By Michael Shabkie, NEMTAC Founder

The Transportation Alliance (TTA) and Non Emergency Medical Transportation Accreditation Commission (NEMTAC) are uniquely positioned to address the many challenges that face the NEMT industry. 

Designated by the American National Standards Institute (ANSI) as an Accredited Standard Developer (ASD), NEMTAC is the consensus-driven, accrediting body that brings non-emergency medical transportation (NEMT) providers, regulators, payers, brokers and other vital stakeholders together to collaborate on significant initiatives. 

TTA is a non-profit trade association of and for the private passenger transportation industry. They are the leading information, education and legislative resource in the passenger transportation industry that serves their members by:

• Representing common federal legislative interests

• Protecting and expanding industry rights and opportunities

• Collecting, interpreting, and disseminating industry information

• Providing forums for professional development and education

• Advancing the image of the industry before the media and general public

TTA and NEMTAC recently brought their leadership teams together to discuss how they could jointly collaborate by advocating for transportation providers and promoting compliance-related best practices.

The State of the NEMT Industry

According to Medicaid and CHIP Payment and Access Commission (MACPAC.org), in fiscal year (FY) 2018, there were over 60 million Medicaid ride-days (days with at least one beneficiary NEMT ride). State and federal spending on NEMT was $2.6 billion, excluding managed care payments to providers. In its entirety, the NEMT industry is estimated to be approximately $12 billion, with around 400 million trips performed annually. 

As background, the NEMT Medicaid benefit includes a broad range of transportation services and is available to all full-benefit beneficiaries. States may manage the benefit directly, contract with a third-party broker, or provide services under Medicaid-managed care contracts. The federal policy encourages coordination across federally assisted transportation programs. However, NEMT is not well coordinated with other programs in most states, and the industry remains exceptionally fragmented.

Medicaid NEMT beneficiaries face many barriers to access, including difficulty arranging transportation to medical appointments. Transportation-related impediments may occur because beneficiaries face a variety of obstacles. Additionally, many reported that they often missed or could not schedule appointments before using NEMT.

NEMT program performance varies across and within states. For example, beneficiaries report late pickups, ill-equipped vehicles, long call center wait times and missed appointments. Over the past five years, the Office of Inspector General (OIG) has completed audits of NEMT program integrity in ten states.

Recent OIG audits confirm the fragmented nature of the industry, along with a failure to implement appropriate oversight of federal dollars. In 2016, the OIG noted the NEMT industry is “at high risk for fraud and abuse.”

The most significant deficiencies noted are: (1) Claims for Federal Medicaid reimbursement for NEMT services did not comply with Federal and State requirements, and (2) NEMT providers did not adequately document or fraudulently submitted driver credentialing qualifications and vehicle records.

States and other entities that administer NEMT benefits are improving program administration, program integrity, and the beneficiary experience.

As best practices and recommendations emerge from the regulatory bodies and industry stakeholders, NEMTAC is working to codify the recommendations into their national accreditation program for NEMT companies, certification programs for NEMT drivers, and ANSI standard development initiatives. 

NEMT Credentialing Oversight Needs Improvement 

In 2020, the OIG conducted an audit of a NEMT benefit administered by a state Medicaid office. The audit goal was to review the monitoring and oversight of its NEMT brokerage program, including compliance with specific Federal and State requirements to determine whether:

• The beneficiary received a qualifying medical service on the date of transportation.
• There was adequate documentation supporting the NEMT service.
• The NEMT service was provided.
• Driver and vehicle qualifications complied with State regulations.

OIG Audit Results

• In 100% of the sampled items, NEMT driver credentials, vehicle inspections, vehicle registrations, and maintenance policies or schedules were not adequately documented.
• 86% of the trip records submitted by local transportation providers did not comply with specific Federal and State requirements.
• The improper claims for unallowable services were approved because the State’s monitoring and oversight were lacking. The State NEMT program did not ensure that NEMT services were for qualifying medical services was adequately documented. 
• There was insufficient information and documentation to assess compliance with driver qualifications (credentials) and vehicle requirements.
• Based on the audit results, the OIG estimated that 758,847Medicaid claims totaling $14,142,730 did not comply with specific Federal and State regulations.

In its summary, the OIG noted that it “cannot be assured that the beneficiaries were transported by qualified drivers in safely maintained vehicles.” 

CMS has further identified one state that did not require and collect essential information for effective oversight, such as criminal conviction information from NEMT providers. To further complicate the process, officials from six states cited challenges obtaining certain information on NEMT providers to reduce program risks. 

Current State of NEMT Credentialing 

As noted, the GAO has designated both the Medicare and Medicaid NEMT programs as high risk because of concerns about the Medicare program’s size, complexity, susceptibility to mismanagement and improper payments, and worries about inadequate federal oversight over state Medicaid programs. 

The reality is that every State, broker, payer, and regulator has different credentialing requirements that result in a fragmented, labor-intensive, and costly process to staff the vehicles needed to provide the service.

The OIG has found that adequately credentialing transportation providers is a concrete step in enhancing program integrity in Medicaid NEMT. Specifically, individual drivers, individual vehicles, and financial requirements are areas with opportunities for improvement.

Industry Led Solution: A National NEMT Credentials Exchange 

The NEMTAC Compliance and Regulatory Advisory Board is comprised of regulators, brokers, providers, TTA members, and subject matter experts who have taken on credentialing as a significant initiative. In 2021, they developed a series of compliance-related solutions to support NEMT providers while ensuring accountability. 

To address the OIG concerns, a national credentialing exchange has been created through a strategic relationship with NEMTCredEx. The Exchange will be a centralized, national repository for NEMT driver and company-related credentials. A pilot program began in the fall of 2021 with 30+ NEMT providers, brokers, state regulators, and payers. Participation in the pilot program is currently open to interested stakeholders. 

Additionally, as an industry first, the advisory board has introduced a set of unified national credentialing criteria for NEMT providers. If formalized through industry consensus, they will become the first set of ANSI-approved NEMT credentialing standards that will streamline the requirements for transportation and NEMT Brokers. 

Promoting the Adoption of NEMT Technology 

In addition to the fragmented nature of driver credentialing, the TTA and NEMTAC have identified the lack of technology as a barrier to enhanced compliance. Approximately 40% of all NEMT providers rely on manual processes, paper manifests, and three-ring binders of information.

As a standard practice, FedEx or UPS envelopes stuffed with the trip or driver credentialing information are sent to payers or brokers for processing. 

While widespread use of innovative tech is currently occurring in most industries, the NEMT industry lags dramatically. The lack of technology can be directly tied to processes that hinder revenue growth and dramatically increase the potential for Fraud, Waste, and Abuse (FWA). 

TTA and NEMTAC are in the process of uncovering the barriers to widespread adoption of technology, such as restrictive costs, lack of broadband connectivity, etc. The information gathered will be used to craft messaging and assist legislative advocacy efforts in 2022 and 2023. 

The NEMT industry is changing rapidly. This dramatic growth creates new opportunities for NEMT providers that embrace technology and have robust compliance policies in place.

These best practices will ensure their operations have screened, credentialed drivers and safe, registered vehicles serving their communities

To learn about serving on a NEMTAC Advisory Board click here: https://bit.ly/3rRXksA

To learn more about TTA membership click here: https://bit.ly/3uNcaCu