Ambulance service loses $147K, gears up for Medicare battle

An audit of Carson City's Ambulance Service has cost Carson City taxpayers about $147,000 and created a potential battle with Medicare.

The Medicare spat could eventually cause the ambulance service to stop being a Medicare provider or could bankrupt the service, Ambulance Battalion Chief Vincent Pirozzi said.

Medicare ordered an audit of Carson's 1,600 Medicare ambulance runs from mid-1995 to mid-1996. A letter from a Medicare official to U.S. Rep. Jim Gibbon's office on behalf of Carson City stated the city's ambulance service was chosen for an audit because of a high number of ambulance calls generated by victims falling.

Transamerica Occidental Life Insurance Co. reviewed 80 cases which Medicare had already paid and determined Carson City shouldn't have been reimbursed for services.

Transamerica said the city owed Medicare $25,000, but dropped the amount to $8,600 after discussions with ambulance staff. Transamerica estimated that if the city owed about $8,600 for 80 cases and those cases were indicative of the 1,600 cases, Carson owed about $147,000.

Pirozzi and Fire Department Chief Lou Buckley said the city plans to request a hearing to recoup the money.

The city has a Dec. 3 deadline to pay Medicare. A check was sent to Medicare last week to avoid interest, but a funds transfer has not been approved by Carson's supervisors.

"What you have here is Medicare saying, 'You're right, we owe you money,' and then three years later saying, 'You weren't right," Buckley said. "They're not accusing us of wrongdoing, but they're changing their minds on what they should have paid.

"This is a situation where you have a bureaucratic organization imposing its will upon local jurisdiction. If we're not successful in overturning this through the hearing process, it will increase the amount of subsidy the ambulance requires from the city's general fund."

The ambulance currently requires an annual $140,000 subsidy. It operates on a $1.9 million budget paid by users, two-thirds of which are Medicare patients. An ambulance trip across town costs the patient about $600.

Pirozzi said when an ambulance is called in Carson City, all patients receive advanced life-support care. The service either bills the individual or the insurance company, but in 65 percent to 70 percent of the cases it bills Medicare.

Transamerica argued in its audit that documentation didn't explain why a woman in cardiac arrest needed an ambulance. Another case points to a patient nearly in a coma and states that the patient could have been transported by other means.

"Every one of these claims was reviewed by Medicare," Pirozzi said. "If they were denied outright, we could have billed the patient, but the fact is they're telling us they want their money back on cases that are three years old."

Pirozzi argued that Medicare is second-guessing the care patients should have received.

"You can't look at a patient lying on the ground with chest pains and say, 'Sorry, you don't need advanced life support. You're a Medicare patient. We can't help you,'" Pirozzi said.

"We're an emergency service. We can't decided who we can and can't transport. We operate by (state imposed) protocol that says we have to give a certain level of service. We can't be in a situation where (Medicare) can dictate the level of service.

"The sad thing about this is the people who most need this service are the people who can least afford to pay and the ones who will be hurt eventually," Pirozzi said. "If we decided we no longer want to be Medicare providers, it would hurt the citizens, there's no doubt about that. If we lose this, it could mean the end of the ambulance service."

Pirozzi said the ambulance faced having all its records reviewed, which could cost the city and the ambulance service more money than they have.

"We have to appeal this. We have no choice," Pirozzi said.

City Manager John Berkich said city officials would likely consult with a Medicare specialist in its appeal.

"If this is held up, it would certainly force us to change the ambulance service pretty fundamentally," Berkich said. "We would have to look at the level of service we provide and the protocols being used when patients are transported. This thing conjures up some fundamental and serious issues for all ambulance services. It threatens the ability of the professional to exercise judgment."