Are We Entering the 'Best of Times' for Medicaid NEMT? Discover the Hidden Opportunities!

By: Dan Reid, President/Managing Member, Grove Transit 

“May you live in interesting times” (English Diplomat, 1936)

“It was the best of times; it was the worst of times.” (Charles Dickens, 1935)

Most people have heard one or both of the above quotes cited during times of uncertainty, turmoil, or simply rapid change.  Lately these phrases keep popping into my head whenever I think about Fraud, Waste, and Abuse (FWA) as it pertains to Medicaid NEMT and the actions being taken in Washington instituted by DOGE and Congressional oversight. “May you live in interesting times” seems as if it could almost be taken as wishing good tidings or excitement on someone, however, it’s considered an ancient Chinese curse (although in truth it is neither ancient nor Chinese) and is intended to be bestowed ironically on the recipient, as in, you’re wishing turmoil and upheaval on them.   Clearly, the potential for devasting disruption to Medicaid NEMT services puts us potentially in times of turmoil and upheaval.  

At the same time, Charles Dickens was pointing out the contrasts in life when he made his famous quote, but I take it to mean that what can seem to be the worst of times to some, might, in fact, turn out to be the best of times.  So, is this article going to be a soliloquy dissecting historical quotes from the 1930’s, or am I going somewhere with all of this?  Well to that point, I believe we are living in a time where we could see tumult and upheaval for Medicaid funded NEMT trips, which would no doubt make for “interesting times” that could land us in the worst of times.  However, I also see the real possibility for turning this upheaval into the best of times and putting a little “ray of hope” on these interesting times.

If we, as transportation providers, sit back and let those in Washington make uninformed, or worse yet misinformed, decisions about NEMT and Medicaid, we will almost certainly see draconian changes that benefit no one; not the recipients of Medicaid benefits, not the transportation providers, and in the long run not even our economy once the deferred bill on health care costs come due from so many individuals not receiving necessary medical treatments that will prevent future, expensive medical treatments, such as dialysis to name a common one.

As an industry we would be foolish to put our heads in the sand and simply say that FWA is not an issue.  The simple fact is that FWA does exists, although not the extent to which some may think it does.  While most of you reading this article are not the perpetrators of fraud, waste, and abuse, it does happen.  To make matters worse, the NEMT industry (which includes any for-hire vehicle transportation going to and from medical appointments, treatments, and other healthcare related services such as pharmacy trips) has been cited by CMS as being at high risk for FWA, so like it or not, the spotlight is shining on NEMT at a time when the “in vogue” trend in Washington DC is to take a chainsaw to everything under the proverbial spotlight.

Taking all that into account, it’s easy to wonder how I see a possibility for the “best of times”.   It won’t come to fruition if we just sit back and watch what happens in DC.  We must be proactive, we must get out front of the problems, and most importantly we must deliver common sense, low-cost, high-results oriented solutions.   No matter how you feel about the people in charge these days, many of them, including elected officials, got to where they are because they could see a could opportunity when it came their way, and they weren’t in the habit of cutting off their nose to spite their face.  In other words, just because it is trendy to slash and cut, doesn’t mean that decision makers won’t consider other routes if those alternatives make sense, can be executed, and, most importantly, provide a better result than “slash and cut”.

The Transportation Alliance is working on just such an approach.  The truth is that many of us, along with other organizations, have been pushing for these changes for many years now, but we’ve gone unheard or been ignored.  I am not going to point fingers or cast blame, but the simple truth is that for years trying to get changes in Medicaid or Medicare for NEMT (such a small dollar portion of a very large pie) has been like trying to convince a ship the size of  the Queen Mary to change course to avoid troubles when all you had to work with was a rowboat to push against the ship’s bow.  In other words, you could expend a great deal of effort and see very little progress.  Now suddenly this ocean liner is headed straight for an iceberg and people just might be willing to listen to suggestions they previously ignored, and take prompt, decisive action to avoid ending up like the Titanic.

We need to accomplish three immediate objectives to put us, transportation providers, in a place where we are heard, will be listened to, and can help guide changes in the right direction.

1. Show the solutions exist. We need to show those in Washington that the pieces of the puzzle necessary to fix many of the problems already exist and can be efficiently and expediently (in Washington terms) implemented. 

2. Cost effectiveness. Demonstrate that the necessary fixes are cost effective, and possibly even cost-savings in the very near future.

3. Change is embraced and desired by the NEMT industry. Deliver the message that the “good actors” in our industry encourage these changes and will both embrace and implement them, primarily because many of us already have.

Let me expand a bit on these points.

• We already have most of the technology necessary to identify, reduce, and, in many cases, eliminate fraud, waste, and abuse.  What we need most is the willingness, or mandate from decision makers, to require implementation.  Without going into our entire playbook, we are developing to take to Washington, let me just highlight a few currently available fixes:

  • Eliminate Ghost Trips (trips claimed for payment but where no one was actually transported).  Camera systems and seat-occupied sensors can be utilized to “count” the number of individuals who enter, exit, and remain in the vehicle at each stop.  Amusement parks such as Disneyland have been using automated passenger counting devices in their shuttles for years, and I can promise you that newer vehicles know when someone is sitting in a seat!  For older cars lacking this technology, cameras, whether telematics cameras or on your tablets, can be used to “count” the number of people who enter or exit a vehicle, or are in it at any given time. This would be done without identifying the individual, put would simply “count elbows”, to use a Jeremy Scalzi example.  Integrating this information with a company’s, mandated, digitized scheduling and dispatching software that “knows” how many people should be in a vehicle at any time would make it easy to red-flag questionable trips for further investigation by either the company, the paying source, or a regulatory authority. 

