DEPARTMENT OF HEALTH &. HUMAN SERVICES Office of Inspector General
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MAY 28 2009
TO: Charlene Frizzera
Acting Administrator
Centers for Medicare & Medicaid Services
;fltwrt~
FROM:
Deputy Inspector General
for Evaluation and Inspections
SUBJECT: Memorandum Report: "Fraud and Abuse Safeguards for State Medicaid
Nonemergency Medical Transportation Services,"
OEI -06-07 -00320
This memorandum report provides information about the safeguards that State Medicaid agencies
use to prevent and detect Medicaid nonemergency medical transportation (NEMT) fraud and
abuse. It also identifies the numbers, types, and outcomes ofNEMT fraud and abuse cases that
State Medicaid Fraud Control Units (MFCU) investigated in recent years.l Federal regulations
(42 CFR  431.53) require each State to ensure that Medicaid beneficiaries have necessary
transportation to and from medical providers and to describe, in its State plan, the methods that the
State wil use to meet this requirement. The Offce ofInspector General (OIG) and other entities
have identified significant vulnerabilities to fraud and abuse in State NEMT programs.2 To
safeguard against fraud and abuse, Federal regulations (42 CFR  455.13) require that each State
Medicaid agency establish methods for identifying and investigating suspected fraud and abuse
cases and referring them to law enforcement.
In a survey of State Medicaid agencies, we found that most States concentrate their safeguard
activities on screening providers, requiring prior approval for services, and implementing methods
to prevent and detect improper payments. Further, the 29 States that use contracted transportation
brokers (hereinafter referred to as "brokers") to administer their NEMT benefit reported using
multiple techniques -to monitor brokers, including complaint investigation, periodic contract
renewal, and broker reporting requirements. State MFCUs provided data indicating that they
1 A MFCU is a single identifiable entity of  State government, annually certified by the Secretary of  the Department of  Health and Human
Services (HHS), that conducts a statewide program for the investigation and prosecution of health care providers that defraud the Medicaid
program. Social Security Act  1903(q), 42 U.S.c. 1396b(q).
2 "Review of  Wisconsin's Non-Emergency Medical Transportation Costs for Services Provided by American United Taxicab, Inc. for January I
Through December 3 1,2005," August 4,2008, A-05-08-00040; Government of  the District of Columbia, Offce of  the Inspector General, "Audit
of  the Maintenance of  Medical Necessity Forms for Non-Emergency Transportation of  Medicaid Recipients," September 29,2006,05-2-
18HC(b); Missouri State Auditor, "Controlling Costs For Medical Equipment and Transportation," October 2005,2005-73.
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Page 2  Charlene Frizzera 
 
 
investigated a combined total of 509 NEMT fraud and abuse cases from 2004 to 2006, with the 
most common types involving billing for services not rendered and unspecified overbilling.3 
 
BACKGROUND 
 
Pursuant to Title XIX of the Social Security Act, the Medicaid program provides medical 
assistance to low-income individuals and individuals with disabilities.  The Federal and State 
Governments jointly fund the Medicaid program.  At the Federal level, the Centers for Medicare & 
Medicaid Services (CMS) administers the program.  Each State administers its Medicaid program 
in accordance with a CMS-approved State plan.4  Although the State has considerable flexibility in 
designing and operating its Medicaid program, it must comply with applicable Federal 
requirements.  Pursuant to 42 CFR  440.170, the transportation benefit includes transportation 
expenses and related travel expenses deemed necessary by the State Medicaid agency to secure 
medical examinations and treatment for a beneficiary.  Examples of modes of transportation that 
States authorize include ambulances; specialized motor vehicles (e.g., wheelchair-accessible vans); 
and common carriers (e.g., taxis, personal vehicles, and public transportation).   
 
The Deficit Reduction Act of 2005 gave States the option to [establish] a non-emergency 
medical transportation brokerage program in order to more cost-effectively provide 
transportation for Medicaid beneficiaries.5  The statute requires that brokers: 
 
  be selected through competitive bidding; 
  have oversight procedures to monitor beneficiary access and complaints and ensure that 
transport personnel are licensed, qualified, competent, and courteous; 
  be subject to regular auditing and oversight by the States; and 
  comply with all prohibitions on referrals and conflicts of interest established by the Secretary 
of HHS. 
 
