Prior authorization to fight ambulance fraud

Photo of ambulance driving with flashing lights on

After years of chasing down expensive ambulance fraud schemes, authorities in Pennsylvania have found an effective solution in prior authorization rules, according to Philly.com.

In December 2014, the Centers for Medicare & Medicaid Services finalized preauthorization requirements for non-emergency ambulance transportation in Pennsylvania, New Jersey, and South Carolina in response to the growing threat of ambulance fraud. In the months that followed, federal prosecutors began focusing on non-emergency transportation in which hospitals and ambulance providers shared liability.

The preauthorization program appears to have worked in southeastern Pennsylvania, where annual spending on ambulance services has dropped from $55.4 million in 2010 to $12.7 million in 2015, according to Philly.com. In the three states where preauthorization rules were implemented, costs for scheduled ambulance trips dropped from $18.9 million in 2014 to $5.4 million last year.

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"We're never going to claim victory, but we think we did a good job of rooting out a lot of these fraudulent companies," Nick DiGiulio, special agent in charge of the Philadelphia regional office of the U.S. Department of Human Services' Office of Inspector General told the website.

Not everyone has been pleased with the changes, and some providers echoed longstanding concerns that patients were being unfairly denied transportation services.

For more:
- read the Philly.com article

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