How Medicare Advantage Plans Can Uncover Fraud, Waste, and Abuse During Dialysis Transportation with VectorCare Hub

The Centers for Medicare & Medicaid Services (CMS) ESTIMATES THAT $16B OR APPROXIMATELY 10% OF ITS PAYMENTS to Medicare Advantage organizations are improper. Improper payments are those made in error or due to potential fraud.

As a result, the Department of Justice has INCREASED ITS FOCUS ON INVESTIGATING MEDICARE ADVANTAGE PLANS suspected of fraud.  

Medicare Advantage plans must take a proactive approach to identify and address potential fraud, waste, and abuse (FWA) within their programs to avoid legal repercussions.

Due to the volume of transportation services required for members with end-stage renal disease (ESRD), non-emergency medical transport (NEMT) for dialysis is ripe for fraud, waste, and abuse.

Continue reading to learn more about the potential sources of FWA related to transporting members to and from dialysis appointments and how VectorCare Hub’s patient care logistics solution can help plans uncover fraudulent charges before it becomes a legal issue.

Sources of Fraud, Waste, and Abuse During Dialysis Transportation

Members with ESRD typically need three in-patient dialysis treatments per week. Individuals without access to reliable transportation rely on their Medicare Advantage plan to pay for NEMT services.

However, without a comprehensive PATIENT CARE LOGISTICS SOLUTION to manage NEMT for members, fraudulent charges submitted for reimbursement by third parties can be challenging to detect.

Here are four potential fraudulent charges related to standing orders for Medicare dialysis transportation services that plans should be on the lookout for:

1. Transportation that never happened. Because members with ESRD have such a high  volume need for transportation every week, one or more trips submitted for reimbursement may go undetected, especially for those members who use transportation services sporadically.
2. Excessive mileage. Padding the number of miles is a common way for bad actors to commit fraud that is nearly impossible to identify without an automated system that tracks mileage trends.
3. Duplicate charges. With such a high volume of transportation needs and a population with irregular use of the services, duplicate claims for the same service can easily be overlooked.
4. Unnecessary ambulance services. NEMT brokers and transportation providers are reimbursed at a higher rate for ambulance services than transportation by van. Transporting an individual by ambulance when it is not medically necessary is one way unscrupulous companies increase their profits and commit fraud.

6 Ways VectorCare Hub Unmasks Fraud, Waste, Abuse

Detecting NEMT fraud requires vigilance and the right technology.

Here are six ways Medicare Advantage plans can utilize VectorCare Hub to reveal FWA related to dialysis transportation:

1. Stop faxing paperwork and start maintaining transportation records from a single, user-friendly software interface. When plan employees cross-reference records across systems and manually match service orders with member records, it increases the likelihood that charges for transportation that never occurred, excessive mileage, and duplicate billing go undetected. A single system also makes it easier for plans to audit NEMT brokers and transportation providers.  
2. Administer STANDING ORDERS FOR DIALYSIS TRANSPORTATION from physician approval through execution. Quickly match the physician order with the transportation services delivered for each member.  
3. Build customized reports that offer visibility and insight into average costs, mileage, and volumes. Develop reports that flag potential duplicate charges and show trends in pricing to identify outliers in your network. Payers can also uncover excessive mileage by comparing miles submitted for the same transportation service from different companies.
4. Coordinate services and communicate with NEMT brokers and transportation providers in real-time. Two-way communication with your network of brokers and third-parties is an easy way to prevent them from utilizing medically unnecessary ambulances to transport members to and from dialysis appointments.
5. Evaluate if an ambulance service is medically necessary. Determining if ambulance services are medically necessary before transportation is scheduled can all but eliminate unnecessary ambulance rides.  
6. Manage contracted pricing with networks of local, credentialed NEMT brokers and transportation providers. Established and agreed upon pricing with trusted vendor partners is a proactive way to ward off fraudulent claims before they happen.

Looking for more ways to fight FWA? GET THE 5 POINT CHECKLIST.

The Power of VectorCare Hub

A comprehensive patient care logistics solution can help Medicare Advantage plans overcome many of today’s most pressing business challenges, including increased pressure to reduce reimbursements for fraudulent claims.

Tap into the power of VECTORCARE HUB to uncover and avoid fraud, waste, and abuse during dialysis transportation.

CONTACT US today to schedule a demo.

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Sources:

‍1. https://www.gao.gov/products/gao-17-761t

2. https://www.modernhealthcare.com/article/20170519/NEWS/170519815/doj-s-medicare-advantage-lawsuits-investigations-likely-to-change-insurance-culture