Review of Medicaid Payments for Nonemergency Medical Transportation Services Claims Submitted by Providers in New York City

Based on our sample results, we estimate that the New York State Department of Health (DOH) improperly claimed approximately $17 million in Federal Medicaid reimbursement for 979,886 nonemergency medical transportation (NEMT) claims in New York City during the period April 1, 2005, through March 31, 2006. In addition, we estimate that DOH claimed $2.9 million in Federal Medicaid reimbursement for 193,375 NEMT claims that may not have complied with Federal and State Medicaid requirements. States are required to ensure necessary transportation for Medicaid beneficiaries to and from providers.

Of the 100 NEMT claims in our random sample, DOH properly claimed Medicaid reimbursement for 54 claims. However, for the 46 remaining claims, DOH claimed Medicaid reimbursement for services that were not allowable or were potentially unallowable. Specifically, 36 claims contained services that did not comply with certain Federal and State requirements, and for 10 claims, we could not determine whether services complied with Federal and State regulations.

The claims for unallowable and potentially unallowable services were made because (1) DOH's policies and procedures for overseeing the Medicaid program did not adequately ensure that providers complied with Federal and State requirements for ordering, documenting, and claiming NEMT services and (2) the New York City social services district's quality assurance mechanism did not adequately ensure that NEMT services were properly provided.

We recommended that DOH (1) refund $17 million to the Federal Government; (2) work with CMS to resolve the claims, totaling an estimated $2.9 million, for which Medicaid reimbursement may have been unallowable; (3) strengthen its policies and procedures to ensure that providers comply with Federal and State requirements for ordering, documenting, and claiming NEMT services; and (4) require the New York City social services district to strengthen its quality assurance mechanism to ensure that NEMT services are properly provided. DOH partially agreed with our first recommendation (financial disallowance) and agreed with our remaining recommendations.