokesman for the FBI said he could neither confirm nor deny the existence of an investigation Friday.
But Previs said when he was interviewed by the FBI, investigators already had a wealth of information on Nelson Ambulance and confirmed the existence of an ongoing investigation into the company’s activities.
Christopher Godialis, director of the state’s Medicaid Fraud unit, said last week that the office has a copy of the Markavich memo, but he declined to comment on whether the document is part of an investigation.
“We routinely receive allegations such as these regarding many types of providers,” he said, “and treat each one of them very seriously.”
Federal officials in recent years have cracked down on billing irregularities by ambulance companies across the nation as part of their overall investigation into Medicare and Medicaid fraud.
Professional Ambulance Services of Norwich pleaded guilty in 2004 to one charge of federal health-care fraud. According to court documents, the company was accused of submitting clams to Medicare when the services were not medically necessary, including claims that patients who were ambulatory required the use of a stretcher.
The company was fined more than $1.5 million by state and federal authorities.
Donald White, a spokesman for the U.S. Health and Human Services’ Office of Inspector General, said fraud in government health care programs costs taxpayers more than $75 billion a year.
“Obviously we take these kind of cases very seriously,” White said.