Fact Sheets

CMS imposes first Affordable Care Act enrollment moratorium on Houston-area ground ambulance suppliers to combat fraud and safeguard taxpayer dollars

CMS imposes first Affordable Care Act enrollment moratorium on Houston-area ground ambulance suppliers to combat fraud and safeguard taxpayer dollars

Moratorium targets high-fraud area while ensuring patient access to care 

The Centers for Medicare & Medicaid Services (CMS) today issued a notice in the Federal Register announcing the first temporary enrollment moratorium under the Affordable Care Act to fight fraud in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). The moratorium will temporarily halt the enrollment of new ground ambulance suppliers in the metropolitan area of Houston for six months.

CMS carefully examined Medicare beneficiary access to ground ambulance services in Houston and concluded that the moratorium will not affect access to care. The agency also worked closely with the state Medicaid Agency in Texas to evaluate patient access to care, and the State reported that Medicaid and CHIP beneficiaries will continue to have access to services. Throughout the moratorium, CMS will monitor access to care to ensure Medicare, Medicaid, and CHIP beneficiaries are receiving the services they need.

IMPACT OF MORATORIUM

Beginning July 30, 2013, CMS and Texas officials will deny all new or pending applications for Medicare, Medicaid and CHIP enrollment from ground ambulance suppliers with practice locations in Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery, and Waller counties in Texas. Applications that have been received from these affected suppliers prior to the moratorium announcement will be denied and returned (along with fees, if applicable). Any supplier that has already received an approval letter from the CMS contractor will not be affected.

The moratorium will be in place for six months and may be extended or lifted if circumstances warranting the moratorium continue or are resolved. CMS will publish a notice in the Federal Register if the moratorium is to be extended. During the moratorium, CMS will closely monitor ground ambulance billing for suspicious activity to root out fraud.

The moratorium does not apply to changes in practice location; changes in provider or supplier information such as phone number or addresses; or changes in ownership (except changes in ownership of ground ambulance suppliers that would require an initial enrollment under 42 CFR 424.550).

BASIS FOR MORATORIUM

Based on data analysis and agency experience, including its work with the HHS Office of  Inspector General (OIG) and Department of Justice (DOJ) in the Health Care Fraud Prevention & Enforcement (HEAT) Strike Force cities, CMS reported a moratorium is needed to combat fraud, waste and abuse of ground ambulance services in Houston. HEAT is a joint initiative between the Department of Justice and the Department of Health and Human Services (HHS) to focus our efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

These efforts are paying off.  Since April 2012, the U.S. Attorney's Office for the Southern District of Texas has filed six cases in Houston alleging that the companies submitted fraudulent claims totaling over $9.5 million to Medicare for ambulance transports, and seven individuals have been charged in connection with these cases resulting in three guilty pleas and one trial conviction. For example, in March 2013, the owner and operator of a Houston-area ambulance company was convicted by a federal jury in Houston of multiple counts of health care fraud for submitting false and fraudulent claims to Medicare. In October 2012, as part of the Medicare Fraud Strike Force activity in Houston, the administrator of a Houston-based ambulance company, pleaded guilty to charges that he submitted approximately $1,734,550 in fraudulent claims to Medicare. In May 2012, the owners and operators of four different ambulance companies were charged in Houston for billing Medicare for ambulance rides that were medically unnecessary as part of a nationwide Medicare Fraud Strike Force takedown.

BENEFICIARY QUESTIONS

If you are a Medicare beneficiary and have a question about the moratorium, please call the Medicare Help line, 1-800-MEDICAR(E), 1-800-633-4227, TTY/TDD 1-877-486-2048.

If you are a Texas Medicaid or CHIP beneficiary and have a question about the moratorium, please call 1-800-252-8263 for Medicaid and 1-877-543-7669 or 1-800-647-6558, for CHIP.

GROUND AMBULANCE APPLICANT QUESTIONS

If you have submitted an application to enroll in Medicare, Medicaid or CHIP as a certified ground ambulance supplier in Houston and have a question about the status of your application, please call the Houston, Texas Part B Contractor, Novitas Solutions, 1-855-252-8782, Option 4.

MORATORIUM AUTHORITY

Section 6401 of the Affordable Care Act added new section 1866(j)(7) to the Social Security Act, that provides the Secretary with the authority to impose a moratorium on the enrollment of new providers and suppliers if the HHS Secretary determines a moratorium is necessary to prevent or combat fraud, waste or abuse in Medicare, Medicaid or CHIP. CMS published a final rule effective March 25, 2011 implementing this authority.

Today’s notice can be downloaded at: https://www.federalregister.gov/public-inspection  

To read the final rule effective March 25, 2011, please see http://www.gpo.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-1686.pdf

###