Some ems com­pa­nies are tak­ing medi­care — and tax­pay­ers — for a ride

Am­bu­lance firms are mak­ing mil­lions off the poor, the sick and the men­tally vul­ner­a­ble, whether they need a costly EMS lift or not

Houston Chronicle Sunday - - FRONT PAGE - By TERRI LANG­FORD

First of two parts

Early each morn­ing, pri­vate am­bu­lances charged to­ward a leafy Tom­ball sub­di­vi­sion where, for a hefty price to tax­pay­ers, pa­tients are dis­patched to psy­chi­atric “ ther­apy” in a brown brick house where two por­ta­ble pot­ties are perched in the drive­way.

The am­bu­lances are but specks among hundreds of emer­gency med­i­cal ve­hi­cles across Har­ris County mak­ing mil­lions of dol­lars off the poor, the sick and the men­tally vul­ner­a­ble, whether they need a costly EMS lift or not.

Medi­care and the Amer­i­can pub­lic pay for the ride — du­bi­ously and of­ten— billed to the U. S. govern­ment as trips of med­i­cal ne­ces­sity to “ clin­ics” or “ hos­pi­tals,” a Hous­ton Chron­i­cle in­ves­ti­ga­tion has found. Much of it fu­eled by the daily traf­fick­ing of the men­tally ill and frag­ile to so-called ther­apy pro­grams in ag­ing strip malls, mid-rises and res­i­den­tial neigh­bor­hoods.

Many of the pa­tients are nei­ther phys­i­cally de­bil­i­tated nor con­fined to a sick bed. They are not headed to, or com­ing from the hos­pi­tal, and there is no med­i­cal emer­gency.

Their rea­son for trav­el­ing in an am­bu­lance — equipped with a driver, a med­i­cal technician, a gur­ney, a de­fib­ril­la­tor and red sirens — is a mys­tery even to some of them.

Yet, the un­abated growth of this enor­mous EMS in­dus­try — 397 com­pa­nies in Har­ris County alone — has al­lowed the na­tion’s largest in­sur­ance provider for the el­derly and dis­abled to morph into a vir­tual ATM, the Chron­i­cle’s ex­am­i­na­tion of Medi­care billings shows.

By the fed­eral govern­ment’s own rules, many of these EMS trans­ports should not qual­ify for fed­eral dol­lars.

The fi­nan­cial con­se­quence: Nearly $ 500 mil­lion in Medi­care dol­lars have flown into the hands of pri­vate EMS op­er­a­tors in Har­ris County over a sixyear pe­riod — $ 62 mil­lion in 2009.

Not even New York City came close to match­ing the cost. Its Medi­care bill for pri­vate trans­ports that year: $ 7 mil­lion.

But this isn’t about one am­bu­lance, one psy­chi­atric pro­gram or one men­tally frag­ile Texan.

It’s about churn­ing up money in Amer­ica’s fourth largest city, us­ing tax dol­lars to feed a rav­en­ous ma­chine.

Six days a week

Twenty-three-year-old Daniel Mc­Call an­swers the front door of his north­west Hous­ton apart­ment stand­ing in stock­ing feet, fresh off an EMS ride from Tom­ball’s Cad­walder Be­hav­ioral Clinic, dubbed a Com­mu­nity Men­tal Health Cen­ter by the fed­eral govern­ment.

He is just back from ther­apy, or in his words, a place where “ they just fed us junk food ... we watch TV and stuff.”

No, he is not bedrid­den or phys­i­cally dis­abled. In fact, he eas­ily am­bles about his apart­ment, some­times de­lib­er­ately dark­ened be­cause he says his care­taker, who han­dles his money, has com­plained about the power bill.

He doesn’t know why he goes to ther­apy, why he rode in an Ur­gent Re­sponse am­bu­lance or who pays for it, only that one was sent to pick him up ev­ery day, ex­cept on Sun­day.