Beyond these requirements, States have considerable discretion regarding what services they 
contract with brokers to provide and how they oversee brokers.  For example, States may choose to 
use brokers in only limited geographic locations, such as metropolitan areas, or they may use 
brokers to handle all aspects of NEMT services statewide. 
 
Fraud and Abuse Safeguards 
Federal regulations require that each State Medicaid agency establish a program integrity (PI) 
program that includes methods for identifying and investigating suspected fraud and abuse cases 
and referring them to law enforcement.6  States must also take action to investigate and resolve 
                                                 
3 The unspecified overbilling category of fraud cases were reported by State MFCUs as overbilling cases without  
further detail.  
4
 The State plan is a comprehensive written statement submitted by the State Medicaid agency describing the nature and scope of its Medicaid 
program and giving assurance that it will be administered in conformity with all applicable laws, regulations, and official issuances  
(42 CFR  430.10).   
5
 P.L. No. 109-171  6083(a)(3), adding  1902(a)(70) to the Social Security Act, effective February 8, 2006. 
6
 42 CFR  455.13. 
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Page 3  Charlene Frizzera 
 
 
cases involving overpayments, including recovery of overpayments made to providers.7  If a State 
detects evidence of potential provider fraud, it must refer such a case to the State MFCU or other 
appropriate law enforcement agency, such as a local district attorney.8  The MFCU is responsible 
for reviewing the referrals it receives from the State Medicaid agency and other sources to 
determine whether the issues involved merit criminal and/or civil investigation.  Although States 
must meet Federal requirements, they have flexibility in the design and execution of their Medicaid 
PI programs.  States that use brokers to administer and safeguard NEMT may also include 
mechanisms for oversight of those brokers.   
 
Recent reports regarding fraud and abuse in State NEMT programs highlight some of the types of 
fraud and abuse and the importance of effective PI activities.  For example, an OIG report found 
that 18 of 100 sample NEMT claims submitted by a taxicab company in Wisconsin in 2005 were 
paid inappropriately for NEMT services on dates when beneficiaries did not receive Medicaid 
services.9  OIG estimated that almost $700,000 in improper NEMT claims for the year could be 
attributed to the single provider.  A report issued by the District of Columbia Office of Inspector 
General found that the programs failure to maintain medical necessity forms for over $16 million 
in NEMT services or to perform any onsite visits or reviews constituted a serious breach of basic 
internal controls.10  Likewise, a report issued by the Missouri State Auditor found that the broker 
hired to arrange NEMT services for beneficiaries failed to arrange the most appropriate mode of 
transportation and acted to maximize its own profit.11 
 
METHODOLOGY 
 
Scope 
For this memorandum report, we examined all 50 States and the District of Columbia (hereinafter 
referred to as States) to identify their safeguards to prevent and detect NEMT fraud and abuse.  
We also examined the numbers, types, and outcomes of fraud and abuse cases that State MFCUs 
investigated from 2004 to 2006. 
 
Data Collection and Analysis 
We obtained written responses from all State Medicaid agencies regarding their NEMT program 
operations and the safeguards in place at the time of their responses (i.e., July to November 2007).  
States provided documentation to support their written responses, and we conducted followup as 
necessary to clarify information reported. 
 
We obtained information regarding 20042006 NEMT fraud and abuse cases from  
49 State MFCUs.  Regarding the remaining two States, the Idaho MFCU was created in 2007 and, 
                                                 
7
 42 CFR  455.16. 
8
 42 CFR  455.15 and 455.21.   
9
 Review of Wisconsins Non-Emergency Medical Transportation Costs for Services Provided by American United Taxicab, Inc. for January 1 
Through December 31, 2005, August 4, 2008, A-05-08-00040. 
10
 Government of the District of Columbia, Office of the Inspector General, Audit of the Maintenance of Medical Necessity Forms for  
Non-Emergency Transportation of Medicaid Recipients, September 29, 2006, 05-2-18HC(b). 
11 Missouri State Auditor, Controlling Costs For Medical Equipment and Transportation, October 2005, 2005-73. 
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Page 4  Charlene Frizzera 
 
 
therefore, did not investigate any cases from 2004 to 2006 and North Dakota does not operate a 
federally supported MFCU. 
 
