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What is Non-Emergency Medical Transport and Is It a Good Opportunity?

If you are looking to start a non-emergency medical transport business, it pays to pick something people will always need, no matter what. One possibility is non-emergency medical transport. So, what is that, how does it work, and why should you consider starting a Non-Emergency Medical Transport business?

What is Non-Emergency Medical Transport?

Non-emergency medical transport or non-emergency medical transportation is a service provided to get the elderly, disabled, and chronically ill to and from medical appointments. These services are used by people who use wheelchairs, people who must be transported in stretchers, and others who need significant assistance and potentially medical monitoring while in transit. However, they are not in crisis, and it is not an emergency. Non-Emergency Medical Transport may be short or long distance and typically the person is transported between their home or a nursing home or another facility and the hospital, doctor's office, or clinic. Long-distance travel might include transportation to a particularly well-known specialist or even relocation of an individual who needs medical monitoring enroute. Short-distance travel includes dialysis, routine doctor visits (including dental and eye care), mental health appointments, and transportation between home and a rehab facility. Some patients may also use these services to return home from the hospital after a stay.

Does Non-Emergency Medical Transport Require an Ambulance?

Sometimes ambulances are used for Non-Emergency Medical Transport. This is sometimes a way for ambulance services to make extra money from either the patient and their family or their insurance or, in many cases, Medicaid. However, most Non-Emergency Medical Transport companies do not use full-size, expensive ambulances. They don't need all the specialist equipment even when the patient is bedbound and has to be moved on a stretcher. Instead, a variety of vehicles are used including stretcher vans and wheelchair vans. Some patients may be transported in a regular car (for example those who need transportation simply because a physical or mental condition, such as visual impairment, makes them unable to drive).

Ambulances may be warranted for people who require very extensive monitoring or are particularly likely to, for example, have a heart attack enroute. But for many Non-Emergency Medical Transport services, wheelchair accessible and/or stretcher-accessible vans are more suitable.

Who Pays for NEMT?

There are two large markets for NEMT. The first is, of course, patients who are paying for the service themselves. They may be choosing a NEMT provider because they have a wheelchair and their area is short of wheelchair-accessible cabs, because they can't use public transportation or there is no route to the location they are going, or because they feel safer with a specialist. Most long-distance transport is paid for by the patient or their insurance company. The other major market is Medicaid, which partners with private brokers to help patients get transportation to their appointments.

What is the NEMT Benefit for Medicaid Recipients?

Medicaid covers the cost of transportation for beneficiaries between their home and their doctor's office, a hospital, or another medical office for Medicaid-approved care. The benefits are available for people who are unable to drive or do not own a car, have significant physical or cognitive limitations, or cannot safely travel alone. For example, a visually impaired person qualifies because they don't drive. Somebody with dementia who might forget where they are going and wander off on the way to their appointment also qualifies. You also qualify if you are unable to afford a car, even if somebody else in the household has a driver's license. The exact rules vary from state to state, but generally, rides are only available to recipients who have no other 'reasonable' way to make it to and from their appointment. In some cases, beneficiaries receive reimbursement for trips by public transportation (if it's available and they can take it). In others, however, Medicaid will use a broker that provides a ride in a suitable vehicle. Medicaid does not cover the use of ambulances unless medically necessary. Also, when possible, rides are expected to be shared.

Is NEMT a Shared Ride?

When possible, most NEMT providers will work on a shared ride basis. They will transport people who are going to and from similar locations at the same time together. This makes larger vehicles such as vans beneficial for NEMT providers, especially as ordinary cars can't take people in wheelchairs. However, this typically requires the driver to have the appropriate license.

You can and should save money and mileage by having patients share rides. However, there might be circumstances under which it is inappropriate. For example, if the patient is severely immunocompromised then their safety may require that they ride alone, and that the driver wear a mask.

Are Patients Often Accompanied?

Patients are often accompanied by a friend or family member to act as an escort. This should be a person at least 18 years or older, and if you are being reimbursed by Medicaid you cannot charge the escort any money. However, they must be required to assist the person, not just give moral support.

Should NEMT Providers Provide Attendants?

If the person needs assistance and lives alone, then you should consider providing an attendant who will help the person during the trip. Attendants typically do not go into the medical facility with the person and should be trained in first aid, CPR, and passenger safety. An attendant is also required if the patient is 12 and under and no family member is available. It's a good idea to hire attendants who are potentially comfortable dealing with children. Not every patient is going to need an attendant. The driver can typically handle helping people in and out of the vehicle.

Do You Need a License to Provide Non-Emergency Medical Transportation?

