Welcome to the “Non-Emergency Medical Transportation” (NEMT) presentation. According to the latest 3-year cycle Payment Error Rate Measurement (PERM) report, Medicaid rejected over 80 percent of transportation and accommodations claims due to no documentation or insufficient documentation. This emphasizes the need for NEMT providers to ensure they are following State rules for reimbursement of these claims. The learning objectives of this presentation are for learners to: Identify general Medicaid-covered NEMT benefits; Identify methods States can use to authorize available NEMT options; and identify common medical transportation fraud and abuse issues. This course will define NEMT and differentiate it from emergency medical transportation. It will also review general Medicaid transportation benefits; general Medicaid driver qualifications; common Medicaid transportation fraud and abuse issues; and provider tips to help prevent fraud and abuse. The course encourages providers to regularly check that their employees and contractors are not excluded from Federal health care programs. As we go through this presentation, keep in mind that while all States must meet the Medicaid rules outlined in the Code of Federal Regulations (CFR), every State’s Medicaid program is different. Providers are responsible for knowing and abiding by the specific Medicaid rules for each State where they furnish services and for each of the programs for which they furnish services. Providers should also be aware of State regulations for owning, maintaining, and operating the vehicles used for transport. State-specific examples are cited in the presentation to illustrate general rules States may follow, even though the rule may not apply to every State or the same rule may be applied differently by each State. The CFR requires States to “specify that the Medicaid agency will ensure necessary transportation for beneficiaries to and from providers” and “describe the methods that the agency will use to meet this requirement” for eligible, qualified beneficiaries. Refer to 42 CFR section 440.170, especially (a)(1),(3), for definitions and Social Security Act section 1902(a)(70) for provisions governing NEMT brokerage programs. States are required to ensure transportation to and from Medicaid providers only if there is an unmet transportation need. If there is no unmet need, the State is not required to provide transportation services. When there is a stated unmet transportation need, the State can inquire if there is a reason the beneficiary cannot obtain transportation (for example, if there is a car in the household, the State can ask why it is not available) Transportation may be provided by mass transit systems, taxis, cars, or vans. Depending on the type of vehicle, the beneficiary may be asked to share the transportation with other Medicaid beneficiaries. In some States, volunteer resources may be used. Generally, pickup and drop-off locations, and the transportation timing, must be specified in advance for each trip. Is this true for Medicaid emergency transportation, too? No Emergency transportation is different. An emergency is any event that puts the health and life of a Medicaid beneficiary at serious risk if treatment is delayed. Real emergencies occur when the medical needs of a beneficiary are immediate and due to severe symptoms. This would include such events as uncontrolled bleeding, heart attack, an automobile accident, or other serious trauma. State Medicaid programs reimburse emergency transportation providers when they furnish services to eligible beneficiaries. State Medicaid rules cover how a State furnishes transportation services and how providers should comply with those rules. States can manage their own transportation services, or they can contract with another entity, such as a broker, to manage them. Additionally, a State may furnish its Medicaid NEMT services through one or multiple managed care plans. Regardless of who manages the services, State Medicaid rules require the transportation provider to have a contract with the appropriate State Medicaid agency (SMA) or State designee before furnishing any services. If the provider is not under contract with the appropriate SMA or designee in the State where the services are furnished, the agency cannot reimburse the services even if the services are medically necessary and the beneficiary is eligible and qualified. Once a provider has a contract agreement with the appropriate agency, many States require preauthorization of transportation services before services are provided to beneficiaries. States preauthorize transportation in a variety of ways. For example, one State may expect a physician to authorize the need for the transportation, but another State may only want to know that the beneficiary’s location drop-off was to a medical service, while a third State may expect the medical facility to phone in the medical transportation request before services are furnished. Each State establishes its own preauthorization rules. There are other important State Medicaid rules. Some States pay a transportation broker or managed care organization a capitated fee or a per-member per month payment for each plan member and loaded mileage is not necessarily required. However, some States’ Medicaid rules may include loaded mileage, location, and wait times. In those States, contracted transportation providers are paid only for loaded mileage. Loaded mileage means the time the beneficiary is actually in the vehicle. If a driver arrives at a preauthorized destination for pickup and transport and the beneficiary does not show up for the appointment, then that person is considered a no-show and the provider may not be permitted to bill for the trip. When that is the State rule, no-shows can cause frustration for the provider, but providers should not bill