This week an ambulance company owner was convicted in Texas of a $3 million fraud conspiracy.  In addition to billing for van transports as ambulance trips, the OIG press release about the conviction noted the owner had “instructed a licensed emergency medical technician (EMT) to create fake ambulance transport records which included fake vital signs, patient narratives and transport mileage.” Wow, that’s an EMT who faces a huge bucket of hot water! I started to think about the many times I heard billers tell me that “the chief thinks we’re staffed ALS so we should bill all ALS,” or “my manager tells us to bill the claims.” In other words, many billers are instructed to bill, but they are not always comfortable doing so.

I’ve also presented documentation training where field providers asked about similar issues – what should they do when they are instructed to write a trip report a certain way? Regardless of whether a field provider, biller, manager or owner, everyone involved in healthcare has a responsibility to do things the right way. If the organization accepts taxpayer dollars from Medicare (as stated in the Medicare application), the assumption is that “the provider will not knowingly submit false or fraudulent claims to Medicare or claims with deliberate ignorance or reckless disregard for their truth or falsity.” What should an EMT, paramedic or biller do? How do you say “no” to your boss?

First and foremost, remember that a biller or a field provider is responsible for what they do as individuals. It is not an acceptable excuse that someone “did as they were told.” People are not robots; they have free will and choice (though it doesn’t feel like it’s a good choice when the decision is “do I keep my job and take care of my family or do I push back?”). In general, people have a hard time saying “no.” Here are some steps to take where you have to say “no” - when asked to do something that feels fraudulent or unethical.

  • Start the conversation with the boss or manager. The best approach is to give the boss the opportunity to do the right thing. Arm yourself with information. The most comfortable safety net for having this discussion is the rules. Go get a copy or link to the rules and familiarize yourself with them. The CMS Ambulance Services Center page has links to ambulance manuals, the definitions for the levels of service, compliance guidance, etc.. Review the rules and state the issue as you understand it.


  • Listen to the response. It is possible that the biller or EMT’s interpretation of an issue was off the mark. Remember, it is not about WHO is right; it’s about WHAT is right.


  • Understand that the boss may not like the fact that an employee is drawing attention to the boss’ error. Try to be objective in your presentation of the rules and try to avoid a power struggle. Avoid making accusations. The rules can be complicated. It is quite possible the boss did not understand the complexities or nuances of billing for an ALS assessment or why the documentation of a two-man sheet lift is not a description of medical necessity for ambulance.


  • Go to the company’s compliance officer or call the compliance hotline. Explain your concern and ask for support. Compliance officers are there for a reason. Most companies are not like the Texas provider noted above. Most ambulance providers want to operate the right way, the compliant way.


  • If the push remains to do something inappropriate and attempts to resolve the issue are not successful, it may be time to seek personal legal counsel.

Yes, there can be a risk in speaking up. Remaining quiet has a greater risk – there can be potential problems related to fraudulent activity, damage to your reputation or a negative impact on the ability to get a future job. Personal health could suffer as anxiety and stress can lead to more serious conditions.

Saying “no” is not always easy. However, taking the right path assures personal integrity, a good reputation and much better sleep at night.

Let us know if we can help!

About the author:  Maggie Adams is the president of EMS Financial Services, with 25 years’ experience in the ambulance industry as a business owner and reimbursement and compliance consultant. Known for a practical approach and winning presentation style, Maggie has worked with medical transportation providers and billing companies of all kinds to provide auditing services, assess their billing for best practices and support their billing and documentation training efforts. “Like” EMS Financial on Facebook, follow us on LinkedIn or for more info, contact Maggie directly at or visit