Medi­care’s rules say tax­payer dol­lars should not be used for am­bu­lance ser­vices un­less it’s “ med­i­cally nec­es­sary and rea­son­able” or should never be used when “ some other means of trans­porta­tion other than an am­bu­lance could be used with­out en­dan­ger­ing the in­di­vid­ual’s health.”

In a re­gion that leads the na­tion in the num­ber of EMS op­er­a­tors, ve­hi­cles and Medi­care pay­ments, the Chron­i­cle’s ob­ser­va­tion of EMS com­pa­nies over the past year re­peat­edly found able-bod­ied pas­sen­gers trans­ported by am­bu­lance from home to ther­apy and back.

Mc­Call’s trip has taken him on a 25-mile trek from his apart­ment in north­west Hous­ton up Tom­ball Park­way, past the neigh­bor­hood Valero, and east to­ward Quinn Road to the Cad­walder Be­hav­ioral Clinic, the three-bed­room house with por­ta­ble toi­lets in the drive­way. Vis­its to Cad­walder found a steady stream of EMS ve­hi­cles pick­ing up and drop­ping off dozens of peo­ple.

“ Best place in Tom­ball to have a heart at­tack,” jokes neigh­bor RoyWoods, tilt­ing his head as the EMS ve­hi­cles — some­times as many as five or more — turn down the street and head to­ward the house.

Lyndy In­gram, co-owner of Cad­walder, said the am­bu­lances are not ar­ranged by the clinic, but by per­sonal care home op­er­a­tors or home health care busi­nesses.

“ We have had them show up ran­domly,” she said. “ We have had them drop off pa­tients who haven’t had med­i­cal ben­e­fits. I don’t know how they ( EMS) get re­im­bursed.”

In EMS Medi­care billing records, the sub­ur­ban setup is doc­u­mented as a “ hos­pi­tal,” a “ clinic” or a “ par­tial hos­pi­tal­iza­tion pro­gram.”

In Mc­Call’s case, the am­bu­lance ride was ar­ranged by Brenda Till­man, who in 2008 and 2009 was cited for keep­ing men­tally in­ca­pac­i­tated adults in an un­li­censed liv­ing cen­ter in her home on Cac­tus For­est Drive, not far from Mc­Call’s apart­ment.

When con­tacted, Till­man de­nied Mc­Call used am­bu­lances. When it was pointed out that the Chron­i­cle saw him get into the am­bu­lance at Cad­walder’s Cres­cent Drive prop­erty that de­liv­ered him to his apart­ment, she in­sisted he used it on a trial ba­sis and no money, Medi­care or other­wise, ex­changed hands.

“ They ( am­bu­lance com­pa­nies) get it set up and come around and trans­port them to that fa­cil­ity, wher­ever they need to go,” she said.

The am­bu­lance com­pany’s owner also in­sisted she had no pa­tient match­ing Mc­Call’s name. But Medi­care was charged twice that day for trips to and from Cad­walder. Pri­vacy laws pre­vent the Chron­i­cle from ob­tain­ing spe­cific data about Mc­Call’s jour­ney.

Ur­gent Re­sponse has col­lected nearly $ 800,000 from Medi­care since 2005.

Wait­ing for the ride

On a 90-de­gree sum­mer day with heat blast­ing off the as­phalt, 54-year-old Alvin Zarker has parked him­self on a cov­ered­wooden bench in the back park­ing lot of a Sharp­stown mid-rise.

“ I’m wait­ing for my am­bu­lance,” he of­fers, on this day pro­vided by Heights EMS.

He can’t say why he rides in an am­bu­lance. Only that Medi­care pays for it.

“ It’s an ar­range­ment be­tween the ( as­sisted liv­ing fa­cil­ity) owner and the EMS,” he said.

Lum­ber­ing and heavy­set, he lives at St. Fran­cis Health Care Ser­vices, an as­sisted liv­ing fa­cil­ity in south­west Hous­ton.

David Opara, who owns the 10-bed fa­cil­ity, said of the am­bu­lances, “ Some­times we look at the phone book and some­times the am­bu­lance peo­ple leave their busi­ness cards on the door.”

Zarker ex­ited his fourhour men­tal health ther­apy ses­sion at the Bel­laire Care Clinic with the aid of a walker.

“ They have catered-in food,” Zarker said, tell-tale signs of spaghetti stains still vis­i­ble on the neck­line of his polo shirt. “ We used to have junk food.”

Only Medi­care can de­ter­mine whether peo­ple like Mc­Call and Zarker are el­i­gi­ble for an EMS ride.

Medi­care re­quires am­bu­lance com­pa­nies to ob­tain a “ physi­cian cer­ti­fi­ca­tion state­ment” for pa­tients who re­ceive trans­ports. Those state­ments are sup­posed to ex­plain why the pa­tient needs them.

Af­ter a re­quest by the Chron­i­cle to view those records — es­sen­tially a pre­scrip­tion to ride at tax­payer’s ex­pense — Medi­care of­fi­cials con­ceded they are never sub­mit­ted to the fed­eral agency. In­stead, EMS providers need only keep them on file.

“ Am­bu­lance providers are not re­quired to sub­mit the physi­cian cer­ti­fi­ca­tion state­ment form when sub­mit­ting a claim,” wrote David Wright, the Cen­ters for Medi­care and Med­i­caid Ser­vices’ act­ing deputy ad­min­is­tra­tor for the Texas re­gion, in a let­ter to the Chron­i­cle.

The Bel­laire Care Clinic Zarker vis­ited in a small sec­ond-story of­fice be­longs to Dr. Gur­dip But­tar. Medi­care records show But­tar last year was paid $ 1.2 mil­lion worth of psy­chi­atric ser­vices through his South Texas Health Ser­vices busi­ness listed at the same ad­dress.

Calls placed to But­tar for com­ment were not re­turned.

Medi­care of­fi­cials have de­clined to com­ment about the Texas am­bu­lance in­dus­try or its role in over­pay­ments. But the agency has been keenly aware of some­thing askew for more than two decades.

Ear­lier this month, Medi­care’s billing con­trac­tor for Texas, Trail­Blazer Health Enterprise­s, is­sued a warn­ing to am­bu­lance com­pa­nies that it has “ tar­geted non-emer­gency am­bu­lance trans­ports in Texas” as its num­ber one prob­lem since 2007. This year, it ran­domly sam­pled 100 Texas EMS claims. The er­ror rate was nearly 80 per­cent.

Even last Novem­ber, Trail­Blazer was cit­ing the very trans­ports doc­u­mented for this story, EMS rides to and from homes: “ From a med­i­cal ne­ces­sity stand­point, if the pa­tient had re­cov­ered suf­fi­ciently to al­low him or her to be dis­charged to home, in most cases, an am­bu­lance trans­port would not be re­quired,” the re­port stated.

“ I think it’s safe to say that the sys­tem down there is out of con­trol and it’s the Wild West,” said David Tay­lor, pres­i­dent of the Tyler-based Texas Am­bu­lance As­so­ci­a­tion.

Billing prob­lems

In 2010, records show, 333 EMS com­pa­nies were the sub­ject of re­views by Medi­care in Har­ris County be­cause of billing ir­reg­u­lar­i­ties or mis­takes, the Chron­i­cle’s in­ves­ti­ga­tion found.

“ We be­lieve that there’s kick­backs go­ing back and forth to pur­chase pa­tients and that’s re­ally the main con­nec­tion that we’ve seen from an in­ves­tiga­tive law en­force­ment an­gle,” said Joseph Prekker, the U. S. Health and Hu­man Ser­vices’ top agent for the Of­fice of In­spec­tor Gen­eral in Hous­ton.