a claim for no-shows. Claiming loaded mileage when the beneficiary was a no-show is illegal. It is called “billing for services not rendered” and could result in prosecution under the Federal or State False Claims Act or similar law. A guidebook from the Centers for Medicare & Medicaid Services (CMS) on NEMT has three suggestions, and the rationale behind them, for dealing with NEMT abuse issues: Client education on rights and responsibilities. While all clients should be informed of their rights and responsibilities under the Medicaid program, specific educational sessions should be considered on how to access transportation, the appropriate use of NEMT services, the penalties for misusing the transportation system, how to report suspected fraud and abuse; lock-in of clients to a single provider; and use of client sanctions. For example, clients found to abuse the system with repeated “no shows” could be required to make a confirming telephone call on the day of the ride or have their request cancelled. State Medicaid rules may require beneficiaries to be picked up at home and taken to their medical services, and then be dropped off at home after they receive services. If a trip is to a nonmedical destination like the grocery store, shopping mall, to meet a friend, or something similar, State Medicaid rules do not cover the trip, and the trip cannot be legally billed. Finally, providers need to know that wait times typically are not separately reimbursable, but there may be State rules governing when a driver should wait for an individual. In some instances, reasonable wait times may be included in determining overhead costs and transportation rates. Check with the State or managing entity for any wait time rules in your State. Certain modes or types of transportation can be offered by State Medicaid programs. Let’s see what types of vehicles are covered. States decide the vehicle types allowed for NEMT and when, if at all, they allow exceptions. The vehicles that are typically used for beneficiary transport to and from covered medical services include wheelchair vans, taxis, stretcher cars, and buses. The SMA may also choose to use other types of transportation, such as air transportation or an ambulette. Check with your SMA for details. While different States have different rules, in most locations, ambulances should only be used when other types of transportation vehicles are not medically possible or available. For example, an ambulance would be appropriate if a beneficiary is medically unable to sit upright for transport and a stretcher van is not available. States may favor cost-effective transportation alternatives, so if a bus is a reasonable option, they may preclude the use of a taxi. Let’s review what we have covered so far. Answer the following question: For a transportation provider to receive reimbursement for furnished services, the transported beneficiary must: A. Have his or her own car; B. Be ineligible for Medicaid; C. Be eligible for Medicaid; or D. Take an ambulance. The correct answer is C. Be eligible for Medicaid. States administer the Medicaid transportation benefit themselves or contract with other entities to provide or manage the services. Other entities that can provide or manage NEMT services include brokers, managed care plans, or transportation companies. States determine the qualifications that NEMT drivers must have for the vehicles they operate. For example, States vary in their driver requirements for taxis and vans. Other standards might include limiting the number of points a driver can have against his or her license, certifying the health of a driver, and carrying vehicle liability insurance. Drivers may also have to complete additional training, such as defensive driving or basic first aid. States may also require a criminal background check. Each State determines what qualifies as a criminal background check. For example, a recent Office of Inspector General (OIG) report found that some NEMT providers in one State had not completed the required online criminal background check. States require vehicles to be licensed, and some States may require vehicles to be inspected on a regular basis. States may also require the entity furnishing the services to maintain specific vehicle documentation. States may, for example, require providers to have documented proof the vehicle belongs to the correct entity and the identification number matches the ownership papers; the vehicle is legally licensed; the vehicle license plate is on the correct vehicle;and the vehicle is in good condition, safe for transport, and receives regular maintenance. In addition, States may require that the entity has proof the vehicle has the current State-required liability insurance. Verifying drivers’ qualifications and ensuring vehicle safety offer protection for the company, its employees, and the Medicaid beneficiaries transported. The same OIG report cited on the previous slide found that current vehicle registrations and inspections could not be verified for several claims. Is this statement true or false? State Medicaid transportation services can only be furnished by the State. The correct answer is false. The State can furnish medical transportation services to eligible beneficiaries or contract with other entities to furnish the services. Most transportation providers are honest and want to do the right thing. For example, a recent OIG report on California NEMT services found that 89 percent of sampled claims were compliant. On the other hand, there are providers billing fraudulent, wasteful, or abusive claims. Any payment a provider receives for an improper claim must be returned to the SMA. Properly billing claims is the responsibility of everyone involved with Medicaid services. Transportation service entities and drivers are all accountable for following Medicaid