Question: When will Medicare pay for an Ambulance?

Answer: When it’s medically necessary, not just for convenience

The Balanced Budget Act of 1997 set federal reimbursement rates and rules under which ambulance services are reimbursed.  Medicare will generally pay for emergency and non-emergency basic life support (BLS), advanced life support (ALS), and specialty-care transport, but only when these transports are deemed necessary and reasonable.  Ambulance services are considered necessary and reasonable under Medicare guidelines when the beneficiary’s medical condition is such that other means of transportation are contra-indicated.

Section 1861 of the Balanced Budget Act says:

“Ambulance services are not covered or paid by Medicare if other modes of transportation (i.e. automobile, taxi, wheelchair van, etc.) could have been used by the beneficiary without endangering his or her health.  If the decision to use an ambulance service is based on the convenience of the beneficiary, the beneficiary’s family, or some other element of personal preference, Medicare coverage is not available.”

Caution: A patient’s condition may meet medical-necessity criteria, but the reason for the ambulance must also be deemed reasonable and necessary.  A trip to the pharmacy, for example, is medically necessary, but making that trip in an ambulance is not.

Examples that meet medical necessity guidelines:

  • Post-hip fracture with physician’s order to remain supine
  • Needs to remain immobile due to possible fracture or splinting requirement
  • Contracture of lower limbs (describe the severity)
  • Facility transfer for higher level of care

Examples that are NOT reasonable and necessary

  • Foley catheter replacement
  • Transport for convenience of patient, family or physician

For more information, go to the Medicare website at www.cms.hhs.gov

 

 

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