Contest Entries

Is Houston EMS Taking Medicare For A Ride?

Entrants: Terri LangĀ­ford, Yang Wang

Affiliation: The Houston Chronicle

Business (large)

Year: 2011

Place: First Place

Provide a brief synopsis of the story or stories, including any significant findings.

Judges’ comments: A very nice distillation of a big problem in health care that could easily been done with a "ripping off the taxpayers" treatment. Instead, the writers and editors personalized the tale by showing how the poor, sick and mentally vulnerable are pawns in a much bigger game. In a time of dwindling resources at big city newspapers, the judges also commend the time and manpower commitment devoted to the series.

Provide names of other  journalists involved.

Yang Wang

List date(s) this work was published or aired.

Oct. 16, 2011-December 31, 2011
See this entry.

Provide a brief synopsis of the story or stories, including any significant findings.

This was a two-part series detailing how Houston leads the nation in the number of private ambulance companies, number of vehicles and their connection to for-profit mental health clinics. This series noted Medicare spending in the Houston area for both areas - EMS and for-profit mental clinics were the largest for these provider areas There were three stories over two days. We also noted how Medicare does not police the spending well, how Medicare overpayments to EMS companies in Texas is the No. 1 problem for the Medicare contractor,TrailBlazer Health Enterprises. This series also noted the problems in city and state regulation of private EMS companies. At last count, there are 397 private EMS companies based here, with about 50 applications from Harris County awaiting approval in Austin. By our count, nearly $500 million in Medicare dollars have flown into the hands of private EMS operators in Harris County over a six-year period - $62 million in 2009, the latest year available. This is a conservative total, because it did not include exactly how much in mileage reimbursement Medicare has paid private ambulance companies. By comparison, Medicare paid nearly $7 million to EMS companies in New York City for the same year. We also detailed how several of the doctors who oversee private EMS procedures have a checkered state medical license history and how the city of Houston has only two inspectors to monitor more than 1,000 private ambulances here. Terri Langford worked on all three stories. Reporter Yang Wang worked on the doctor's story featured in Day 1. Also included in the entry are: the Chronicle's editorial on the series, three follow-up stories regarding ambulance or clinic fraud arrests and a staff story detailing U.S. Rep. Kevin Brady's call for a committee hearing on Medicare fraud in Houston.

Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?

This series relied heavily on FOIA and PIA (the Texas Public Information Act) requests. All of the Medicare payment data for EMS companies and clinics in Texas and the selected trip data came from the Centers for Medicare and Medicaid (CMS). FOIAs and PIAs were used to get it and all of it, except where noted, was free. We used all of the following and all of it was electronic: -Excel spreadsheets from CMS of all Texas ambulance companies (private and 911 operators) over a six-year period with the amount of Medicare payments they received, -Spreadsheets of all Texas EMS provider license holders which included the name of each physician working as a medical director, -Spreadsheets of all Houston EMS permit holders, -Spreadsheet of NYC private ambulance payments by Medicare, -Medicare payments to Partial Hospitalization Programs in Texas. -Spreadsheet of all violations of Houston EMS company permit holders. -Spreadsheet of six-year payment totals to Texas ambulance companies by Medicaid. -Origin/Destination data from CMS which showed where a handful of companies were dropping off and picking up their patients. -City of Houston Health Department's map of dialysis centers and ambulance companies -Provider B billing and payment data for 2009. We paid $250 for that data set. -The Texas online databases of assisted living inspection reports and state health department's online EMS licensure database were constant sources. -Brazoria and Harris County court records as well as heavy use of PACER, the federal court system, were also used. These records were critical in proving the considerable size of the private EMS business in the Houston area and how much Medicare money it was using.

Explain types of human sources used.

While the press officers at the Texas Department of State Health Services and its parent, the Texas Health and Human Services Commission were extremely helpful in retrieving state information and data for us, these stories were guided primarily by street-level access to those intimately involved in the ambulance and health care business. From EMS professionals and doctors to clinic neighbors and patients, to scofflaw personal care home owners, clinic owners and staffers, all helped guide these stories. A whistleblower plaintiff, Dan Block, still in the EMS business, was a terrific source for how Medicare billing was structured and introduced us to the origin/destination data that allowed us to see how often a handful of EMS companies used psychiatric patient runs as a revenue generator. Daniel McCall, who was dropped off by an ambulance from a clinic to the run-down apartment he shared with three other mentally disabled men, was able to share how he and his roommates were taken to various clinics by ambulances. Although mentally disabled, McCall was able to clearly name who cared for him, kept his food stamp card and the names of clinics and how he and other spent hours smoking, watching TV or sitting outside until an ambulance took him home in the afternoon. Joseph Prekker, a U.S. Health and Human Services' Office of Inspector General investigator and other investigators at other agencies helped verify our findings when the Centers for Medicare and Medicaid Services, would not. Everywhere Langford traveled for this story, she talked to someone. Not all were cooperative. But those who were became critical sources for these stories.

