Ambulance providers are more likely these days to face a Medicare audit due to incorrect or incomplete documentation of services.  It has become increasingly important to make sure emergency medical service providers and billing staff are well informed of the latest Medicare regulations to maximize coding and billing compliance. EMS Management & Consultants recently recommended to EMS1.com important tips to help successfully navigate the auditing process.

  1. Know what factors may trigger an audit by your Medicare Administrative Contractor.

Most audits are triggered by a statistical analysis done by your Medicare Administrative Contractor (MAC), and take two forms: a prepayment review and a post-payment review. The MAC will examine three key factors:

  • Is it Advanced Life Support or Basic Life Support?
  • Is it an emergency or non-emergency response?
  • Is the ambulance transport medically necessary?

Providers have up to thirty days to respond to the audit with further documentation and the MAC has another 60 days to review and make a decision based on the additional documentation provided.


  1. Know what takes place during prepayment reviews.

In a prepayment review, an ambulance provider will be requested to provide further documentation for each claim filed, usually for the same service.  The Medicare contractor triggers reviews when a provider has a higher rate of ALS or emergency procedures submitted than their peers in the same geographical area. This review does not take in to consideration that one ambulance provider may have a different patient profile than another ambulance service.


  1. Know what to expect during post-payment reviews.

A post-payment review will investigate randomly selected trips by an ambulance provider. Medicare uses RAT-STATS a statistical tool for its reviews, which is available as a free download for providers to do their own internal audits to assure compliance with Medicare.  Once a post-payment review is done, the provider must submit all medical records for these audited trips to the MAC. If the MAC decides there is a high rate of error, the MAC will extrapolate to all claims submitted by the provider in that same period.  For example, if the MAC determines there is a 40 percent error rate on 90 randomly selected trips during a two year period, it will deny payment at that rate and expect this amount to be repaid to Medicare for this two year time frame.


  1. Train EMS providers and billing staff to stay in compliance by keeping meticulous records.

An ambulance provider must have a compliance plan in place to conduct regular internal quality assurance audits.  The EMS personnel and billing staff should be well trained on the latest regulations, and proper coding of medical services.


Source: 5 Things You Need to Know to Survive a Medicare Audit, by EMS Management & Consultants, emsbilling.com

Medtrust Transport provides emergent and non-emergent ambulance services in Charleston, Myrtle Beach and Georgetown, South Carolina. We have expertly trained EMT personnel and fleet of fully-equipped ambulances. We aim to provide compassionate and timely patient care.