N0N-EMERGENCY MEDICAL TRANSPORTATION October 27, 2011 Sheila Platts Sharon McDougal

1. N0N-EMERGENCY MEDICAL TRANSPORTATION October 27, 2011 Sheila Platts Sharon McDougal Carolyn McClanahan

2. Current Medicaid Transportation Policy • Title XIX of the Social Security Act does not specifically mandate provision of transportation as a Medicaid service. • Authorizes states to cover transportation as either an optional service and/or as an administrative service. • Administrative service reimbursement for transportation arranged. • Paid by the county department of social services (DSS) acting as an agent for the state.

3. Current Medicaid Transportation Policy • Pays for transportation if the recipient receives a Medicaid covered service provided by an enrolled qualified Medicaid provider. • Pays for the least expensive means suitable to the recipient’s needs. • County DSS must arrange for or provide transportation to Medicaid covered services for authorized recipients • if the recipient is unable to arrange and/or pay for transportation.

4. Current Medicaid Transportation Policy • Must meet the recipient’s needs. • Must be aware of available transportation sources in the county and locality where the recipient lives. • Must make use of the most appropriate and cost-effective method. • including free transportation

5. Current Medicaid Transportation Policy • Documentation must support expenditures and requests for reimbursement. • DSS may maintain the documentation in: • Income Maintenance case record • Transportation record for the recipient • A centralized system.

6. Current Medicaid Transportation Policy • Reimburses the county for the Federal and State share of certain transportation costs. • Must complete forms for reimbursement • DMA-2055 Reimbursement Request Form • DMA-2056 Medicaid Transportation Log

7. Current Structure • On-site Transportation Coordinators. • Written transportation plans. • Contracts with transportation providers. • Various ‘No Show’ policies • some do not have a “no show” policy.

8. Medicaid Transportation Costs • Approximately $43M for State Fiscal Year 2010 • Overall Medicaid Budget $9,450,000,000 • Required Budget Reductions • $356,151,356 (state) • 2% rate reduction • Reductions in utilization of services – limits on services • $90 m thru CCNC • Increased PI recoupments • Assessments • More Prior authorization • Must meet budget targets or additional cuts will occur such as • Additional rate cuts • Elimination of services

9. 2007 Quality Assurance Audit Findings • The Medicaid Quality Assurance Section of the Division of Medical Assistance conducted a review of county reimbursements for Medicaid transportation costs. • The focus of the review was to verify that recipients were authorized for Medicaid on the dates transportation services were provided and to verify that recipients received Medicaid covered services on the dates of the Medicaid transportation. • The findings of the audit were published in DMA-Administrative Letter 04-07, Qualify Assurance Transportation Audit Results.

10. 2007 Quality Assurance Audit Findings • The Qualify Assurance Section reviewed 15,843 claims statewide with Medicaid reimbursements totaling $397,892.52. • They found that 1,567 claims totaling $38,379.59 did not meet the criteria required by policy to claim reimbursement. • This resulted in an overall error rate of 9.89% based on the number of ineligible claims and a payment error rate of 9.65% based on the dollar amount of ineligible claims. • The individual counties payment error rates ranged from 0% to 41.41%.

11. 2007 Quality Assurance Audit Findings • 1068 incidents of No evidence that a medical service was received on the date of transport. • 164 - Transportation provided to non-allowable services such as WIC voucher pick up, after school care and employment. • 113 - Recipient was not authorized for Medicaid on the date transportation was provided.

12. 2007 Quality Assurance Audit Findings • 91 Reimbursements claimed for transportation provided for MQB and NC Health Choice recipients. • 77 Reimbursements claimed when recipient failed to keep transportation appointment or cancelled medical appointment. • 16 Transportation reimbursements claimed for lunches on trips that did not include an overnight stay.

13. 2007 Quality Assurance Audit Findings • 14 - Transportation was provided for Special Assistance recipients not participating in the SA In Home Program. • 13 -Transportation claimed when the only medical service provided was received at the recipient’s home as home health or personal care services. • 3 - Transportation was billed twice for same trip.

14. 2007 Quality Assurance Audit Findings • 2 - Medicaid identification number (MID) and corresponding recipient name did not match. Unable to determine if valid claim existed. • 2 - Transportation was provided for recipient residing in skilled nursing facility. • 2 - Medicaid reimbursement claimed when transportation provider was unable to transport recipient.

15. 2007 Quality Assurance Audit Findings • 1 - County paid provider directly for ambulance transportation rather than requiring ambulance provider to bill Claims Contractor. • 1 - County paid for attendant‘s “wait time”. • DMA did not recoup for claims paid in error resulting from this audit, but used the audit as an educational tool for additional training and policy development.

16. CMS Compliance Review Process In addition to internal Quality Assurance Audits, the Centers for Medicare and Medicaid Services (CMS) conduct periodic comprehensive program integrity reviews of the Medicaid Program. The CMS compliance review process focuses on the following objectives: • Determine compliance with Federal program integrity laws and regulations;

17. CMS Compliance Review Process • Identify program vulnerabilities and effective practices; • Help States improve its overall program integrity efforts; and • Consider opportunities for future technical assistance.

18. Feb 2008 CMS Compliance Review • DMA cited for not adequately conducting oversight of the NEMT program • Placed under corrective action plan • Recommendations: Provide consistent oversight of NEMT; issue guidance to counties on obtaining Provider disclosures; check for excluded Providers; and verify the delivery of services billed.

19. Quality Assurance 2011 Trends • Not a Medicaid covered service • No Medicaid Authorization • No medical service received • No assessment • No approval letter • No valid vehicle insurance

20. Quality Assurance 2011 • No valid vehicle registration • No valid driver’s license • Reimbursements for no shows • Incorrect program/Class • Not a Medicaid enrolled provider • Medical necessity not verified

21. Public Meeting • July 14, 2011 • DMA held a Public Meeting to discuss NEMT. • Representatives from county DSS, transportation Providers, other state agencies and the general public attended.

22. Public Meeting • The general response to the public meeting was to give the DSS agencies and the transportation Providers a chance to fix the problems with NEMT. • It was recommended that a Stakeholder Group be formed to develop ways to cut transportation costs and reduce error rates.

23. Stakeholder Group A Stakeholder Group was formed with its members representing the county DSS agencies, transportation providers, county managers, county commissioners, and other state agencies. The Stakeholder Group objective was to: • Develop and write a comprehensive statewide Transportation Plan, to be provided to DMA no later than October 15, 2011. Transportation Plan will use existing DMA Transportation policy as the baseline. Transportation Plan will define how DSS and Transportation Providers will work together to achieve expected outcomes. • The Plan will set measurable parameters for reducing costs such as determining $amount of budget reductions to be achieved; will establish a timeline for reducing costs this FY; and will establish consequences for failing to reduce costs.

24. Stakeholder Group • The Plan will set measurable parameters for reducing the error rate such as requiring %reduction of error rates; will establish a timeline for reducing the error rate this FY; and will establish resulting consequences for failure to reduce errors. • The Plan will set uniform standards and requirements for Transportation Providers to use in claiming reimbursement including the use of standard logs, established codes, rates and provider requirements; and will establish consequences for failure to follow uniform standards and requirements.

25. Stakeholder Group • The Plan will establish reporting requirements and performance posting of quality indicators for DSS and Transportation Providers. • Establish a Medicaid Transportation Training and Communication Plan for county DSS that will address current policy requirements and provide State direction, oversight and expectations. The training plan will utilize the findings of audits to drive the curriculum content.

26. Policy Revisions • Revisions have been made to MA-2910 and MA-3550. • Policy revisions are effective January 1, 2012.

27. Statewide NEMT Training • Training on the revised NEMT policy will be provided statewide in November and December 2012. • Consistent training will be provided with the same trainers delivering the training at each session.

28. Next Steps • The Stakeholder Group will meet to finalize the statewide comprehensive Medical Transportation Plan on November 3, 2011. • Beginning in November 2011, NEMT Compliance reviews will be conducted in each of the 100 county DSS agencies by a private firm the State is contracting with. • Based on the results of the compliance reviews, there will be recoupment of funds claimed for reimbursement in error. • Training on the revised policy will be provided in November and December 2011. • New policy will be implemented effective January 1, 2012.

29. Questions?