Medicaid: Efforts to Address Fraud in Nonemergency Medical Transportation
Fast Facts
State Medicaid programs often contract with third party transportation brokers or managed care organizations to arrange nonemergency transportation for beneficiaries who can't get to medical appointments on their own.
Medicaid fraud investigations led to about 200 criminal convictions, civil settlements, and judgments against transportation providers in 25 states from FY 2015-20. Fraud included these providers billing for trips that didn't occur and using unauthorized drivers or vehicles.
To curb fraud, some states' Medicaid programs verify eligibility before scheduling or validate completed trips via trip logs, GPS data, and claim reviews.
Highlights
What GAO Found
State Medicaid programs are required to provide nonemergency medical transportation to beneficiaries who are unable to provide their own transportation to medical appointments. Within broad federal guidelines, states have flexibility in how they administer this benefit; GAO found that states used three broad approaches to do so. These approaches included administering the benefit directly (in-house), contracting with third-party transportation brokers, or contracting with managed care organizations. Most states used a combination of these approaches.
Approaches to Administer Medicaid Nonemergency Medical Transportation in 50 States and the District of Columbia, December 2021
Federal and state agencies have identified fraud and non-compliance with requirements related to Medicaid nonemergency medical transportation. From fiscal years 2015 to 2020, state Medicaid Fraud Control Unit investigations resulted in nearly 200 criminal convictions, civil settlements, and judgments against transportation providers in 25 states. Officials in three selected states said that credible allegations of fraud included providers billing for trips that were not provided or providing trips with unauthorized drivers or vehicles.
State officials and their contractors in seven selected states identified a variety of strategies to address fraud, including the following:
- Provider and vehicle screening, such as enrolling providers and monitoring driver and vehicle credentials.
- Pre-trip approval, such as verifying eligibility prior to scheduling a trip.
- Post-trip validation, such as validating that trips occurred through trip logs, GPS data, and claims reviews.
Why GAO Did This Study
The Centers for Medicare & Medicaid Services (CMS) oversees the design and operation of state Medicaid programs, including nonemergency medical transportation. This Medicaid benefit is essential to ensuring beneficiaries' access to necessary health care. CMS has identified it as a program area at risk for fraud.
Congress included a provision in the Consolidated Appropriations Act, 2021 for GAO to examine Medicaid nonemergency medical transportation. This report describes (1) states' approaches to administer this benefit; (2) outcomes and findings of related fraud investigations and program audits; and (3) strategies selected states used to address related fraud.
GAO reviewed relevant federal statutes, regulations, and guidance, as well as documentation across 50 states and the District of Columbia to determine their approaches to administering this benefit. GAO also reviewed related fraud investigations and program audits conducted by Medicaid Fraud Control Units, the Department of Health and Human Services' Office of Inspector General, and state audit organizations.
In eight states, GAO interviewed Medicaid officials. In seven of these states, GAO also interviewed officials from Medicaid Fraud Control Units and contractors that administered the benefit, such as brokers or managed care organizations. The eight states were selected based on variation in benefit approaches and geography.
For more information, contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov.