In a recent fraud indictment case, a provider was charged with over $3 million dollars1 in billing fraudulent claims for non-emergency medical transportation (NEMT) services including rides with no corresponding medical visits. Don’t get taken for a ride with non-emergency medical transportation fraud – audit your claims to avoid high dollar payment recoupments.
NEMT benefits vary depending on the type of payer – Commercial Health Plans, Medicare and Medicaid. For example, commercial insurances as well as some Medicare Advantage programs offer NEMT, depending on plan policy.2
Medicare, on the other hand, provides NEMT via ambulance only when other means of transportation such as a taxi or wheelchair van would jeopardize the health of the beneficiary. Medicare does not cover routine transportation to or from the beneficiary’s home to or from their healthcare provider, but under certain specified conditions will reimburse providers for medically necessary, non-emergency, scheduled ambulance transportation to and from dialysis treatments provided to beneficiaries with end stage renal disease (ESRD). Ambulance services are medically necessary when provided to such beneficiaries who cannot be transported by any other means without endangering their health, or were bed confined before, during and after transportation.
Medicaid NEMT is generally available for beneficiaries who have no other means of transportation to medical services. States are responsible for the daily operations of their Medicaid programs and have discretion in how they deliver NEMT.3
Although NEMT fraud can impact Medicare claims, the more vulnerable payers are some Commercial Health Plans, Medicaid and Medicaid MCOs. If your Health Plan requires medical necessity for NEMT trips, it is important to audit claims across the board for a beneficiary. As in the recent fraud example mentioned, if your Health Plan requires that an NEMT meets medical necessity only if a corresponding medical visit occurs, it is important to be able to match up the date of service billed for an NEMT claim with a corresponding date of service for a medical visit by a provider.
C4H offers a series of FWA reports which can help your Health Plan identify aberrant claims from many different angles. Included is our Trips to Nowhere Claim Data Extract which identifies medical transportation encounters that have no medical claim on the DOS of the transport for the beneficiary, thereby identifying medical records worthy of audit. These “Trips to Nowhere” are at a high risk for fraud.
Don’t waste your Health Plan’s valuable resources paying fraudulent NEMT claims. If your Plan is at risk, consider Context4 Healthcare’s suite of FWA reports and edits. For more information, visit our Medical Payment Integrity webpage. 4
References
- https://www.telegram.com/story/news/crime/2025/04/01/instant-transportation-llc-ardit-islamaj-indicted-in-masshealth-fraud/82763580007/
- https://www.uhc.com/news-articles/medicare-articles/medicare-transportation-services
- Consolidated Appropriations Act, 2021 Division CC, Title II, Section 209(a) (Public Law 116-260): https://www.congress.gov/116/plaws/publ260/PLAW-116publ260.pdf
- https://www.context4healthcare.com/solutions/medical-payment-integrity/
