The Roanoke Valley Rescue Squad submitted thousands of false claims for nonemergency transport and made thousands of corresponding false records material to the claims, the federal government alleges in a lawsuit filed against the agency.

“The total number of false claims made and false records made or used are too numerous to specify details for each with greater particularity, but ten representative examples are provided and total damages will be established using an accepted extrapolation method from an audit based upon a statistically valid random sample of the universe of the RVRS claims during the 2004 to 2010 time period,” the lawsuit says.

In its first and second causes of action — submitting false claims and use of false statements to get claims paid — the government says it suffered damages in an amount to be determined at trial.

The government says under the third cause of action — payment under mistake of fact — it should be paid an amount to be determined at trial, as it does in its fourth cause of action for unjust enrichment.

For violation of the false claims act, the government seeks treble damages plus the costs of investigation and prosecution and civil penalties for each false claim.

The government also seeks an amount equal to the money mistakenly paid to the rescue squad along with interest and investigative costs.

Jeffery Batts, the attorney for the squad, denies the government’s allegations.

U.S. Department of Health and Human Services

The government filed the lawsuit in November for the U.S. Department of Health and Human Services and involves Medicare and Medicaid reimbursements to the rescue squad.

The Medicare regulations during much of the time of the lawsuit, January of 2004 to present, provide Medicare Part B would pay for ambulance transport only if other means of transportation would endanger the patient’s health.

Medicaid requires written certification the transport is medically necessary and that the patient must be transported by stretcher.

The lawsuit says, from January of 2004 to now, “RVRS knowingly submitted or caused the submission of false or fraudulent claims to Medicare and Medicaid and made, used or caused to be made or used, false records and statements material to get Medicare and Medicaid claims paid for transporting dialysis patients and others from their nursing homes or residences.”

The lawsuit maintains the squad was required to, but failed to submit accurate individual claims for its regular dialysis and other routine patients. The government says the squad submitted knowingly generic, incomplete, inconsistent and false and fraudulent claims to Medicare through CIGNA Healthcare and Medicaid through the North Carolina Division of Medical Assistance.

These claims, the suit alleges, said dialysis and other routine patients were being transported because they were unable to stand and apply weight to legs or lower extremities because of end stage renal disease and met the medical necessity requirements.

However, the suit alleges, “Many Medicare and Medicaid patients were able to sit or stand, were able to ambulate, were not bed confined, did not require stretcher service and did not require ambulance transportation or qualify for ambulance transportation reimbursement by Medicare or Medicaid. For example, many of these patients often walked or rolled in a wheelchair to or from the ambulance and many of these patients walked without assistance during their visits to the dialysis center.”

Reports

Patient care reports were made by drivers and physicians medical necessity certifications were made or used by squad office employees. The records were then sent to the squad’s billing company, Certified Ambulance Group.

“RVRS knowingly claimed on its Medicare and Medicaid claim forms that patients were unable to stand and that the transport was medically necessary even when the information available to its employees indicated that the patient was able to sit, stand or walk on the day of ambulance service.”

The lawsuit continues, “The information available to RVRS employees indicated that the patient did not meet the Medicare medical necessity requirements on the day the patient received ambulance transport to dialysis treatment in many instances, but RVRS nonetheless submitted claims that falsely stated the patient did meet the Medicare medical necessity requirements. RVRS also knowingly submitted claims to Medicaid for ambulance transports that did not meet Medicaid’s requirements for the reasons set forth above.”

Says the lawsuit: “RVRS knowingly submitted claims for routine transport by ambulance between residences or nursing homes and the patient’s regularly scheduled therapy, including dialysis treatment. RVRS was not entitled to Medicare or Medicaid reimbursements for these nonemergency transports to dialysis treatment centers, hospitals or private doctor’s office.”