Overview
MassHealth paid for 10 nonemergency transportation claims out of 75 without a qualifying medical service, indicating that the transportation was not needed under MassHealth rules. Furthermore, 4 out of the 10 claims without a qualifying medical service also did not have trip sheets, indicating that the trip did not occur.
We extrapolated the test results related to the four unallowable nonemergency transportation claims to the entire population and estimate that MassHealth overpaid at least $1,669,323 for nonemergency transportation services.
Consequently, the claims submitted for these nonemergency transportation services represent unallowable costs to the Commonwealth.
Authoritative Guidance
According to Section 407.411(A) of Title 130 of the Code of Massachusetts Regulations (CMR),
Covered Services. The MassHealth agency pays for transportation services that meet the requirements of 130 CMR 407.000 only when such services are covered under the member’s MassHealth coverage type and only when members are traveling to obtain medical services covered under the member’s coverage type.
Reason for Issue
MassHealth stated in an email dated March 3, 2025,
MassHealth agrees that there appears to be no corresponding medical claim on the date of service of the transportation claim. MassHealth notes there still may be instances where the individual received medical services such as cases where a Medicare claim did not crossover into MassHealth’s claims system or a medical provider’s billing error resulting in the service appearing to have been delivered on a different date.
Recommendation
MassHealth should ensure that brokers maintain documentation for all transportation services provided to MassHealth members.
Auditee’s Response
[The Executive Office of Human Services (EOHHS)] agrees with the [Office of the State Auditor’s (OSA’s)] recommendation. Brokers have implemented software that will collect and maintain trip logs, driver credentials, and vehicle credentials within a central repository which will ensure documentation for older claims are available upon request by EOHHS or external auditors. EOHHS will continue to audit brokers annually to ensure that all records and documentation are stored properly and accurately reflect the [nonemergency medical transportation (NEMT)] services billed to MassHealth and will explore expanding the scope of these audits to better enforce broker and transportation provider compliance.
Regarding the claims the OSA identified without a corresponding medical service, EOHHS notes that these cases may reflect circumstances where the member did receive the medical service but did not result in a claim that EOHHS or OSA can identify. For example, MassHealth members with Medicare or commercial health insurance may have a medical claim that is paid in its entirety by the third payer and does not cross over into MassHealth’s claims processing system. In addition, providers’ billing errors may result in the corresponding medical service being captured in a claim with a different, incorrect date of service. Finally, certain codes are billed as a bundle of services provided over a period of days, with only the first date of service appearing in [the Medicaid Management Information System] as the date of service (e.g. G2067: Medication-assisted treatment, methadone, Use to cover episodes of care lasting 7-days in a row). For these claims, the medical service’s date of service may not match up with the transportation, even though the medical service was provided each of the seven days.
Auditor’s Reply
Based on its response, MassHealth is taking measures to address our concerns regarding this matter. As part of our post-audit review process, we will follow up on this matter in approximately six months.
| Date published: | May 8, 2025 |
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