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Other Matters: Non-Emergency Transportation for Services Out of the Office

The audit points to a single day in which Dr. Wagner was paid for 27 travel claims, but visited only two nursing facilities.

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Before June 2007, MassHealth regulations allowed providers who traveled to nursing facilities to bill for non-emergency transportation (service code T2002) once per facility per day, regardless of how many patients they saw. At that time, Section 402.418(D)(2) of Title 130 of the Code of Massachusetts Regulations (CMR) stated,

[MassHealth] will pay once per facility per date of service for the following services: the delivery and adjustment of eyeglasses; the pickup of broken eyeglasses; or the delivery of repaired eyeglasses.

In 2007, MassHealth revised its non-emergency transportation regulation in Vision Care Bulletin 14:

Effective June 1, 2007, MassHealth pays for Service Code T2002 once per member per date of service for each member for whom the provider delivered or picked up eyeglasses, or to whom eye exam services were provided, in a nursing-home or home setting.

Subsequently, on June 1, 2008, MassHealth revised 130 CMR 402.418(E)(2) as follows:

The MassHealth agency pays separately for transportation once per member per date of service for each member for whom the provider delivered or picked up eyeglasses, or to whom vision care services were provided out of the office.

In the Office of the State Auditor’s opinion, this amended regulation can create situations where MassHealth will incur unnecessary transportation costs, because it allows providers such as Dr. Frederick Wagner Jr. to bill for transportation costs for each member even if multiple members are treated at the same facility. For example, on September 24, 2014, Dr. Wagner billed for 27 non-emergency transportation claims for traveling to only two nursing facilities to provide vision care. For that date, Dr. Wagner was paid $250.02 for travel because he was allowed to bill once per member, for 27 trips, rather than once per location, which would have required MassHealth to pay him only $18.52, or $231.50 less.

During the audit period, Dr. Wagner submitted 14,149 claims, totaling $131,020, for non-emergency transportation. These claims represented Dr. Wagner traveling on 930 days to approximately 1,383 nursing facilities. If Dr. Wagner had billed non-emergency transportation by facility, he would have been paid $12,807, or $118,213 less. Therefore, we believe that MassHealth should consider amending this transportation reimbursement regulation to provide for more fair and equitable reimbursement amounts.

MassHealth’s Response

Prior to 2007, MassHealth paid once per nursing facility per day, and in 2007 MassHealth changed its methodology to a per-member per-day rate. The reason for the change was in fact to enhance program integrity because MassHealth’s [Medicaid Management Information System] cannot enforce a per-facility-per-day methodology, but it can enforce a per-member-per-day methodology and includes edits to ensure that this limit is not exceeded. If MassHealth were to revert to the old methodology, it would have to address operational and systems challenges that may carry significant additional cost. Therefore, MassHealth does not concur that it would be more cost-effective to pay a per-facility-per-day rate.

Date published: September 24, 2019