How NEMT Fleet Operators Can Ensure Compliance

Non-Emergency Medical Transportation (NEMT) fleet operators ensure patients can access the necessary medical care. However, some individuals exploit the NEMT system, exposing the industry to fraud and abuse.  

Such fraudulent activities can result in significant financial losses for transportation providers and the government.  

Typical forms of fraud include:  

• Billing for fraudulent services 
• Upcoding trips 
• Using patients’ medical information without their consent  

This blog post will explore how NEMT fleet operators can ensure compliance and prevent fraud and abuse. It will also outline the importance of compliance and the role of technology in detecting and preventing fraudulent activities.  

By understanding the risks and taking proactive measures to prevent fraud and abuse, NEMT fleet operators can ensure that the industry remains healthy for patients and providers.  

What are Fraud and Abuse in NEMT?  

According to Medicaid rules, fraud and abuse are distinct concepts in NEMT.  

Fraud is any deliberate act or misrepresentation by someone, being fully aware of the consequences, to corner unauthorized benefits.  

On the other hand, abuse refers to practices that conflict with sound business, fiscal, or medical practices, resulting in an unwanted cost to the Medicaid program. Such methods also lead to reimbursement for medically unnecessary services that do not meet recognized standards for healthcare professionals.   

Why is Compliance Important for NEMT Companies?  

Ensuring compliance is crucial for NEMT companies to avoid significant financial losses and legal headaches.  

Intentional abuse can damage the integrity of the entire healthcare system and erode trust and credibility among patients, providers, and payers.  

The onus for ensuring compliance often falls on the NEMT company, which may face fines or penalties for not having a process to flag and deal with fraud and abuse. The company may also be suspended or lose its contract with its payers, leading to substantial revenue loss.  

Compliance Checklist for NEMT Service Providers 

Preventing fraud in Medicaid transportation is a responsibility that NEMT providers must shoulder.  

Providers must document all necessary information required by the state and ensure that records of provided services are accurate and complete. Providers must also verify services rendered as stated in their documentation and bill correctly within their authority and job responsibilities.  

Using NEMT software solutions can simplify daily NEMT business operations, including tracking and implementing compliance processes.

Documentation and Record Keeping  

According to the Social Security Act, all Medicaid providers must keep records and provide them to the state upon request. To ensure compliance with state and company documentation requirements, providers should establish clear policies and procedures for transportation documentation.  

Ensuring their drivers have the proper training to maintain accurate documentation is crucial. This process will enable the fleet operator to accurately record and produce all required information if the state requests it.  

Proper documentation is vital for submitting claims that accurately reflect the services provided. To ensure this, NEMT providers should enforce strict disciplinary measures for any instances of falsification or misrepresentation by their drivers.  

The ultimate goal of documentation is to support the claims service providers are billing for and ensure compliance with state and broker requirements.  

Service Verification  

To ensure the accuracy of transport records, the fleet manager or a designated employee should regularly verify the services provided. This verification is done manually by contacting service beneficiaries and personnel at the healthcare provider rendering medical services.  

Making random calls and checking the beneficiary’s signature on the trip document are two ways to do this.  

However, systemizing a process for selecting trips for verification and documenting service verification will ensure NEMT operators meet compliance requirements.  

Accurate Billing  

The claims submitted must accurately reflect the services provided. After services are verified, fleet operators can easily bill them correctly.  

Providers usually bill state transportation services using the Centers for Medicare & Medicaid Services Form-1500 (CMS-1500). Instructions for the CMS-1500 include a warning that anyone who knowingly files a statement of claim containing any false, incomplete, or misleading information may commit a criminal offense and face civil penalties.  

Therefore, it’s essential to code claims correctly and accurately to represent the services provided. Educating drivers not to exaggerate their work records is also critical since this is a serious legal violation.   

To ensure that claims are processed correctly, providers should follow the guidelines set by CMS for claim submission.  

CMS’s guidelines for claim submissions mandate:  

• Using the original CMS-1500 claim form 
• Printing in dark ink 
• Making corrections with lift-off tape 
• Avoiding handwriting or stamps on the form 
• Not using staples, clips, or tape 
• Not removing perforated edges 
• Submitting any required documentation along with the claim form

Checking for Excluded Individuals and Vendors 

Protecting their business and avoiding improper billing is crucial for NEMT providers. However, by providing service to or utilizing ineligible service providers, NEMT operators risk being blocked in the federal medical transport system.

By leveraging the right NEMT software solution, operators can automate tracking credentialing and Medicaid eligibility.

In the absence of a software solution, a policy for screening all employees and contractors before hiring or working with them is essential to ensuring compliance. Repeating these checks regularly to ensure their staff are eligible for employment in Federal health care programs is also important.  

The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) can bar individuals and organizations from participating in federal programs for various reasons, including criminal convictions, loss of professional or financial competence or integrity, or violation of Medicaid regulations.  

The HHS-OIG maintains a list of individuals and entities not allowed to participate in federal programs, known as the List of Excluded Individuals and Entities (LEIE). Providers should check the Exclusions Extract on the System for Award Management (SAM) for this information.  

Businesses must also verify that their riders are eligible for Medicaid transportation. Business owners can do this by collecting their customer’s personal information along with their Medicare Beneficiary Identifier (MIB) before the ride and matching patient eligibility using these online services: 

• Medicare Administrative Contractor (MAC) online provider portal 
• MAC Interactive Voice Response (IVR) system 
• Billing agencies, clearinghouses, or software vendors 
• Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS) 

Conclusion  

The integrity of Medicaid NEMT is essential for people who rely on this service to attend medical appointments. Therefore, all parties involved in transportation must work together to prevent fraud and abuse.   

It is essential to be aware of the specific regulations of each state’s Medicaid program and ensure that NEMT services are documented accurately and billed correctly. By adhering to these guidelines, providers can avoid steep fines and penalties for noncompliance.