San Juan Island Public Hospital District No. 1 responded to the September letter wherein San Juan Island Emergency Medical Services was fined $350,000 for Medicaid fraud.

“It’s been over four years since your office opened this investigation and we’ve had no substantive discussions during that time,” Jim J. Fredman, the PHD’s attorney, wrote in the response letter. “We look forward to finally starting a dialogue to resolve this matter.”

The September letter was from Washington Assistant Attorney General Nickolas Bohl who is with the Medicaid Fraud Control Division. The determination by the attorney general’s office was that SJI EMS ordered more than 400 medically unnecessary flights from Island Air Ambulance prior to April 2016.

SJI EMS was tasked with supplying written assurance that it will abide by Medicaid regulations and must develop and follow protocols for making independent judgments about whether air transportation is medically necessary.

Fredman explained that during the time period in question, Peace Island Medical Center maintained the lowest level trauma designation, therefore most complex emergency medical conditions would require transport to a larger hospital.

“Transportation of emergency patients by air ambulance service was directed by medical control which consisted of the Washington Department of Health designated county medical program director and Hospital board certified emergency department specialists,” Fredman wrote. “No Medicaid patient was flown off the island unless a board certified emergency physician or medical control determined that the patient had an emergency medical condition that required transport via air ambulance.”

Fredman wrote that getting from the islands to a mainland hospital via ferries is not an easy task. The ferry system is unreliable at times and the wait can be significant, he added. The patient then would have to be driven by ambulance to the nearest appropriate hospital and hope that there is space available, he said.

Washington Medicaid pays for air ambulance flights when the necessary medical treatment isn’t available locally or ground transport isn’t accessible; for being transported to an acute care hospital; and when the patient’s condition requires immediate and rapid response not achievable by ground transport, Fredman explained.

“Applying these guidelines means that air ambulance transport of nearly every patient on one of the islands served by SJI EMS with an emergency medical condition that requires rapid ambulance transport due to trauma, acute illness, broken bone, or accident, is justified,” Fredman wrote.

Bohl’s September letter noted that more than 400 improper Medicaid claims were filed for fixed-wing air ambulance flights. Fredman replied that SJI EMS records only show approximately 226 Medicaid patients flew air ambulance between Jan. 1, 2010 to April 2016. He added that the cost to SJI EMS per flight was more than $3,500.

“SJI EMS simply had no financial incentive to fly Medicaid patients via air ambulance,” Fredman wrote. “SJI EMS was solely driven by the need to ensure that the patients received necessary treatment in a timely manner and that no patient’s condition was put at risk due to a delay in transportation to the appropriate hospital.”

Fredman’s letter continues to address the use of ambulance coding, inter-hospital transports, mental health transports, intra-island flights and Medicaid integrity audit. To read the letter in full, visit https://bit.ly/2P3in6X.

The investigation began in September 2015, when SJI EMS and the public hospital district were asked for their compliance in a Civil Investigative Demand wherein the attorney general’s office looked into concerns of Medicaid fraud. In a 25-page document, the attorney’s office requested billing documents, reimbursement claims, forms and “all communication” between Dr. Michael Sullivan, the medical director at the time; Jim Cole, EMS chief at the time; Dr. Michael Edwards, the chairman of the public hospital district; and Larry Wall, director of critical care transport, regarding air ambulance service, medical billing or medical reimbursement.

“SJI EMS believes that the air ambulance flights it billed to the Washington Medicaid program were appropriate,” Fredman’s letter concluded. “We look forward to beginning a dialogue so that your office and SJI EMS can put this time consuming and unnecessary process behind us.”