Claims review system results in overpayment for ambulance transports

A recent OIG inspection uncovered oversight issues involving non-emergency ambulance claims approved by Driscoll Health Plan, a Texas Medicaid managed care organization (MCO). The inspection sought to determine if Driscoll has appropriate controls to ensure claims for ground transportation via ambulance met requirements for reimbursement.

Texas Medicaid permits ambulance services for emergency medical and behavioral conditions and non-emergency ambulance transport to scheduled medical appointments, licensed treatment facilities, or the member's home after discharge from a hospital when a client's medical condition requires an ambulance to travel. Claims that do not meet these standards require coding to contain a GY modifier, which indicates the costs are not payable by Medicaid due to statutory exclusions.

The inspection discovered that nine of the 33 reviewed claims containing a GY modifier were inappropriately paid. Driscoll representatives said their claim system included Texas Medicaid coding requirements that would deny claims with a GY modifier. However, claims that also had an additional emergency transport modifier and mileage claims were erroneously paid.

Driscoll was informed they should recover payments for the nine erroneous payments made to providers, which representatives for the insurer have indicated are complete. OIG recommended changes to the claims processing system, which will prevent future errors, were also completed.