Acadian Ambulance Services audit
The OIG conducted an audit of ground emergency ambulance services at Acadian Ambulance Service of Texas, LLC. Emergency ambulance services are allowable when the client has an emergency medical condition. For this audit, auditors examined payments from three selected managed care organizations (MCOs). The audit objective was to determine whether Acadian billed Superior HealthPlan, Texas Children’s Health Plan and UnitedHealthcare for claims for ground emergency ambulance services in accordance with applicable statutes, rules and procedures in the managed care environment for the period from September 1, 2018 through May 31, 2020.
Acadian met most of the requirements tested. For all 180 ground emergency transport claims tested for all three MCOs, Acadian recorded accurate client and receiving facility data, accurately calculated mileage from pick-up to destination, and transported patients to an appropriate facility such as a hospital. However, Acadian did not always report transports correctly or maintain all needed support for claims. Specifically:
- Four of 180 (2.2 percent) claims tested were not medically necessary according to documentation in Acadian's billing system. The claims were billed although Acadian determined that they were not medically necessary.
- Acadian billed 8 of 176 applicable claims (4.5 percent) tested for a higher level of service than should have been charged based on services documented in medical records. Incorrectly classifying claims at a higher level of service can lead to overpayment for services.
- Acadian did not provide sufficient support for one out of 134 (0.7 percent) transports tested for patients that did not have a corresponding receiving facility claim, which makes the claim not supported for payment under Medicaid rules.
By extrapolating the results of each of the three samples to the appropriate population of claims within the scope of the audit, the OIG determined that the exceptions represented an overpayment for the populations of $43,037. In addition to overpayments identified in statistical samples, auditors identified one overpayment of $888 in a non-statistical sample. Acadian should (a) code non-medically necessary encounters appropriately, (b) ensure it maintains sufficient support for all claims and (c) repay $43,925.
Read the full audit on the OIG website.