NEW BERN — A federal prosecutor has filed a complaint against a Carteret County-based medical transport company for alleged fraudulent billing of thousands of dollars to the health care programs Medicare, Medicaid and TRICARE.
Thomas Walker, U.S. Attorney for the Eastern District of North Carolina, filed the action Feb. 19 with the U.S. District Court for the Eastern District of North Carolina against Crystal Coast Medical Transport (CCMT), a non-emergency medical transport company based at 534 N. 35th St. in Morehead City.
Mr. Walker alleges the company filed false and fraudulent claims to Medicare, the health care program for seniors; Medicaid, the health care program for low-income families; as well as TRICARE, the health program for uniformed service members, retirees and their families. The claims were for reimbursement ambulance transport.
The complaint named Kenneth Lohr of Highway 24 west of Morehead City as the relator, a person who provided a government agency with information on which a legal complaint is based, also known as a whistleblower. News-Times staff contacted Mr. Lohr, but he declined to comment on his involvement with the complaint.
Mr. Walker is seeking a trial by jury for this complaint. He’s asking for triple damages for submission of false claims and for false statements to get a claim paid.
Mr. Walker is also seeking equal amounts in damages for money paid under misrepresentation of facts and equal amounts in damages for unjust enrichment. He’s also seeking reimbursement for the cost of the legal action, plus interest, and investigative costs as provided by the law, as well as any other relief deemed just by the court.
According to the complaint, the company filed claims for reimbursement with the programs on ambulance trips that weren’t medically necessary. While the three programs reimburse companies for emergency ambulance trips, they only reimburse for non-emergency trips when the patient has no other means of getting to a hospital, such as bedridden patients who need to make regular treatment visits.
“From at least November 2010 through the present, CCMT billed Medicare, Medicaid and TRICARE for ambulance transports that were not medically necessary,” the complaint says, “including non-emergency, scheduled, repetitive ambulance services of patients to and from routine outpatient dialysis treatment.”
The complaint alleges that in some cases, CCMT altered paperwork to make it look like they were complying with regulations. Medicare requires written orders from a patient’s attending physician before it will cover non-emergency, regular ambulance services. These orders are referred to as physician certification statements or certificates of medical necessity.
The complaint alleges CCMT falsified and fabricated PCS’s in a number of cases. It says some of the patients for whom CCMT was requesting reimbursement were able to sit in a wheelchair or stand; others were able to walk, didn’t require stretcher service and had other means of getting to their treatment besides an ambulance.
The complaint includes six examples of its allegations. The patients’ names were abbreviated to initials in order to protect their privacy.
Each of the example patients had been transported by ambulance for routine outpatient dialysis treatments. They’d been taken by ambulance to their appointments multiple times, with CCMT billing Medicare, Medicaid and TRICARE each time.
The most expensive case was for a patient who’d been transported three times a week from Oct. 29, 2010, to at least Jan. 15. According to the complaint, CCMT billed Medicare $573,927.75 for the transports between Nov. 1, 2010, and Sept. 30, 2013, at an average cost of $650.71 per trip.
Medicare paid $351,066.74 for the trips. TRICARE had been billed $29,067.78 as a secondary payer for trips from Oct. 29, 2010, to July 24, 2013; it paid the full amount.
CCMT officials did not respond by presstime.
Contact Mike Shutak at 252-726-7081 ext. 206, email email@example.com; or follow on Twitter at @mikesccnt.