“ You have am­bu­lance com­pa­nies some­times pay­ing the pa­tients to ride in the am­bu­lance,” he said. “ You have per­sonal care homes sell­ing pa­tient in­for­ma­tion to ei­ther the am­bu­lance com­pany or the CMHCs ( Com­mu­nity Men­tal Health Cen­ters). It’s kind of like a cir­cle. ( Some) CMHCs are pay­ing the am­bu­lance com­pa­nies to bring the pa­tients.”

Buried deep in­side a 2008 fed­eral crim­i­nal court case, tran­scripts and records doc­u­ment the everesca­lat­ing quest for Medi­care dol­lars by the Hous­ton EMS in­dus­try and the pa­rade of trans­ports that ini­tially tar­geted kid­ney dial­y­sis pa­tients.

The case, a cul­mi­na­tion of a fed­eral in­ves­ti­ga­tion that started in 2003, un­rav­eled a con­spir­acy of kick­backs, fraud and the hunt for pa­tients with Medi­care ben­e­fits, many of whom didn’t need an EMS ride and oth­ers who were fic­ti­tious char­ac­ters cre­ated by cun­ning EMS and health care providers.

Records doc­u­mented EMS com­pa­nies swarm­ing a dial­y­sis cen­ter wait­ing room and fight­ing over clients, so much so that one Hous­ton doc­tor scripted an edict ban­ning so­lic­i­ta­tion.

“ We had a lot of so­lic­i­ta­tion of the EMS among each other’s pa­tients ..,” Dr. Shatish Pa­tel, the di­rec­tor of the Beech­nut Dial­y­sis Cen­ter, tes­ti­fied at the trial of two Hous­ton men ac­cused of fraud. “ They ( am­bu­lance driv­ers) used to have ar­gu­ments in there. So, we asked them that you bring your pa­tient, you take your pa­tient with you, but don’t try to look for an­other


At the time, the FBI and fed­eral reg­u­la­tors were clos­ing in on fraud­u­lent billings by EMS trans­ports, or as Pa­tel con­ceded, “We were find­ing so many of our pa­tients rid­ing am­bu­lance ser­vice they did not re­quire and there was quite an in­ves­ti­ga­tion go­ing on at that time, also.”

Among the pa­tients was a wo­man who suf­fered from re­nal fail­ure, di­a­betes, asthma and de­pres­sion — but who man­aged to walk each day to a clinic from her home less than a mile away.

An­other wo­man, ac­cord­ing to records, was reg­u­larly trans­ported by EMS, even though she rode to church in her broth­erin­law’s “old lit­tle truck,” and used her walker to shop at Wal­mart.

The con­spir­acy, pros­e­cu­tors ar­gued, was cooked up by the own­ers of the now-de­funct Amer­icare EMS: Mazem and Wes­lam Ab­dal­lah, two broth­ers from New Or­leans who came to Hous­ton af­ter Hur­ri­cane Ka­t­rina. Both men went to prison for con­spir­acy to com­mit health care fraud af­ter a jury found that pa­tients’ med­i­cal con­di­tions did not qual­ify them for Medi­care-re­im­bursed am­bu­lance trans­port.

Just this year, Kelvin Washington, an ad­min­is­tra­tor at a Su­gar Land nurs­ing home, was ar­rested and ac­cused of re­ceiv­ing kick­backs from the Ab­dal­lahs’ am­bu­lance com­pany for pro­vid­ing pa­tients.

He sup­pos­edly so­licited fraud­u­lent am­bu­lance pre­scrip­tions from un­sus­pect­ing doc­tors, though some of the pa­tients were no longer nurs­ing home res­i­dents and oth­ers never had been.

In re­turn, Washington is ac­cused of re­ceiv­ing com­mis­sions of $ 1,000 or more and in one in­stance, a $ 697.80 air­line ticket for a trip to Hawaii.

“At what point is this so big that no one can han­dle it any­more?” asked Daniel Block, a former EMS ex­ec­u­tive, who filed a whistleblo­wer’s law­suit years ago that ex­posed Texas EMS op­er­a­tors of­fer­ing kick­backs to fa­cil­i­ties in ex­change for Medi­care and Med­i­caid pa­tient re­fer­rals.

