Medicaid sure doesn’t pay much per trip. The rate of reimbursement for Medicaid transport services is usually far below Medicare (we know Medicare doesn't reimburse the cost of service). The number of Medicaid recipients has grown. Which means that for the average ambulance service, more Medicaid transports occur leading to increased claims submission for Medicaid (or Medicaid managed care).

Since there’s not a whole lot of money, you would think there would be less concern about fraud and abuse. The amount of reimbursement is small. Nevertheless, it is taxpayer money. As such, Medicaid compliance is as important as Medicare compliance. Just ask the folks from Essex County, New York where thirteen people were arrested in May related to Medicaid transportation fraud. According to the U.S. Attorney’s Office for the Northern District of New York, there was a two-year investigation of local medical transport organizations.

On June 26th, CMS announced an “Enhanced Medicaid Program Integrity Strategy” because spending on Medicaid grew “…from $456 billion in 2013 to an estimated $576 billion in 2016.” Medicaid is a combination of federal and state dollars. Among the many goals of the program are to protect the integrity of the program and reduce “aberrant billing…”

Here’s the message – yes, ambulance services can be audited by Medicaid and Medicaid managed care. Documentation and billing compliance must be maintained. How does a provider accomplish that goal? First, start with the Medicaid provider manuals usually available on the state’s website. Make sure that operational and billing management understand the requirements of documentation and billing for Medicaid. We occasionally see that certain services may be covered by Medicare, but not Medicaid. For example, every state does not recognize ALS 2 services.

Assure that billing personnel are thoroughly trained on the requirements of Medicaid. There are often special modifiers or unique codes related to Medicaid billing. Go to the state’s website and find a copy of the contract the state has with Medicaid managed care and with non-emergency transport brokers. Those contracts will outline what medical transportation services are covered. Non-emergency services need to pay attention to contract or prior authorization requirements. Emergency providers need to stay updated on what services is covered by managed care.

Many states outsource their non-emergency transport management to transport brokers. If your state has such a program, it’s important to understand what the state requires of the broker. The same approach applies – go to the state website to see the contract. Next, investigate what requirements providers must meet to assure services get provided properly and paid promptly. When working with the brokers, it’s a good idea to confirm with them that the services you think you will provider (whether an ambulance or wheelchair van transport) are the services that they are authorizing for a particular patient.

Finally, include Medicaid claims and Medicaid managed care claims in the company’s internal audit review program. A good internal audit program will catch problems, identify denial issues and pinpoint overpayments. Like Medicare, Medicaid overpayments need to be refunded promptly.

As we said earlier, Medicaid financing is a combination and federal and state dollars. From a compliance perspective, Medicaid and Medicaid managed care needs to be treated with the utmost respect and diligence. Medicaid numbers continue to grow which means providers need to monitor this topic closely.

Let us know if we can help!

About the author:  Maggie Adams is the president of EMS Financial Services, with 25 years’ experience in the ambulance industry as a business owner and reimbursement and compliance consultant. Known for a practical approach and winning presentation style, Maggie has worked with medical transportation providers and billing companies of all kinds to provide auditing services, assess their billing for best practices and support their billing and documentation training efforts. “Like” EMS Financial on Facebook, follow us on LinkedIn or for more info, contact Maggie directly at maggie@ems-financial.com or visit www.ems-financial.com