We analyzed information reported by State Medicaid agencies and MFCUs to identify: 
  States fraud and abuse safeguards for NEMT services; 
  States use of brokers and States activities for oversight of these brokers; and 
  numbers, types, and outcomes of NEMT fraud and abuse cases investigated by State MFCUs 
from 2004 to 2006. 
 
Limitations 
This report relies on information reported by State Medicaid agencies and MFCUs, which we did 
not independently verify.  Further, determining the extent to which States and/or their contractors 
actually implemented reported safeguards and oversight activities was beyond the scope of the 
study.  
 
Standards 
This study was conducted in accordance with the Quality Standards for Inspections issued by the 
Presidents Council on Integrity and Efficiency and the Executive Council on Integrity and 
Efficiency (now Council of the Inspectors General on Integrity and Efficiency). 
 
RESULTS 
 
States Reported Focusing Medicaid Nonemergency Medical Transportation Safeguards on 
Screening Providers, Requiring Prior Approval of Services, and Implementing Methods To 
Prevent and Detect Improper Billing 
All States reported conducting a variety of safeguard activities to protect against fraud and abuse of 
NEMT services.  However, most States and their brokers concentrate their safeguard activities on 
three areas:  screening providers, requiring prior approval for services, and implementing methods 
to prevent and detect improper billing.  Depending upon the State, responsibility for conducting 
these activities lies with the State Medicaid agency itself, other State agencies, brokers, or some 
combination of these entities. 
 
Screening Providers.  Forty-five States reported conducting NEMT provider-screening activities in 
2007 to safeguard their NEMT programs from fraud and abuse.  The remaining six States did not 
enroll NEMT providers.  All 45 States that enroll NEMT providers check applicant information 
against the OIG list of excluded providers, and 43 States require transportation providers to 
disclose relevant prior criminal convictions.12  (See Table 1.)   
 
                                                 
12
 OIG maintains a list of all individuals and entities currently excluded under various legal authorities from participation in Federal health care 
programs. 
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Table 1:  Provider-Screening Activities of States That Enrolled Medicaid 
Nonemergency Medical Transportation Providers 
Percentage of States 
Number   That Enrolled 
Safeguard  of States  Providers (n=45) 
Check for exclusion from Federal health care programs  45  100% 
Require disclosure of criminal convictions   43  95% 
Require special license, certification, or training  38  84% 
Check driving records  32  71% 
Conduct onsite visits  30  67% 
Conduct criminal background checks  28  62% 
Require periodic provider reenrollment  24  53% 
Source:  OIG analysis of survey responses and documents submitted by State Medicaid agencies in 2007. 
 
Thirty-eight States require providers to obtain specific licenses or certifications, including drivers 
licenses, vehicle inspections, or certifications for operating passenger transportation vehicles.  
Additionally, 10 of these 38 States require special licensure and/or training, such as defensive 
driving, first aid and cardiopulmonary resuscitation, passenger assistance, special needs assistance, 
and others.  Thirty-two States check the driving records of NEMT providers, and 30 States conduct 
site visits to verify the legitimacy of providers.  Site visits include both random and targeted 
inspections of provider locations by State agencies and/or brokers.  Twenty-eight States require 
NEMT providers to submit to criminal background checks.  Twenty-four States require providers to 
periodically reenroll, which typically involves some combination of completing new applications, 
updating driving record checks, conducting new criminal background checks, and/or renewing 
professional licenses and certifications. 
 
