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Committees press department on Medicaid rate spikes, NEMT billing and audits
Summary
Lawmakers questioned the Department about unusual NEMT billing and a sharp rise in XL wheelchair payments after guidance led some providers to use ambulance rates; department said it will increase audits and examine intentional upcoding while stressing implementation and CMS processes for rate changes.
OSPB and the Department addressed several Medicaid-related comebacks as the committees probed recent rate changes and unusual utilization trends.
Mark Farandino outlined a roughly $53 million set of accountable-care-quality payments and said a prior-year set-aside was $43.5 million, creating an approximate $10 million delta that shaped his office's proposed reductions. He also summarized the timing and process for provider-rate changes and the role of the Medical Services Board and CMS.
A sustained portion of the hearing focused on nonemergency medical transportation (NEMT) and an "extra-large" wheelchair billing issue. Committee members cited a pickup cost cited as $232.44 in earlier material and an ambulance-level payment that reached $639 for some transports after guidance allowed use of a higher benchmarked rate. Director Flores Brennan told the committee the department had told brokers to use an ambulance rate in some circumstances and benchmarked to Medicare; that advice later widened and utilization increased.
"To the extent that people are using the ambulance rate for ambulances, that would be appropriate," Flores Brennan said, adding that it will be difficult to determine intentional upcoding because the department previously told providers to use the higher rate in certain cases.
Committee members pushed for more audits and for the department to clarify where guidance was given. Farandino and Flores Brennan said the department is increasing audits, adding a claims modifier for XL wheelchair codes and considering recoupment only where intentional inappropriate billing is found. They emphasized that actions will be targeted and that follow-ups to providers and case management agencies are planned.
No formal statutory change was made; the committee asked staff and agencies to provide further analysis and documentation for the fiscal note, rate calculations and any planned audits.