  • Eliminate Non-compliant Drivers and Vehicles.  How many of you already use facial recognition or thumbprint identification to log into your phone?  This existing technology can be required to log in and complete trips for claiming payment.  The data can be integrated with facial recognition in a camera system (or require for each trip) to insure the “credentialed driver” remains in the vehicle, and operators’ telematics system can tie into the OBD2 port to confirm the correct vehicle is in use.  A further step would be to tie this information into a centralized credentialing system, such as ProCredEx, and the operators dispatching system to confirm that each trip is assigned only to a currently credential driver in a currently credentialed vehicle for each paying source.

  • Mandate all paying sources using Federal funds to require all parties, transportation providers, brokers, software and hardware suppliers to provide open integration for users.  I realize this is easier said than implemented, but the bottom line should be, if you want to play in the industry and utilize Federal dollars, you have to comply.

• We are most certainly in a political climate where expensive fixes to problems, or even cost-effective fixes that require substantial payment today for a return tomorrow are not held in favor.  The good news is that many of the changes we need to implement have an almost immediate, or certainly very short term, payback on the investment.  Here are just a few:

  • Eliminating historic inefficient and costly processes can be achieved without jeopardizing integrity.  For example, requiring signatures to be collected on each trip performed is expensive (especially when you consider the cost to store and transmit the signature), time consuming to audit, and adds zero, or at best marginal, value in terms of trip integrity.  All the “wet signature” really confirms is that someone in the vehicle (including the driver) could sign a name on a piece of paper or electronically.  The signature does not verify the individual in the vehicle.  NEMTAC has a standard, BSR/NEMTAC 1006-202X, Passenger Verification in Lieu of Signature, pending finalization by ANSI that addresses this very issue.  Requiring adoption of this standard and allowing for some of the recommended alternatives for passenger verification should have an immediate positive ROI for Medicaid spending related to NEMT.

  • Allow NEMT transportation providers to make decisions in the field to account for the real-life situations that arise.  For example, if a member is not ready for a return ride, the TP should be able to verify through GPS data in their systems that they were at the pick-up location at the intended time and then change the trip to a will call trip.  This will allow the TP to come back when the member is ready, eliminates the costly process of canceling the current return ride and then the paying source having to “find a transportation option” (often at last-minute add-on premium pricing) when the member is ready, and reduces the number of passengers left stranded with no way home.  Other examples are allowing TPs to correct incorrect trip information (wrong address, incorrect appointment times, etc.) when identified and without having to “rerun” all the trip changes back to the broker.  Again, if everyone is integrated with their data, then items can be easily “flagged” and systematically verified through gps coordinates, etc., instead of the inefficient and costly manual processes now required.

  • Require paying sources such as brokers to utilize a centralized credentialing exchange(s) to store and validate driver and vehicle credentials.  This easy to implement step has several immediate areas for potential cost savings and efficiencies:

    1. Paying sources (brokers) would stop spending unnecessary funds developing “proprietary” credentialing databases and can instead funnel those funds to providing improved trip economics.

    2. TPs would no longer have to waste time and money submitting essentially the same documents to multiple paying sources, and could eliminate wasteful redundant requirements, such as each broker having their own HIPPA training, when it is all essentially universal.

    3. States or CMS can quickly take action against brokers or payors failing to meet required standards and replace them because the “provider network” will no longer be the proprietary property of the broker but will correctly be available to and easily accessed by the State or other regulatory authority.

    4. Reduce cost and time required to audit NEMT trip information, provider credentials, and broker information.  The State of Tennessee’s division of Medicaid, TennCare, in conjunction with ProCredEx and NEMTAC conducted the hugely successful Tennessee Medicaid NEMT Credentialing Pilot.  The results of their pilot project showed a 75% decrease in redundant compliance tasks, 95% decrease in credential handling, and reduced audits that normally took many hours and included only a sampling of credentials to 16.6 seconds and covered all credentialing documents.  Audits of payments would be performed in almost real time instead of the highly manual process we now see where audit results to tend come out many years after the trips are performed, and when many of the violators have left the industry thereby often leaving the States holding the “liability” bag. 

• The industry, as a whole, endorses and embraces the desire to reduce or eliminate fraud, waste, and abuse.  Most providers want to weed out the bad apples giving NEMT transportation a bad name because these violators are the reason we have many of the archaic requirements in place today, and a leading impediment to necessary and desire improvements in our industry.  For the most part, participants in the industry are already complying with many of the changes we will suggest being implemented, and if they are not, they are certainly willing to once mandated. By cleaning up the industry several benefits will inure to the remaining providers, not the least among them is that everyone will be operating on a more level playing field. Quality providers will no longer have to be undercut by a provider willing to commit fraud or cut corners on safety and quality to allow them to operate at below market rates.  Further, paying sources will have the information to be able to pay for performance and recognize, and pay, when providers are performing extra services or completing complicated, hard to fill trips.

  
  
  
  

  We have a good deal of work ahead of us, and not a lot of time to act.  The good news is TTA was ahead of this curve long before DOGE was created.  While many are fearing the chainsaw approach DOGE appears to be taking with cutting spending, I see this as an opportunity to achieve much needed and desired change within our industry, if we can simply direct the ocean liner in the right direction.  Tune in to TTA’s webinars, come to the Washington DC Fly-In, and participate.  Now is our chance to make these “interesting times” we are living in, the Best of Times.

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Dan Reid operates NEMT Provider companies in Mississippi and Louisiana.  He currently serves as President of The Transportation Alliance and on NEMTAC’s Board of Directors.  Dan is Co-Chair of NEMTAC’s Certification and Standards Advisory Committee and serves on the NEMTAC’s Accreditation Advisory Committee, Compliance & Regulatory Advisory Committee, and Technology Advisory Committee.  Dan is a frequent author and speaker on issues related to the passenger ground transportation industry.