Zurik: Taxpayers face emergency with non-emergency medical transport

Zurik: Taxpayers face emergency with non-emergency medical transport

BATON ROUGE, LA (WVUE) - Red flags. Abuse. Potential fraud. Just some of the words the state's legislative auditor used to describe a state program that lacked oversight for almost a decade - potentially wasting millions and millions of your dollars.

Undercover video obtained by FOX 8 News shows a man in a red shirt, walking to his doctor's visit.  Through a window, the camera captures a wheelchair leading the way as the patient takes step after step outside. And then, he sits in the wheelchair and gets loaded in a non-emergency ambulance.

This video means something to you, because you paid for the ride. And those shots of him walking may mean you paid a lot more than you should have.

"There's a lot of money being spent here," warns Daryl Purpera, Louisiana's legislative auditor. "We're talking $20 million a year."

For the past eight years, Purpera has looked into the state's Non-Emergency Medical Transportation program, provided for people on Medicaid.

And in each of those eight years, he told the Department of Health and Hospitals he found significant problems of oversight and potential abuse.

"When we repeat a finding, all it's saying is, 'we've told you once before, we're telling it to you again and again and again,'" Purpera tells us.Taxpayers fund these trips when Medicaid recipients need to visit the doctor. Purpera says his staff found "55,000 cases over a four-year period of time where we had a trip charge, non-emergency medical trip charge. But there was no corresponding visit or payment to a doctor on that same date for that particular patient. Naturally you would have both."

He's saying those 55,000 claims could only use the transportation to go to the doctor. And since records show the state never paid for a Medicaid-funded doctor's visit, the claims are questionable.

The cost of those 55,000 ambulance rides to you, the taxpayer: $1,682,286.

The auditor also found trips to the pharmacy, against program rules, and found that when DHH discovered non-compliant providers, it failed to recoup money.

"For eight years, the department has failed the state, from a perspective of 'we kept reporting it,'" Purpera says. "This is not a new issue. This goes back to 2008. We reported this program as not being operated properly, from 2008 forward.  And every year we're having to report it again. They took no action."

But the most frequent abuse could be committed by some nursing homes in the state.

"They had never monitored the ambulance service through the nursing homes," Purpera says. "It absolutely could be fraud."

FOX 8 asked the La. Department of Health and Hospitals for all non-emergency medical transportation trips from nursing homes. And, while the state never took a look, the legislative auditor and FOX 8 examined those records.

The program has two types of transportation, each with strict rules. Non-emergency medical transportation is the lowest tier - mostly small businesses make up this group, and the cost to taxpayers is 36 cents to $1.60 a mile.

But if a doctor or nurse at the nursing home says an ambulance is needed to transport the patient, then a non-emergency ambulance is used.  Those fees are much higher, $6.34 a mile plus a base rate of $165.96.

Here's the catch: If a nursing home transports a tenant in a non-emergency medical transportation vehicle, the nursing home has to pay for it.  But if the nursing home's own doctor or nurse determined the patient needs an ambulance, then the state and its taxpayers pick up the tab.

Purpera calls it a financial advantage for nursing homes. "That seems like an unusual anomaly," he says.

Consider our list of ambulance trips contracted by nursing homes.  We found two stand-outs when it comes to these NEMT trips. - two homes with more than 1,100 ambulance trips a piece in four years, That's almost 500 more than the nearest nursing home.

The Ruston Nursing and Rehabilitation Center had the most ambulance trips during the period, 1,159.  The nursing home wouldn't tell us why it transported so often, but did write:

From time to time, residents are in need of non-emergency medical transportation which can most safely be accomplished via ambulance, as opposed to another means of transport.  The determination of whether it is medically necessary to transport a resident via ambulance is made by the resident's attending physician.

And one block off St. Charles Avenue in New Orleans, the Uptown Healthcare Center has the second most ambulance rides, 1,155 in four years. We reached out to Uptown Healthcare and asked why, but they never responded.

"That's just plain wrong," says DHH Secretary Rebecca Gee. "And one of the things I would say is, 'You get what you pay for.' Those are clearly incentives we've created in our system to use an ambulance and not non-emergency medical transportation, which are typically cabs, you know, non-ambulance type - much cheaper modes of transportation."

The new DHH chief says she expects issues with the program to stop. "That's unacceptable," Gee insists.  "Let me just say, those eight years were Jindal's years, and I'm not about that.  When we have a finding, we're going to change, we're going to improve."

She called the repeat findings insane, but notes the budget crunch of the past eight years contributed.

"My department was more than 12,000 people, eight years ago," Gee says.  "We are now at 5,500.  And to think that the very few staff we have - I learned it was just a handful, managing thousands and thousands of trips - that they could manage this was just a fallacy. It wasn't working."

DHH has flipped the system to what they call managed care – a non-public company now runs the program and gets paid a flat fee.

"It's certainly in that managed care operator's best interest to not pay bad claims," Purpera says.

Because of the state's history of abuse and overpayments, the negotiated rate the state pays the managed care operator may be inflated.

"With managed care now involved, we need to review," Gee tells us. "Now that every case is prior-authorized, we're looking at it much more closely. We need to take a look again at costs and make sure that, if the costs are really lower, that we then lower rates."

In the wheelchair patient's case above, taxpayers may have paid a significantly inflated rate. This person did not live in a nursing home, so the state had to fund the ride regardless.  But if this person didn't need a wheelchair, didn't need an ambulance, it could have meant the difference between a $32 or $292 trip for taxpayers – in just this one case.  This patient got the more expensive trip and taxpayers could have been taken on a ride with him.

"We're in dire straits with our budget," Purpera says. "And we don't have money to spend on the things we should be spending it on.  We need to be saving every dollar we can.  So, if we can transport someone in a cheaper way then we ought to be doing that, as long as that way is… you know, provides the right care for him."

We've asked the state for a breakdown of costs paid to different providers in this program.  We were promised the information last month, but the state has yet to fulfill our request.

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