Non-emergency transportation is an essential function that helps Medicaid members access necessary care when they cannot safely use standard transportation. But because these services involve multiple billing components like vehicle type, mileage, and wait time, they can also create vulnerabilities when utilization appears unusually high or inconsistent with policy limits.

Recent public attention around transportation-related Medicaid fraud, waste, and abuse (FWA) in Minnesota has reinforced the need for health plans to assess whether exposure may exist in other markets, particularly given complex reimbursement rules that potentially make these services more vulnerable to bad actors.

In this edition of FWA Insights, we explore how special investigative units (SIUs) can take a proactive, data-driven approach to identifying potential FWA in non-emergency transportation claims.  

Investigation uncovers high risk 

In a preliminary review, Cotiviti investigators evaluated exposure for a California Medi-Cal client and identified a provider that appeared as a statistical outlier for several non-emergency transportation-related HCPCS codes. These included: 

• T2005: Non-emergency transportation by stretcher van 

• T2007: Transportation wait time for air ambulance and non-emergency vehicle services in half-hour increments 

• A0425: Ground mileage per statute mile 

Investigators discovered that the provider’s paid amount for T2007 was 24 times higher over the past three years than the next highest-paid provider for the same code. This billing behavior warranted further review due to the extreme variance when compared to other providers.

Investigators found that the provider consistently billed T2007 above the three-unit limit per member on a single date of service described in Medi-Cal guidance. Under that guidance, providers may bill waiting time in 30-minute increments, but reimbursement is generally limited to a maximum of three units, except in limited circumstances. The preliminary at-risk amount associated with the review was estimated $3 million.

Audit findings were released to the provider who appealed, but the investigation was upheld and resulted in an identified extrapolated overpayment of >$6 million dollars. Medical necessity of transportation could not be justified due to a lack of transportation records and no physician order for the services. 

Action steps for recovery

For health plan SIUs, the first step in reviewing similar activity is to use claims data to identify providers with unusually high utilization, high paid amounts, or repeated billing above defined limits for transportation-related codes. Outlier analysis can help prioritize leads, especially when a provider’s billing is different from peers serving similar populations or operating in the same line of business.

From there, SIUs can assess whether the claims editing environment is effectively preventing payments for non-covered or excessive services. Transportation billing rules can vary by program and jurisdiction, so investigators should compare claims against the applicable fee schedule, coverage requirements, and unit limits. When claims exceed policy thresholds, medical records or documentation may be needed to determine whether billed services were supported, medically necessary, and reimbursable.

Extreme outlier status becomes more meaningful when paired with specific policy indicators, such as repeated billing above unit limits, unusually high wait-time reimbursement, or disproportionate use of transportation mileage and stretcher van codes. By combining peer benchmarking, claims editing review, and documentation requests, SIUs can better distinguish legitimate transportation needs from billing patterns that may indicate fraudulent activity. 

Key takeaways

Non-emergency transportation should be monitored as part of a broader FWA prevention strategy. Proactive analytics can help health plans determine whether similar exposure exists within their own Medicaid populations before improper payments accumulate.

Health plans should also evaluate whether their claims systems are configured to detect and prevent payment for services that exceed applicable limits. Strengthening prepay edits for high-risk transportation categories can help reduce payment for non-covered services, support more consistent policy enforcement, and protect program resources while preserving access to transportation for members who need it.

Webinar: Future-proofing FWA prevention

Strong governance and collaboration are the key to reducing FWA. Watch our on-demand webinar as health plan leaders join us to discuss how to:

• Build an intentional prevention plan
• Align goals across teams to drive a unified strategy
• Leverage trusted partnerships through collaborative preparation, shared insights, and joint decision-making