Medicare Advantage Plan 5 Point Checklist to Reduce NEMT Fraud, Waste, and Abuse

In 2016, the Government Accountability Office (GAO) ESTIMATED THAT $16B OF ITS PAYMENTS TO MEDICARE ADVANTAGE PLANS WERE IMPROPER.

It's critical that Medicare Advantage plans take a proactive approach to curbing fraud, waste, and abuse (FWA) to ensure the integrity of their programs.

Transportation benefits and non-emergency medical transportation (NEMT) services are particularly vulnerable to FWA.

One study estimated that 15-20% OF MEDICAID SPENDING ON FRAUD, WASTE, AND ABUSE CHARGES ARE DIRECTLY CORRELATED TO NEMT SERVICES.

Further, multiple states have reported cases of TRANSPORTATION SERVICE PROVIDERS ABUSING THE SYSTEM to receive excess payments and seeking payment for services never delivered.

5 Point Checklist to Fight NEMT Fraud, Waste, and Abuse

Is your team mobilized to handle fraud, waste, and abuse? Here is a checklist of the 5 ways you can be prepared.

1. Partner only with credentialed/approved service providers. One of the easiest ways to fight fraud is to validate that the companies you’re contracting with can provide the services for which you’re hiring them. There should be no exceptions.
2. Audit service providers yearly to ensure they're meeting specified criteria and performance expectations. Regular examination of financial and performance records enables your plan to have a snapshot of the service providers for apple-to-apple comparisons. This is one way to identify trends that may indicate fraud or excessive charges that go undetected in other reports.
3. Utilize a comprehensive digital solution that allows services to be requested, assigned, and delivered in a single platform. Records spread out across systems make it difficult to detect duplicate charges, charges for services not delivered, and bad actors.
4. Develop and maintain reports that detect and flag potential fraud, waste, and abuse. Real-time reports give your plan transparency into the services and associated pricing for which your vendors seek reimbursement. Intelligent reporting that identifies patterns of potential FWA is critical.
5. Train employees on company protocols for reporting fraud, waste, and abuse. Identifying FWA is not just the responsibility of your compliance department. It’s essential that all employees understand your compliance plan and the protocols for reporting potential FWA violations.

These best practices aren’t limited to NEMT providers. This list can be used to evaluate any third-party service providers your plan contracts with.

Eliminate FWA and Better Serve Members

Reducing the time and resources spent on fraudulent and wasteful spending means more attention toward serving members.

Instead of spending time tracking down transportation providers seeking payment for services they did not deliver, plans should be able to focus on implementing solutions across the entire patient journey, such as providing durable medical equipment and helping members fill prescriptions in a timely fashion.

Learn how a comprehensive PATIENT CARE LOGISTICS SOLUTION can help Medicare Advantage plans eliminate NEMT fraud, waste, and abuse while also expanding member benefits.

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

https://www.hilarispublisher.com/open-access/nonemergency-medical-transportation-and-the-promise-of-blockchain-applications.pdf

https://oig.hhs.gov/oas/reports/region1/11900004.asp