How to Overcome Fraud in NEMT Services
All businesses across all industries face the risk of fraud. This includes the non-emergency medical transport (NEMT) sector; in fact, the transportation industry at large experiences a lot of fraudulent activity in billing and other areas.
Detecting fraud can be quite challenging—it requires a thorough analysis of all data transactions and comparing them to known models of fraud.
State governments and private companies are constantly reviewing ways to reduce the risk of fraud. These can have a dangerous effect on passengers and patients, especially those who need efficient services for medical treatments.
This guide outlines tips to overcome all kinds of fraudulent activities in NEMT services.
- Medical Transportation Fraud
- Types of Fraud Common in NEMT
- Tips to Prevent and Detect NEMT Transport Fraud in 2023
- How to Protect Your NEMT Business
- Prevent Fraud in NEMT With the Right Technology
Medical Transportation Fraud
Transport providers are required to meet federal and state regulations. Unfortunately, many transport service companies have seen integrity concerns rise in recent years. This is mainly due to fraudulent billing activities and patient safety.
NEMT companies usually work with passengers who are covered by Medicaid. Since states are required to provide NEMT services to beneficiaries, they have set up some regulations for transport providers. But they also have considerable discretion in delivering their services.
As a result, providers have different ways of providing for their passengers’ needs. Some work directly with state transportation departments, while others partner with brokers or managed care organizations (MCOs).
Given this wide range of services and the gaps in Medicaid data systems, it is essential to have measures in place to prevent fraud in NEMT.
Types of Fraud Common in NEMT
Providers experience several types of fraud when they work with all kinds of healthcare providers and facilities, and that includes government NEMT programs.
Here are some of the most common ones:
These issues in the NEMT industry include billing for services not rendered, additional fees for undisclosed items, and client claims after payment has been submitted to other providers.
Some providers face fraud when it comes to the eligibility of a patient for Medicare or Medicaid programs. Many NEMT companies do not require prior approval before providing standard services to passengers. The priority is bringing patients where they need to go.
State regulations require that some NEMT services require prior approval, especially when it requires extended service hours, trips that exceed the maximum mileage, and trips that require lodging, food, or unusual transportation modes (such as air ambulances).
Many NEMT providers find that some passengers are not eligible for such services, and the trip remains unpaid due to a lack of approval at the state level.
Many states require specific certifications and permits for an NEMT service provider to operate. However, some states are not strict enough with these regulations, resulting in many transport providers that lack first aid certifications, vehicle and driver permits and licenses, or even staff with criminal backgrounds.
Some drivers also declare they completed a service or trip, even though they did not pick up any passenger. When they make these claims, they can receive payment for services they did not render.
Additionally, if a driver does not have the training to provide medical aid, this puts the safety of the passengers at considerable risk. If a passenger suddenly requires medical attention in the middle of a trip, they will not get the help they need.
Another form of fraud is passengers taking unauthorized rides. Most NEMT companies receive only a name, a contact number, and a pickup point. Some passengers take advantage of this and use fake identities to receive transport services.
Often these passengers use their Medicaid or Medicare privilege to take trips unrelated to medical treatments or therapies. They book a subsidized trip ostensibly for a checkup, but then go somewhere else, like a movie theater or grocery store. Some even pass on the discounted trip to another person.
Sometimes drivers and passengers partner up to defraud transport companies through NEMT ghost rides. The passenger schedules a long-distance trip, and the driver picks them up. However, they do not go to their destination and instead share the profits.
Tips to Prevent and Detect NEMT Transport Fraud in 2023
The industry is facing a significant challenge in avoiding and overcoming instances of fraud. They are a drain on resources and waste efforts to provide help to those who truly need medical assistance.
Dealing with fraud requires a combination of technology and human persistence.
Preventing Improper Billing
One way for a service provider to control improper billing is to leverage robust NEMT software to ensure that each transaction is certified and completed. They can review each passenger, the service provided, and the hours or miles of the trip.
Billing systems can also verify the eligibility of a passenger to a state Medicaid program, which reduces issues arising from eligibility.
Here are some ways NEMT companies can deal with improper billing:
- Unannounced internal audits
- Medical records reviews
- Passenger claims monitoring
- Data analysis
- Prepayment edits
Monitoring Medicaid Eligibility
This type of fraud can be reduced using NEMT software as well. A digitized system can review all patient documents and verify identities before they can schedule a trip. Coordination with state government agencies and brokers will be easier to review whether the service requires prior approval.