rules. Failure to comply with Medicaid transportation rules can result in penalties, fines, and prosecution, as previously discussed. Take the time to learn the definitions of fraud and abuse, understand common transportation schemes, and learn tips for preventing fraud and abuse. We will start by defining Medicaid fraud and abuse. The CFR defines Medicaid fraud as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.” Fraudulent acts can include both simple and elaborate schemes. An example of the latter involved a group of 18 persons, including seven former employees working for the Texas Medicaid Medical Transportation Program call center and the Texas Health and Human Services Commission (HHSC). The employees working at the call center authorized hundreds of fictitious claims by falsifying documentation for medical transportation billings using the names of individuals they knew. Those claims then went to employees working at the Texas HHSC, where the fictitious claims were processed. The employees involved in the scheme split the embezzled proceeds between themselves and the individuals whose names were used on the claims submitted. Eight of the people, including some of the former State employees, were convicted in 2012. Some were sentenced to terms of imprisonment ranging up to 18 months. Others received probation. All were ordered to pay restitution. This particular scheme was elaborate. Not all schemes are elaborate like this one. A scheme can be as simple as adding a few extra miles to the transportation log, known as padding, or billing for services not rendered. However, whether a fraud scheme is elaborate or simple, it is illegal. An owner of a Massachusetts medical transportation company was sentenced to 18 months in prison and ordered to repay over $475,000 for billing for rides for deceased beneficiaries and for services never rendered. Abuse is different from fraud The CFR defines Medicaid abuse as “practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care.” Abusive practices can include charging excessive prices for furnished services, or furnishing medically unnecessary services. Two ambulance companies in Connecticut paid almost $600,000 to settle allegations that they provided ambulance transportation for dialysis patients who did not have a medical need for ambulance transportation. Let’s look at what happened to some individuals who were caught in fraud schemes. Some States reimburse parents for the cost of medically necessary medical trips. These parents are considered independent contractors. For example, a woman in Idaho was State-approved to regularly transport her child from their home in Idaho to Utah for necessary medical treatment. However, from late 2007 through 2010, she billed for trips that never occurred. The State Attorney General’s Medicaid Fraud Control Unit (MFCU) filed criminal charges against her. She was charged with three counts of Medicaid provider fraud and one count of grand theft. She pleaded guilty to two Medicaid fraud charges for falsifying her medical trip records and for receiving payment for the claims billed. On June 4, 2012, she was sentenced to jail In addition to jail time and 5 years of probation, she was ordered to pay fines, restitution, and investigative costs of nearly $21,500. Providers normally use ambulettes to transport beneficiaries who have a disability or who are convalescing and need additional care. Beneficiaries who use a wheelchair may be transported by ambulette. It is cost prohibitive to use ambulettes for those who do not need them. In the following case, the provider billed for ambulette services but furnished no services. On May 17, 2011, an employee who assisted in the operation of a transportation company was indicted and charged with two counts of theft by deception for participating in a fraud scheme. She helped bill for ambulette services that were not furnished. On May 2, 2012, she pleaded guilty to the charges and was later sentenced to 5 years of community control, which is a combination of probation and additional sanctions. She was ordered to pay $57,048.74 in restitution. If she violates the community control, she will receive an 18-month prison sentenced. An ambulance company billed for ambulette services when it did not provide the personal assistance required for such service. The cost to Medicaid is four times greater than the standard service. In January 2015, the company agreed to a $300,000 settlement. The owner of another ambulance company modified physician-ordered forms authorizing taxi service for patients to indicate ambulette service was ordered. The owner was sentenced to 6 months in jail, 5 years of probation, and had to repay the $200,000 he stole from Medicaid. In addition, his company was fined an extra $10,000. On August 2, 2011, the owner of an ambulance company was indicted and in 2012 was convicted of unnecessarily transporting ambulatory beneficiaries by ambulance and for billing ambulance services when he used unmodified vans. On January 23, 2012, he pleaded guilty to conspiracy to commit Federal health care fraud. On April 2, 2012, he was sentenced to 6 months in prison and 2 years of supervised release. He was also ordered to pay a fine of $100 and restitution in the amount of $124,605.24. Previously in the presentation, we discussed that beneficiaries who qualify for transportation services may only use these services for transportation to and from providers. Providers may not be reimbursed for services, even if they are furnished, if the services do not meet Medicaid rules. On December 18, 2012, a taxi driver in Alaska was convicted of violating Medicaid rules by taking beneficiaries to locations other than medical appointments, purchasing unused vouchers from investigators, and submitting vouchers for reimbursement that did not reflect the actual services he furnished. The