Watched by the state

Off County Road 144 in Alvin, the first of three Prom­ise EMS ve­hi­cles slides into the drive­way of a ru­ral ranch-style house at 4: 30 in the af­ter­noon. An el­derly wo­man emerges, steps out of the am­bu­lance and shuf­fles to the De­sire to Live per­sonal care home, an un­li­censed care fa­cil­ity she shares with oth­ers.

The women, some of them frail, have been to ther­apy at Cad­walder in Tom­ball, a round trip of 135 miles, one they make nearly ev­ery day.

Ac­cord­ing to state re­ports, the home’s owner, Wanda But­ler, has been il­le­gally op­er­at­ing an as­sisted liv­ing fa­cil­ity and has been or­dered to shut down.

Though she wouldn’t tell the Chron­i­cle why the women needed an am­bu­lance, she did tell state in­ves­ti­ga­tors prob­ing con­di­tions at the home that none of the women are phys­i­cally in­ca­pac­i­tated.

In fact, she adamantly de­clared them com­pe­tent to care for them­selves — though she did de­cide they needed a tax­payer-spon­sored med­i­cal am­bu­lance each day.

The owner of Prom­ise EMS, which gets paid by Medi­care to carry the women, of­fered this ex­pla­na­tion: “ They need to be mon­i­tored around the clock ... They go to a pro­gram, a psych cen­ter,” owner Egbe Ware said.

Not only did the Chron­i­cle watch the women un­load more than once, but a state in­ves­ti­ga­tor did, too.

Last year, the in­ves­ti­ga­tor vis­ited Cad­walder to in­ter­view the women — just as they were ar­riv­ing by am­bu­lance.

“ At ap­prox­i­mately 10 a. m., res­i­dents … ar­rived to the pro­gram in an am­bu­lance,” the in­ves­ti­ga­tor wrote. “( Res­i­dent’s name) was brought in on a stretcher. The EMS said that she was very weak.”

The in­ves­ti­ga­tor’s notes de­tailed her in­ter­view with one res­i­dent who was “ very un­steady and very thin.” She noted she could see the res­i­dent’s “ bone struc­ture pro­trud­ing in her neck and shoul­der.” An­other wo­man, the in­ves­ti­ga­tor re­ported, ex­ited yet a dif­fer­ent am­bu­lance and walked to an of­fice out back.

But noth­ing in state records in­di­cates the in­ves­ti­ga­tor ques­tioned why one wo­man was trav­el­ing 65 miles to Cad­walder for ther­apy if she was so weak, or why the other was rid­ing in an am­bu­lance at all.

Medi­care billing records show dozens of pick­ups and drop-offs in the same Alvin ZIP code as the County Road 144 home over the past 10 months,

with the cost to tax­pay­ers more than $ 1,000 for each round trip.

Fed­eral records show Prom­ise EMS has been paid more than $ 1.5 mil­lion by Medi­care since 2005.

‘ A pretty big bar­rel’

No one agency — not the Texas Depart­ment of State Health Ser­vices, the city of Hous­ton’s Health Depart­ment nor the Cen­ters for Medi­care and Med­i­caid Ser­vices — has com­plete reg­u­la­tory con­trol of pri­vate am­bu­lances.

The state of­Texas is­sues an EMS li­cense to any­one with an am­bu­lance, a few thou­sand dol­lars for fees and li­censes, ba­sic emer­gency equip­ment and a post of­fice box for an ad­dress.

At least two peo­ple in the am­bu­lance are sup­posed to have, at a min­i­mum, an emer­gency technician’s li­cense.

Once li­censed and per­mit­ted, the com­pa­nies sub­mit to a one-time in­spec­tion from the Cen­ters for Medi­care and Med­i­caid Ser­vices, are is­sued a provider num­ber and can sub­mit claims for pay­ment and col­lect tax.

