Suspected NEMT FWA Confirmed With VectorCare Hub

Use Case: Suspected NEMT FWA Confirmed With VectorCare Hub

September 28, 2021
David Emanuel

Use Case: Suspected NEMT FWA Confirmed With VectorCare Hub

A major challenge healthcare payers face is the fight against fraud, waste, and abuse (FWA) going undetected within their organization—an issue that calls for an intelligent and comprehensive solution.

Payers are well aware that cases of FWA need to be addressed, considering that in FY 2020, THE ESTIMATE OF PART C (MEDICARE ADVANTAGE) IMPROPER PAYMENTS TOTALED $16.27 BILLION.

An area of care that’s particularly susceptible to cases of FWA is non-emergency medical transportation (NEMT) services. This issue has not gone unnoticed, in fact, multiple states have REPORTED CASES OF TRANSPORTATION PROVIDERS ABUSING THE SYSTEM.

But how exactly can payers go head-to-head against NEMT fraud, waste, and abuse?

Below is a use case detailing the experience of a healthcare payer who suspected fraudulent activity within their NEMT services and couldn’t confirm or prove their suspicions until they employed the help of VECTORCARE HUB.

Quick Facts

  • Organization: Healthcare payer Medicare Advantage plan.
  • Goal: Identify and confirm suspected fraudulent activity within their NEMT services.
  • Partners and systems: Member benefits and in-network transportation service providers.
  • Data to exchange: Member pre-authorizations, transportation service requests, bids, scheduling confirmations, service completion confirmations, and claims.

Story: Identifying NEMT FWA With VectorCare Hub

A Medicare Advantage plan run by a large healthcare payer manages a network of non-emergency medical transportation (NEMT) vendors who take members to and from their appointments and/or treatments.

The mileage reports submitted by transportation providers did not seem entirely accurate. The plan began to suspect fraud, waste, and abuse (FWA) were stemming from these services but weren’t 100% sure. Unfortunately, the payer didn’t have the correct technology in place to dig deeper.

They knew that padding mileage is a common way for bad actors to commit fraud and that it’s nearly impossible to identify without an automated system that tracks mileage trends.

Upon implementing VectorCare Hub, this payer was able to confirm their suspicions through intelligent automation and customized reporting.

Here’s what their journey looked like:

  1. After noticing suspicious activity, they knew they needed reports that provided insights into their transportation network’s average costs, mileage, and volumes.
  2. Once they started working with VectorCare, reports were implemented to track activity. VectorCare Hub offers a fully functional BI tool that helps payers build custom dashboards that offer operational insights and leverages machine learning (ML) to identify potential fraud, waste, and abuse.
  3. After the configurable reports were in place, they dug into their transportation network’s data, analyzed pricing and mileage trends, and compared mileage reports from different companies for the same services.
  4. These reports helped them spot outliers within their system—which were indeed fraudulent excessive mileage claims for transportation.
  5. They realized significant operational and financial gains through the identification and elimination of NEMT FWA.

VectorCare Hub Helps Payers Fight NEMT Fraud, Waste, and Abuse

Not only does VECTORCARE HUB’S REVENUE MANAGEMENT SOLUTION HELP PAYERS ROOT OUT CASES OF FWA by excessive mileage, but other common NEMT fraud tactics such as charging for services that never happened or charging for one service multiple times.

Medicare Advantage plans that use VectorCare Hub have the peace of mind that suspicious activity will be brought to their attention in real-time. This means they can allocate time and operational efforts to serving members better.

Learn how VectorCare Hub can aid you in the fight against NEMT FWA.

CONTACT US today to schedule a demo.