Close X
Attorney Spotlight

Find out which two countries Cheryl Palmeri gets the most questions about related to International Trade in today's market? Find out more>


Close X


Search our Experience

Experience Spotlight

In June 2016, AmSurg Corp. and Envision Healthcare Holdings, Inc. (Envision) announced they have signed a definitive merger agreement pursuant to which the companies will combine in an all-stock transaction. Upon completion of the merger, which is expected to be tax-free to the shareholders of both organizations, the combined company will be named Envision Healthcare Corporation and co-headquartered in Nashville, Tennessee and Greenwood Village, Colorado. The company's common stock is expected to trade on the New York Stock Exchange under the ticker symbol: EVHC. Bass, Berry & Sims served as lead counsel on the transaction, led by Jim Jenkins. Read more.

AmSurg logo

Close X

Thought Leadership

Enter your search terms in the relevant box(es) below to search for specific Thought Leadership.
To see a recent listing of Thought Leadership, click the blue Search button below.

Thought Leadership Spotlight

Inside the FCA blogInside the FCA blog features ongoing updates related to the False Claims Act (FCA), including insight on the latest legal decisions, regulatory developments and FCA settlements. The blog provides timely updates for corporate boards, directors, compliance managers, general counsel and other parties interested in the organizational impact and legal developments stemming from issues potentially giving rise to FCA liability.

Read More >

Providers Can Look Forward to MooreCare in Audits


August 19, 2011

A pair of recent opinions from the Federal District Court for the Middle District of Tennessee offers a victory for ambulance providers and potentially positive implications for other healthcare providers and suppliers that are subject to a claims audit by a Medicare contractor. In the recent opinion of MooreCare Ambulance Service, LLC. v. The Department of Health and Human Services ("HHS"),1 the Court overturned a decision by the Medicare Appeals Council ("MAC"), which had denied several claims for reimbursement of ambulance transports, on the ground that the MAC applied the wrong standard for nonemergency, scheduled repetitive transports. In so holding, the Court ruled that a physician’s written order certifying the medical necessity of the transport was by itself sufficient to support the claim and that the MAC’s review of additional medical records was inappropriate.

MooreCare Audit and Administrative Appeal

In 2007, AdvanceMed Corporation, ("AdvanceMed"), a Program Safeguard Contractor ("PSC") that contracts with the Centers for Medicare and Medicaid Services ("CMS") to "safeguard" Medicare from abuse,2 subjected MooreCare Ambulance Service, LLC, ("MooreCare"), an ambulance service provider, to an audit. AdvanceMed audited medical records and supporting documentation for 60 ambulance transport services claims submitted by MooreCare to Medicare over a year-and-half period. After reviewing the records, AdvanceMed found that MooreCare had improperly billed 89.32 percent of the reviewed claims for a total overpayment of $19,131.59. AdvanceMed characterized this error rate as a "high level of payment error," and extrapolated the finding over all claims submitted to Medicare during the audit period for an extrapolated overpayment amount of $2,114,613.3

MooreCare appealed this determination through Medicare’s five-step administrative appeals process.4 Eventually MooreCare reached the MAC, which upheld most of AdvanceMed’s findings. Although MooreCare provided written physician certification statements attesting to the medical necessity of ambulance transportation for the vast majority of its repetitive ambulance transport claims at issue, the MAC unequivocally found that a written physician order certifying the service’s medical necessity is not, by itself, sufficient to support medical necessity for the purpose of reimbursement.

MooreCare in the Middle District of Tennessee

In a review of the MAC’s opinion upholding the denial of MooreCare’s claims for reimbursement of nonemergency, scheduled and repetitive services, the Court expressed "serious concerns" about the MAC’s unsupported rationale on medical necessity and concern for "hindsight bias" in the MAC’s review of claims. The critical ruling from MooreCare is this: A valid written order by a physician certifying the medical necessity of a nonemergency, scheduled, repetitive ambulance transport service is conclusive of medical necessity, and any further review of additional medical records or documentation is unnecessary.

The Court explained that under the basic rule for ambulance reimbursement, ambulance services are covered by Medicare where other forms of transportation are contraindicated by the patient’s condition.5 The regulations provide a general and a special rule for ambulance service. Under the general rule, ambulance transport is reimbursable if medically necessary – demonstrated by bed confinement and documentation that other forms of transportation are contraindicated or demonstrated by the patient’s medical condition, regardless of bed confinement.6 Where the ambulance service is nonemergency, scheduled and repetitive – such as transport for dialysis – the "special rule" applies. Under the "special rule," ambulance services are reimbursable where a physician’s order certifies the medical necessity of the transport. The Court found that this order is conclusive of medical necessity and rejected HHS’ arguments that the Medicare Benefit Policy Manual provisions or other CMS guidance imposed additional requirements that ambulance providers must also meet.

Impact of MooreCare

The MooreCare decision may have positive implications for other Medicare providers. It is common in Medicare audits for the contractors conducting the audits to request records in addition to the physician orders to support the medical necessity of ancillary services, such as ambulance transports, laboratory or other diagnostic tests, or durable medical equipment. Healthcare providers facing an unfavorable Medicare audit result should review the applicable statutes and regulations to determine if the contractors have denied claims based upon requirements that are in addition to or inconsistent with those found in the applicable statutes and regulations. In these situations, the MooreCare decision may provide a defense to the audit result.

1  Moorecare Ambulance Serv., LLC v. Dep't of Health & Human Services, Civ. No. 1:09-0078, 2011 WL 2682987 (M.D. Tenn. July 11, 2011) and Moorecare Ambulance Serv., LLC v. Dep't of Health & Human Services, Civ. No. 1:09-0078, 2011 WL 839502 (M.D. Tenn. March 4, 2011).
2  CMS has replaced the PSCs with Zone Program Integrity Contractors ("ZPICs"). AdvanceMed is the ZPIC assigned to Zones 5 (encompassing the states of Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia) and 2 (encompassing the states of Alaska, Arizona, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming). ZPICs’ specific responsibilities include identifying vulnerabilities in the Medicare program, identifying and investigating potential cases of fraud, and referring cases to law enforcement for possible prosecution.
3  The Court reserved ruling on whether this extrapolation was justified.
4  A Medicare provider subject to an audit has the right to appeal an unfavorable audit result through a five-step process: (1) redetermination from the Medicare Administrative Contractor, (2) reconsideration from a Qualified Independent Contractor, (3) hearing before an Administrative Law Judge, (4) review by the Medicare Appeals Council, and (5) appeal to a federal district court.
42 U.S.C. § 1395(x)(s)(7)
6  42 C.F.R. § 410.40(d)(1)

Related Services


Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.