The city of Hous­ton re­quires an­other $ 1,000 for a per­mit, a sticker that gives EMS ve­hi­cles ac­cess to pick up pa­tients in­side the city lim­its.

Only two city EMS in­spec­tors are charged with mon­i­tor­ing safety on the nearly 1,000 am­bu­lances, in­clud­ing whether equip­ment is op­er­at­ing prop­erly. That’s one in­spec­tor for ev­ery 500 am­bu­lances.

“ It’s a pretty big bar­rel,” Hous­ton EMS safety in­spec­tor Chris Hoff says of the vi­o­la­tors who, be­cause of their sheer numbers, are able to elude de­tec­tion.

In two hours con­duct­ing ran­dom in­spec­tions in the park­ing lot of a kid­ney dial­y­sis cen­ter, Hoff picked off at least six com­pa­nies with ex­pired am­bu­lance per­mits, ex­pired Texas li­cense plates, Epi-Pens past their ex­pi­ra­tion dates and heart de­fib­ril­la­tors with­out work­ing bat­ter­ies.

Stream of am­bu­lances

“ At the end of the day, who is re­spon­si­ble?” asked Elia Gab­banelli, who along with her hus­band owns an ac­cor­dion store in south­west Hous­ton. “ These are tax dol­lars.”

For more than a year, Elia and Mike Gab­banelli wit­nessed with trou­bled fas­ci­na­tion the pri­vate am­bu­lances stream­ing into the park­ing lot of the strip cen­ter at 4975 West Bell­fort.

On any given day, dozens of “ pa­tients” emerged from the EMS ve­hi­cles and headed to a sign-less build­ing tucked be­hind a Kroger gro­cery store.

Clients, they said, roamed through the park­ing lot, even stop­ping in their store. They called the Texas health depart­ment’s am­bu­lance in­spec­tion team to com­plain about the high vol­ume of am­bu­lances, but no one called them back.

Yet again, the un­mis­tak­able rou­tine: EMS ve­hi­cles con­gre­gate in the pot-holed park­ing lot, first in the morn­ing for dropoff, later for pickup.

The de­posited pa­tients, many walk­ing, saunter into the build­ing for treat­ment.

When asked about the am­bu­lances, Ann Castillo, fa­cil­ity man­ager of Be­hav­ioral Medicine, which op­er­ated the clinic, said pa­tients ar­range the EMS trans­port.

A few days af­ter the Chron­i­cle’s visit, how­ever, the West Bell­fort build­ing had been in­ex­pli­ca­bly va­cated, the am­bu­lances equally van­ished.

“ They don’t re­ally go away,” said Prekker of the U. S. Of­fice of the In­spec­tor Gen­eral.

They just move some­place else.


LEAV­ING THE AM­BU­LANCE: An el­derly man ex­its an Amer­icare United EMS am­bu­lance at the Kash­mere Gar­den Res­i­den­tial Care Fa­cil­ity in Hous­ton in July.

EN­TER­ING THE CAR: Af­ter leav­ing the am­bu­lance, the man makes his way to an­other car parked at the Kash­mere Gar­den Res­i­den­tial Care Fa­cil­ity. A Chron­i­cle re­view re­peat­edly found able-bod­ied pas­sen­gers trans­ported by pri­vate am­bu­lance to med­i­cal...

Nick d la Torre :

CAR­A­VAN OF CARE?: Am­bu­lances line up for pa­tient trans­port at Con­tin­uum Clinic, now part of West­bury Com­mu­nity Hos­pi­tal, in late 2010. Tax­pay­ers of­ten pay for the ride, even though the pas­sen­gers may not re­quire it or know why it is be­ing done.


ON THE JOB: Chris Hoff, an EMS in­spec­tor with the City of Hous­ton Health Depart­ment, pre­pares to make a sur­prise in­spec­tion in Au­gust of one of the many am­bu­lances lined up to load and un­load pa­tients at a med­i­cal fa­cil­ity.

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