Licensing and regulation vary by state. However, all your drivers must have the appropriate license to carry passengers in the vehicle type they are driving. This often means a chauffeur's license as well as a license endorsement for vans. Some states have additional requirements, such as a minimum time holding a license or a maximum number of points. Most states also require that you have a business license to operate within the state. If you are located on a state border or in cities that straddle state lines (such as New York City, Washington, DC, St. Louis, etc.) you may need to get a business license in more than one state, and you may also need to get motor carrier operating authority from the Federal Motor Carrier Safety Administration. You will also need this if you plan on running long-distance trips. Other states have tighter rules. For example, in Virginia, you need a certificate to transport patients for Medicaid...and can only transport Medicaid recipients, and you are also required to be insured, bonded, and have special vehicle license plates and registration. States that do allow you to do both typically do not allow you to charge Medicaid more than you charge those paying themselves.

Should You Screen Employees?

Yes! All employees who will be involved in handling patients need to have a background check. Individuals who are convicted of certain crimes or have lost a professional license often can't work on Medicaid contracts. States also typically require that they have not lost their driver's license. You should also assess employees for their comfort in handling patients, including people with cognitive challenges who may become belligerent. Employees need to follow certain very clear rules, such as not touching a patient without permission unless they need medical care. They are expected to be always courteous to patients and escorts. As attendants may have to watch minors, they should be comfortable dealing with children. Also, bear in mind that some of your patients may be traveling with a service dog; make sure that you don't assign employees with severe dog allergies to those runs. All employees should be trained in first aid and CPR. Drivers must be very familiar with the area, including knowing how to get to an emergency room in the rare situation that non-emergency transport becomes an emergency.

How Do You Become a Medicaid Provider?

This also varies a lot by state. Some states meet the transportation requirement solely by providing recipients with bus passes and don't allow NEMT to operate at all. Most, however, have some mechanism for signing up and registering as a provider, whether directly with Medicaid or through a broker who matches recipients with transport providers. You will need to fulfill all licensing requirements plus any extra requirements related to insurance or staff training, as well as any other rules, which can include things like wearing a uniform (so patients know that this is their official driver), not abusing alcohol, etc. Some states also have requirements for vehicles which can include having functioning air conditioning and having seat belt extensions available. Once you meet the requirements, you will receive reimbursement from Medicaid and assignments to collect patients. Medicaid expects you to use ridesharing when possible. You must allow one (but only one) escort to travel with the patient free of charge. If the room is available, you should also transport minors who would otherwise have to be left alone but are not required to do so.

What About Medicaid Fraud?

While we're assuming you don't want to commit fraud, certain things can get you into trouble. You should not:

  • Charge for wait time. This is generally considered in your rates.

  • Bill for a patient no-show. Unfortunately, if the patient does not show up, you may be out some mileage. This is one of the most common forms of fraud and is called "Billing for services not rendered."

  • Taking patients to a nonmedical location, even if you are driving right past it. You must pick up the patient at their home or residence and take them only to their appointment and back. You can't stop at the grocery store.

  • Bill patients for services they did not receive.

  • Use an ambulance when a van will do, or otherwise "upgrade" the vehicle from what is medically necessary for the sickest passenger on the route.

Document everything to make sure your bill is accurate, and you are also required to document which patient you are taking where. Remember that HIPAA applies and be careful with patient information.

What Vehicles Should You Buy?

First, while transportation is not for an emergency, it is for something the person needs. You need to make sure you can always reliably cover all trips. To do this, it's a good idea to have a couple of backup vehicles.

Also, because of Medicaid rules, you benefit from having different "classes" of vehicles. If you only have large vans and somebody doesn't need that, then the broker will send them to your competitor.

Suitable vehicles include:

  • Ambulettes. An ambulette is a fully medically equipped vehicle that is used for non-emergency transportation of people who need monitoring. Having an ambulette can let you take on these cases, but it should only be used when necessary.

  • Wheelchair vans. These are vans that seat several passengers and have a ramp for wheelchair access. They are used for patients who use wheelchairs and for people with other mobility issues who may have difficulty getting in and out of a normal vehicle.

  • Stretcher vans. These are vans equipped to load and unload a patient who must be transported via stretcher.

  • Minivans. Non-accessible minivans can be used to transport patients who are not physically disabled and often carry more people. If you are working in a densely populated area where it's easy to share routes, it's worth considering.

  • Cars. Regular cars can be used when you only have a couple of people to move. However, most NEMT companies don't use ordinary cars. Medicaid tends to give those contracts to taxi drivers.

Choosing a fleet depends on the demographics and needs in your area as well as your budget. Many companies start with only one wheelchair van, which can transport most patients, and rely on brokers to find them work so they can afford to expand their services. Having more than one vehicle, though, makes you more reliable, as does having more than one qualified driver. Running a NEMT business can be hugely rewarding but is complex to set up and does require some capital. This includes the right vehicle, and a well-equipped wheelchair van (or, ideally, two) is a good place to start.