Requiring Prior Approval.  Forty-six States reported that they require beneficiaries to obtain prior 
approval before using some or all NEMT services.  The five remaining States do not require prior 
approval.  Prior approval typically involves verification of the beneficiarys Medicaid eligibility, 
the medical necessity of the trip, and the beneficiarys lack of alternative transportation options.  
Thirty-one of the forty-six States require prior approval for all NEMT services, although these 
States may authorize standing orders for certain types of recurring trips, e.g., trips to and from 
dialysis treatment.  The remaining 15 of the 46 States require prior approval for only certain 
NEMT services.  A common approach among these States is to have lists of standard NEMT 
services that do not require prior approval.  A beneficiary must seek prior approval only when 
transportation needs differ from the standard list.  For example, in one State, a beneficiarys trip to 
a Medicaid-covered physicians office does not require prior approval, whereas prior approval is 
required for trips out of the State; trips exceeding certain mileage limits (e.g., 50 miles); and trips 
requiring food, lodging, or unusual transportation modes (such as air ambulance). 
 
Implementing Methods To Prevent and Detect Improper Billing.  Fifty States reported 
implementing one or more methods to prevent and detect improper billing.13  (See Table 2.)  Forty 
States reported operating public hotlines for beneficiaries or others to either pass along fraud and 
                                                 
13
 State Medicaid agency officials from the one remaining State reported that its NEMT program relies on a capitated payment to its 
transportation broker that shifts much of the risk of improper NEMT payments from the State to the broker. 
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Page 6  Charlene Frizzera 
 
 
abuse tips or make complaints about NEMT providers or services.  States direct complaints to PI 
staff or contractors for further investigation.  Depending upon the State, investigations may include 
unannounced audits, medical record reviews, referral to the MFCU, or other action.  Thirty-six 
States reported conducting reviews of randomly selected NEMT claims after payment has been 
made and/or all claims submitted by specific providers.  Such reviews may occur periodically (e.g., 
monthly) or only in response to a complaint.  Claims reviews can result in requests for further 
records from transportation providers or further audits. 
 
Table 2:  Methods To Prevent and Detect  Medicaid Nonemergency Medical   
Transportation Improper Billing   
 
Number   Percentage of 
Method  of States   States (n=51)    
 
Fraud or complaint hotline  40  78% 
 
Claims review  36  71% 
Data analysis and monitoring  35  69%   
Prepayment edits  23  45%   
Source:  OIG analysis of survey responses and documents submitted by State Medicaid agencies in 2007.   
 
Another common fraud and abuse detection method, reported by 35 States, involves analysis of 
claims data.  Data analysis methods include simple comparisons between physician billings and 
charges as well as more sophisticated data mining.  For example, use of computer algorithms 
enables States to monitor an individual providers billing patterns and usage trends over time.  
These algorithms can repeat certain claims analysis routines for each provider or each claim and 
flag those that meet predetermined criteria for suspicious activity or inappropriate billing, such as a 
surge in a providers billing or reimbursement.  If data analysis uncovers aberrant patterns or 
suspected fraud and abuse activity, State Medicaid agencies or their brokers can conduct further 
audits or refer the case to the MFCU for investigation.  Finally, 23 States reported using 
prepayment edits specifically designed to process NEMT claims.  Prepayment edits are automated 
programs that check multiple elements of each claim for specific inconsistencies or errors that, if 
present, trigger the denial of the claim.  For example, a State using a prepayment edit might deny a 
NEMT claim because the beneficiary did not receive any other Medicaid services on the same day. 
 
The 29 States That Used Brokers Reported Using Complaint Investigations, Reporting 
Requirements, Contract Renewal, and Other Techniques To Oversee Brokers  
Twenty-nine States reported that brokers administered all or part of their NEMT programs at the 
time of the States responses in 2007.  The remaining 22 States did not use brokers, but 4 of these 
States were in various stages of developing brokerage programs.  Of the 29 States using brokers, 
25 States estimated that brokers provided at least half of their NEMT services and the 4 remaining 
States estimated that brokers provided less than half of their NEMT services.  The primary services 
that States contracted with brokers to provide include screening and enrolling providers, arranging 
NEMT services for beneficiaries, processing NEMT claims, tracking and reporting NEMT usage to 
the States, conducting PI activities, and vetting prior approval requests.   
 