driver was convicted of committing medical assistance fraud and was ordered to pay a $500 fine and restitution. He was also sentenced to 3 years of probation and received a lifetime ban from billing for Medicaid services. This action is called termination from a State Medicaid program. Providers who are excluded from one State’s Medicaid program are, by law, excluded from any health care program funded in whole or in part by the Federal government. This includes all Federal health care programs and all State Medicaid programs. Understanding exclusions is important for every provider and will be discussed in greater detail later in the presentation. Drivers must be qualified to transport Medicaid beneficiaries in accordance with State requirements. Otherwise, the services are ineligible for reimbursement. On May 1, 2012, a Wisconsin specialized medical vehicle transportation company was convicted of falsifying drivers’ records. The company documented that its drivers were trained and certified to furnish the services rendered to Medicaid beneficiaries. Former employees testified that the documentation was false. The company was convicted of 18 counts of medical assistance fraud and ordered to pay a $10,000 fine and court costs. As stated previously, an ambulance company billed for ambulette services when it did not provide the personal assistance required for each service. A major U.S. city paid nearly $2.5 million to settle a whistleblower suit under the False Claims Act. The whistleblower contended that the city instructed its billing contractor to upcode all 911-dispatched transports as more expensive advanced life support trips, even when such services were not medically necessary. According to court documents, the projected overpayment, based on a statistical sample that showed a 100 percent error rate, could have been as high as $27 million. The whistleblower also reported similar violations by 11 other cities that used the same billing contractor, which resulted in an additional $1.69 million recovered. Medicaid fraud and abuse are serious offenses, and providers should do all they can to prevent them. Let’s take a moment to discuss fraud-prevention tips. All providers are responsible for preventing Medicaid transportation fraud. Over the next few slides, we will discuss tips for preventing it. Providers should, within the scope of their authority and job duties, document the information the State wants; document furnished services completely and accurately; verify services were furnished according to the documentation; and bill correctly. For example, brokers, company owners, and drivers each have documentation responsibilities and should be sure their documentation is complete and accurate. But only brokers and owners have responsibility for verifying services were furnished according to what was documented. Let’s take a closer look at each of these tips. The Social Security Act requires all Medicaid providers to keep records and furnish them to the State upon request. Each State determines what must be documented, and providers are responsible for keeping the information and producing it if the State asks for it. Transportation brokers and companies typically have their own documentation requirements in addition to what the State wants. To make sure records are documented appropriately, providers should develop and implement specific policies and procedures in this area and see that their drivers are fully trained to meet the expectations. Policies and procedures should emphasize the importance of drivers documenting records accurately and completely and provide for disciplinary action, up to and including termination, for falsifying transportation records. The main goals of documentation are to submit claims that represent the services furnished and justify the claims billed. These goals are unattainable when records are inaccurate or incomplete. At a minimum, all States require providers to document the beneficiary’s name and Medicaid identifier, the pickup and drop-off locations, the date and time the services were furnished, and the number of miles traveled with the beneficiary in the vehicle. Drivers should only document the number of loaded miles, as discussed during this presentation. Although there is no rule requiring it, transportation records should be recorded using ink instead of pencil. Some providers furnish drivers printed computer sheets and allow them to document information directly on the sheets. Include this process in the policy, so if audited, the auditor understands why there is written information on the computer-generated documents. Remember, if a service is not documented, there is no point in submitting a claim for reimbursement. Who is responsible for verifying services? Some States and brokers require drivers to obtain the beneficiary’s signature on the transport record at the end of the trip. Even if the beneficiary’s signature is required, it is the responsibility of management or a designee to verify documented services were furnished according to the record. This can be done by making random calls to beneficiaries listed on the record and to personnel at the medical appointment location verifying beneficiary arrival and services. Once services are verified, they can be billed to reflect the actual services furnished. The next slide reviews the importance of accurate billing. State fee-for-service transportation services are normally billed on Form CMS-1500. Instructions for the CMS- 1500 include the following: “NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties,” so be sure claims are coded correctly and represent the services furnished. Be sure to teach drivers not to embellish their records. This is for their own well-being. CMS offers some tips for improving the outcome of claim submissions. Tips include using only original