Results (if any).

After the series ran in October, the Harris County District Attorney provided the Chronicle documents showing how she had been fighting Medicare officials for two years about ambulance fraud. Immediately following the series, federal investigators arrested a one-time nightclub backer who had hidden ownership in four private ambulance companies that billed Medicare more than $8 million to ferry mentally ill to clinics. In December, U.S. Rep. Kevin Brady, R-The Woodlands has asked the House Ways and Means Committee hearing into Houston-area Medicare fraud. Readers have pummeled us with tips to other fraud practices in the Houston area. Also in December, federal investigators arrested two men who owned a mental health clinic. Although no mention in the indictment was made of ambulance rides, our ambulance trip data indicated that at least $19 million had been paid to companies who dropped off or picked up patients at that clinic. Readers continue to contact us with possible fraud leads.

Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.

An owner of one of the companies featured was upset that we named a patient as riding in her company's ambulance when she had no records of a patient by that name. We had said in the story that she had no records of the patient. However, we included the incident because we had seen the patient in the ambulance and followed it to his home from a clinic. The same owner claimed she had not made as much as we reported, from Medicare. When asked what the right number was, the owner, a lawyer, declined to tell us how much she thought she made, insisting that we had no right to access Medicare payment numbers. We pointed out to her that Medicare is taxpayer-funded and that, yes, we do have every right to see them. She also claimed that she didn't "do" a lot of psych patient business. After we pointed out that we also had detailed ambulance trip data involving her company to clinics, she never contacted us again. Because the owner could not prove an error had been made and we had provided her side of the story in the original stories, we did not run a correction.

Advice to other journalists planning a similar story or project.

Take a deep breath and be persistent. This was one of the hardest stories Langford has attempted. It was hard because no on had ever written about private ambulances before, according to Nexis and Google. There was nothing in the Investigative and Editor's story database. We started from ground zero. Troll through the online databases of the U.S. Department of Health and Human Services Office of Inspector General reports and the Government Accountability Office (GAO) audits. You can search by keyword. Learn about your health care area's problems first. That will help you figure out a story plan. Spend some time cultivating your own stable of spirit guides/professional consultants. Langford attended a local EMS regional trauma service meeting. She contacted trade associations, company owners and talked to an instructor from a local junior college who teaches paramedics. These people will help guide you through the Medicare billing process. They'll also tell you what's wrong and what's right with the system. Set up a dozen or so Google alerts. There is a high volume of Medicare stories that are written daily. Slice out of that, what you're interested in with a Google alert. Become familiar with the Medicare billing contractor for your region. Sign up for their online alerts and newsletters. Even though CMS refused to discuss the Texas EMS billing problems, she had the provider "alerts" sent out by the CMS contractor TrailBlazer that stated "overpayments" to ambulance companies was the contractor's No. 1 problem in Texas. Learn Medicare's lingo and billing codes. Medicare does not distinguish between 911 operators and private ambulance except with its billing codes, also known as ICD9 codes. Once Langford was able to isolate that a0426 and a0428 were the payment codes used for "non-emergency" EMS service, she was able to make write more focused FOIAs asking just for that. The billing code a0428 is the code for "basic life support" and it is the code most used by private ambulance companies nationwide. Learn about origin/destination data. Medicare has EMS companies file their trips, indicating where they pick-up and where they drop-off patients. While the data can be pretty ugly, it can show you what type of facilities they are going to the most. Ask for it by date, payment made. There will be some redaction if the designation is a patient's home address. The street address will be scrubbed, but the zip code will not. Insist on the zip code even if the street address is redacted. Always follow-up on your FOIAs or you will be forgotten. It's easy to become overwhelmed with spreadsheets and calculations. One thing that really helped Langford was creating a spreadsheet of her major findings and facts then identifying the spreadsheet where it could be found. Ambulance service falls under Medicare's Provider B category. You can buy Provider B payment data by year but it's not for beginners to CAR. We purchased it at the end of our reporting to verify what we were seeing from the six-year snapshot of payment totals we already had for free.