States reported using multiple techniques to ensure that brokers administered NEMT services 
appropriately and helped to safeguard the programs from fraud and abuse as required by the States.  
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Page 7  Charlene Frizzera 
 
 
(See Table 3.)  All 29 States reported using at least three of the seven oversight activities listed in 
Table 3.  For example, 26 States reported that they investigate complaints made by beneficiaries or 
others about their NEMT services.  Twenty-five States required their brokers to periodically, e.g., 
quarterly, report to the State Medicaid agencies administrative data, such as the numbers of hotline 
telephone calls and complaints received, the number of trips provided, and certain details about 
each trip.  Twenty-five States also periodically renew their broker contracts, giving them the 
opportunity to evaluate broker performance and rebid the contracts if necessary.  Twenty States 
reported that their staffs conduct onsite reviews of brokers, which included random audits of claims 
data, inspection of vehicles, and monitoring of call center activity.  Twenty-one States reported 
using information generated through complaint hotlines to monitor brokers.  Finally, 19 States 
reported service trip verification activities that include audits of a wide range of broker records, 
such as records of prior authorization, proof of medical necessity, appropriate routes taken, 
verification of beneficiaries medical appointments, and other records.  
 
Table 3:  Oversight Mechanisms of Twenty-nine States That Use Medicaid 
Nonemergency Medical Transportation Brokers  
Percentage of 
Number  States That Use 
Oversight Mechanism  of States  Brokers (n=29)  
Complaint investigation  26  90% 
Regular reporting requirements  25  86% 
Periodic contract renewal  25  86% 
Beneficiary satisfaction survey  23  79% 
Complaint hotline  21  72% 
Onsite broker review  20  69% 
Service trip verification  19  66% 
Source:  OIG analysis of survey responses and documents submitted by State Medicaid agencies in 2007. 
 
State Medicaid Fraud Control Units Reported Investigating 509 Medicaid  
Nonemergency Medical Transportation Fraud and Abuse Cases of Various Types From 
2004 to 2006 
State MFCUs provided data regarding the types and outcomes of their NEMT fraud and abuse 
investigations from 2004 to 2006.  Forty-two MFCUs reported a total of 509 NEMT fraud and 
abuse cases, two States did not operate MFCUs during this period, and the remaining seven 
MFCUs did not report any NEMT fraud and abuse cases.  These seven MFCUs indicated that 
NEMT fraud was not tracked separately from other types of Medicaid fraud and, therefore, could 
not be distinctly reported. 
 
The cases investigated by MFCUs from 2004 through 2006 included a variety of types of fraud 
and abuse.  The two most common types involved provider billing fraud, including billing for 
services not rendered (104 cases) and unspecified overbilling (93).  Other common types 
included upcoding (57), undocumented or forged documentation (32), billing for excess mileage 
(31), and nonmedical use of NEMT services (25).  Table 4 contains examples of these and other 
frequently reported types of fraud and abuse involving providers.  
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Of the 509 cases reported by State MFCUs, 371 (73 percent) were closed and the remaining  
138 cases (27 percent) were open at the time the MFCUs submitted data to OIG during the 
second half of 2007.  States either reported that open cases were under active investigation or 
provided no further detail about the status of open cases.    
 
 
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Page 9  Charlene Frizzera 
 
 
 