red-ink-on-white-paper CMS-1500 claim form; using black ink on the form; avoiding hand-written, printed, or stamped information on the form; making sure there are no staples, clips, or tape on the claim form; removing any perforated edges on the claim form; using lift-off correction tape if making corrections to the form; and including any required documentation within the claim form. Providers will want to take one final action to protect themselves and their businesses from improper billings. Providers need to have a policy and procedure in place to check for excluded individuals and parties. As part of doing business, providers should always be diligent in screening all employees and contractors before hiring or contracting with them and repeat the checks monthly to determine whether they are excluded from participation in Federal health care programs. The U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) has the authority to exclude individuals and entities from participating in Federal programs for various reasons. Reasons include being convicted of certain crimes, losing one’s license for professional competence or financial integrity, or engaging in conduct prohibited by Medicaid rules. When HHS-OIG excludes individuals or entities from participation, it places their names on the List of Excluded Individuals and Entities (LEIE.) As indicated earlier, individuals placed on this list are excluded from all federally sponsored health programs, including all State Medicaid programs. In the past, providers were also encouraged to check the Excluded Parties List System. This has been replaced by the Exclusions Extract on the System for Award Management (SAM). SAM combines the Federal procurement systems and the Catalog of Federal Domestic Assistance into one new system and includes the functionality of the Central Contractor Registry, Federal Agency Registration, Online Representations and Certifications Application, and the Exclusions Extract. SAM is a Federal government site and is intended to streamline information for providers. It is important to note that an HHS-OIG exclusion does not technically prohibit an individual or entity from participating in Federal programs, but it does prohibit them from receiving Federal payment for items or services furnished by an excluded individual or entity. Federal health care programs will not pay for items or services furnished by an excluded individual or entity. Furnished is a key word–it refers to items or services provided directly or indirectly by an excluded individual or entity. According to HHS-OIG, “The effect of an OIG exclusion is that no Federal health care program payment may be made for any items or services furnished by an excluded person or at the medical direction or on the prescription of an excluded person.” All claims furnished or submitted by an excluded individual or entity may be considered overpayments subject to recoupment. In addition, the transportation entity may be liable for civil monetary penalties and possible exclusion from Medicaid and other Federal health care program participation. Almost anyone can face exclusion. CMS has issued guidance to SMAs stating that they should require providers to screen their employees and contractors for exclusions by checking the LEIE database on a monthly basis. The guidance further advises States to require all providers to immediately report any exclusion information discovered. The guidance to the States is found in the State Medicaid Director Letter Number 09-001. Providers are encouraged to check the SAM Exclusions Extract, as well. To prevent hiring excluded individuals or entities, implement a process for exclusion screening. It is the business owner’s responsibility to make sure excluded individuals are not working for him or her. Check for excluded individuals by visiting the LEIE on the HHS-OIG website and the SAM Exclusions Extract on the SAM website. If additional information is needed, it is available in the Exclusions FAQ section on the HHS-OIG website. What step needs to be taken if fraud or abuse is suspected? If you suspect fraud or abuse, report it! Most States do a preliminary investigation and determine whether to send the case to the MFCU. Some States may have regulatory language requiring reporting simultaneously to the SMA and MFCU. Check with your SMA for reporting procedures and document any cases reported to the SMA or MFCU. Fraud and abuse carry consequences for perpetrators. Penalties depend on the act and the intent. Those found guilty might have to repay Medicaid funds and pay fines and penalties; might be excluded from Federal health care programs; or might face probation, house arrest, or prison. Medicaid fraud and abuse are serious offenses; be part of the solution. Medicaid NEMT is an important and necessary service for beneficiaries who do not have the means to get to and from their medical appointments. Everyone associated with Medicaid transportation must play a part to stop fraud and abuse. Be aware of the rules pertaining to each State Medicaid program where services are furnished. Be sure furnished services are documented, and the documentation is accurate and complete by verifying services occurred as recorded. Once services are verified, bill them correctly, and be sure there are no excluded individuals or entities on staff. If the rules of Medicaid and these tips are followed, the Medicaid transportation program will be protected along with the provider, the provider’s employees, and the beneficiaries. This presentation was current at the time it was published or uploaded onto the web. Medicaid and Medicare policies change frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. Use of this material is voluntary. Inclusion of a link does not constitute CMS endorsement of the material. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.