DHH Does Not Routinely Monitor Medical Transportation Program; $1.6 Million Spent for Rides Without a Medical Claim on the Same Day

An $18 million-a-year Medicaid program that pays for non-emergency rides to the doctor is receiving almost no monitoring by the Department of Health and Hospitals (DHH) to ensure that those rides are medically necessary or even occurred at all.

A legislative audit released Monday found that from 2011 through 2014 DHH paid out $1.6 million for 55,474 transport claims that had no corresponding medical claim on the same day the ride happened. Not having a medical claim on the same day could indicate that transportation providers are billing for trips that did not occur, that recipients did not actually attend their appointment, or that medical providers did not correctly bill for their services.

Auditors found that DHH has not conducted on-site monitoring of non-ambulance providers in the Non-Emergency Transportation (NEMT) program since January 2014. Further, DHH has never monitored ambulance providers to determine if support exists for the rides they provided to Medicaid recipients. Ambulance transportation accounted for $45.8 million of NEMT's payments from 2011 through 2014.

"For seven consecutive years, we have cited audit findings on potentially improper payments in the NEMT program," Legislative Auditor Daryl Purpera said. "DHH can sanction NEMT providers for non-compliance, but even when DHH did conduct some onsite monitoring in 2013 and in 2014, DHH did not sanction the providers it found to be non-compliant, nor did it go back and recoup those payments."

Nursing homes are responsible for the cost of non-ambulance transportation within 65 miles for their residents, while Legacy Medicaid is responsible for the cost of any ride over 65 miles. However, the state auditor identified 386 rides for $12,524 where the ride was less than 65 miles, but the non-ambulance transportation was billed to Legacy Medicaid instead of being paid by the nursing home.

The audit further notes that monitoring nursing homes' use of ambulance transportation is especially critical because nursing homes have a financial incentive to over-utilize ambulance transportation. NEMT program rules say nursing homes are responsible for their Medicaid residents' transportation unless a medical provider, who may be on staff at the nursing home, determines that an ambulance is medically necessary. Between 2011 and 2014, the audit found DHH paid out $4.7 million for 19,283 ambulance rides for nursing home residents.

DHH said it concurs with all of the Legislative Auditor's findings. DHH noted that, as of December 1, 2015, NEMT is now under the administration of Bayou Health's five Managed Care Organizations (MCOs) instead of DHH. In his recommendations, the Legislative Auditor urged DHH to ensure proper oversight of the MCOs' administration of the program going forward.