Prior approval, GPS tracking, and patient verification can prevent driver fraud as well. This eliminates payments made for trips that never happened.
Reviewing Fraudulent Credentials
State agencies and transport providers can institute additional screening activities to check a provider’s permits, licenses, and certifications.
Transport companies can also use NEMT software to ensure they have met these requirements. They can easily track whether their staff or drivers have the required licenses and certifications.
They can also use GPS data to track drivers and passengers at all times. This reduces the instances of fake trips that drivers and passengers could claim.
Here are ways to limit fraudulent credentials:
- Check for exclusions in federal healthcare programs
- Disclosure of criminal convictions for staff
- Review required licenses, certifications, and training
- Review driving records
- Daily, in-person checks of vehicles and staff
- Criminal background checks
- Require provider re-enrollment for updated licenses
Reducing Unauthorized Rides
The best way to resolve unauthorized rides is to use technology to authenticate passenger identity. From initial scheduling, NEMT companies can check whether the patient is eligible for the requested service.
Drivers should be trained to detect suspicious behavior from passengers. They must be able to confirm that each passenger was dropped off at the indicated facility on the booking.
Companies can also ask for additional identification to certify passenger identities. If the passenger wants to apply for several claims, the NEMT provider must review each one. They must confirm that the patient is eligible before they provide the service.
Additionally, you should consider using cameras in your vehicles, this will help you prevent trips with the empty vehicle when the driver is partnering with the passenger and just does rides that were never required.
How to Protect Your NEMT Business
Fraud and scams happen every day in any industry. In an industry like NEMT, which deals with several stakeholders, including state agencies, brokers, and other third-party providers, there are many opportunities to take advantage of the system.
The best way to reduce fraudulent activities is to implement strict guidelines and regulations. These should closely monitor the activities of providers, passengers, and brokers alike.
Along with such checks, all businesses and entities in the NEMT industry should also use the best tools to track data and behavior.
Choosing the right NEMT software is the best way to overcome the misuse of NEMT services. It can monitor trips, schedules, and claims to ensure that the passenger is truly eligible. GPS tracking ensures that all trips are completed by the drivers.
It Provides Transparency
The software platform can automate the medical billing process, ensuring all requirements are met. This can be done even before a payment claim is made to the government or health provider.
This process provides transparency for NEMT companies, patients, brokers, and healthcare agencies. All parties will know the kind of service the passenger will receive.
The system can also break trips down to hours and miles, so stakeholders know what they are paying for.
It Tracks All Trips
Companies will always know all drivers’ locations. The software easily monitors whether the driver is on their way to the pickup point. It also logs when the passenger is in the vehicle.
The tracking system monitors the trip from beginning to end, following the vehicle and the passengers throughout the journey. It can use GPS data to confirm if the driver is on-site. It prevents unauthorized rides and scams between drivers and passengers.
It Can Review Fraudulent Claims
Robust NEMT software reviews all claims and insurance policies. The provider and broker can work together to review their passenger’s policies. If a passenger does not meet certain requirements, the provider can offer a service that will suit the patient.
This also reduces unauthorized rides because NEMT software can manage all scheduled trips with strict passenger identification. Automated scheduling and efficient routing ensure customer satisfaction and streamlined operations.
Data monitoring and analysis also review whether the passenger altered their schedule. The transport provider can verify the veracity of the schedule change and intervene if the change was unauthorized.
Prevent Fraud in NEMT With the Right Technology
It’s an exciting time for the NEMT industry. Demand is rising, and more people are seeing the benefits of using transport services for their medical checkups and appointments.
However, the rise of fraud and scams can affect providers, patients, and government agencies. It can give the industry and providers a bad reputation and leave patients without the medical attention they need.
Leverage NEMT software to meet the regulations and guidelines set by the state. It can also increase your revenue, build trust in your passengers and brokers, and eliminate wasted time and resources.
About the author
As RouteGenie's Marketing Director, Yurii gained deep knowledge in the NEMT industry. He is an expert in marketing, utilizing all marketing channels to build RouteGenie's brand and to make sure NEMT providers have access to powerful NEMT software that can boost their growth. Yurii shares his knowledge by writing content on topics related to marketing, and the healthcare industry: medical transportation, home care, and medical billing.