Table 4:  Types of  Medicaid Nonemergency Medical Transportation Provider Fraud and 
Abuse Cases Investigated by State Medicaid Fraud Control Units 
Number 
Fraud and Abuse Type and Examples  of Cases 
Billing for Services Not Rendered  104 
  Billing for trips that never actually occurred. 
  Billing for an additional attendant (i.e., a beneficiary caretaker) when none was 
provided. 
Unspecified Overbilling  93 
  Engaging in deceptive billing practices to receive excess payment. 
  Misrepresenting invalid trips and services to receive excess payment. 
Upcoding  57 
  Billing for an attendant when one was not necessary. 
  Billing for an ambulance when a less expensive form of transportation could have 
been used. 
  Billing for nonambulatory support services when the beneficiary was ambulatory. 
Undocumented Trips and/or Forged Documents  32 
  Missing and forged supporting documentation of trips, including transportation 
provider trip logs, signed certificates of medical necessity, and signed transportation 
vouchers. 
Billing for Excess Mileage  31 
  Billing for a 30-mile trip when a 15-mile trip was actually taken. 
Nonmedical Use of NEMT Services  25 
  Billing for services when taking a beneficiary to pick up groceries or run other errands. 
Billing Without a License and/or Using Unauthorized Providers  23 
  Providing services through unauthorized personnel.  In these cases, NEMT providers 
might be unlicensed, have bad driving histories, have failed drug tests, or have been 
convicted of felonies. 
Double Billing for the Same Service  21 
  Submitting two claims for the same service by changing the service date on one of the 
claims. 
Kickbacks  19 
  Providing free rides for nursing home providers to gain the business of the Medicaid 
beneficiaries who live there. 
  Paying beneficiaries to use a particular service. 
  Paying anyone who has influence over beneficiaries use of services, including 
caseworkers, nursing home or hospital transportation coordinators, dialysis center 
employees, and rehabilitation center employees. 
Ineligible or Deceased Beneficiary  15 
  Inappropriately providing rides to the family members of beneficiaries. 
  Billing Medicaid for services for deceased beneficiaries. 
Patient Abuse or Neglect  9 
  Physically or sexually abusing beneficiaries. 
  Leaving beneficiaries unattended or deserting them. 
  Not picking up beneficiaries in a timely manner, resulting in missed appointments. 
Notes:  
  Ninety additional cases did not fit meaningfully into the fraud and abuse types listed above. 
  The numbers of cases do not sum to 509 because some involved circumstances that fit into more 
than one fraud and abuse type. 
Source:  OIG analysis of fraud and abuse case information submitted by State MFCUs in 2007. 
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Page 10  Charlene Frizzera 
 
 
The outcomes of the closed cases are listed in Table 5.  Among the 371 closed cases,  
150 (40 percent) were reported by MFCUs as dismissed because the allegations were 
unsubstantiated after investigation.  Another 68 cases (18 percent) were investigated and closed 
without prosecution, typically because there was insufficient evidence for prosecution.  Forty-
three of the 371 closed cases (12 percent) resulted in criminal convictions.  In 37 cases (10 
percent), the parties agreed to civil settlements; typically in these cases, defendants reimbursed 
Medicaid for disallowed expenses but avoided criminal conviction.  Outcomes for the remaining 
cases either were not reported to OIG by the MFCUs (54 cases), resulted in referral to separate 
law enforcement agencies (10 cases), or did not fit into any of the other categories (9 cases).   
 
Table 5:  Outcomes of Closed Medicaid Nonemergency Medical Transportation Fraud   
Cases Investigated by State Medicaid Fraud Control Units From 2004 to 2006   
Percentage of   
Number   Closed Cases   
Outcome  of Cases   (n=371)  
 
Allegations unsubstantiated  150  40%   
Cases not prosecuted  68  18%   
Convictions  43  12%   
Civil settlements reached  37  10%   
Outcomes not reported by MFCUs  54  15%   
Referred to other law enforcement agencies  10  3%   
Other  9  2% 
 
Source:  OIG analysis of fraud and abuse case information submitted by State MFCUs in 2007.   
 
CONCLUSION 
 
This memorandum report provides information that CMS may find useful in its oversight of the 
Medicaid program.  All State Medicaid agencies reported multiple NEMT fraud and abuse 
safeguards, particularly screening providers, requiring prior approval of services, and 
implementing methods to detect and prevent improper billing.  Twenty-nine States contracted with 
brokers and most frequently reported using complaint investigations, reporting requirements, and 
periodic contract renewals to oversee their brokers.  Despite these measures, NEMT fraud and 
abuse has been and may continue to be a problem across States, with State MFCUs reporting that 
they investigated 509 NEMT fraud cases from 2004 to 2006.  Billing for services not rendered and 
unspecified overbilling were the most common NEMT fraud and abuse cases investigated by 
MFCUs.  
 
This report is being issued directly in final form because it contains no recommendations.  If you 
have comments or questions about this report, please provide them within 60 days.  Please refer to 
report number OEI-06-07-00320 in all correspondence.   
OEI-06-07-000320       Fraud and Abuse Safeguards for Medicaid Nonemergency Medical Transportation