WE CARE TRANSPORTATION

This subject is a transportation company in Overland Park, Kansas that was placed on the federal exclusion list on January 20, 2010. Even so, Medicaid paid it 4,441,513 dollars during 31 months between January 2018 and July 2020, which is more than eight years after the exclusion date. During the 12 months before the exclusion, Medicaid paid it nothing, so all of the recorded money in this evidence falls after the list action. Most of the money, about 79 percent, sits in one ambulance transport code, with two other transport codes making up about 10 percent each. One of those codes, the non emergency transport code, is billed at 228 dollars per patient month against a typical 90 dollars, which places it at the 85th percentile of providers billing that code.

1. 01The subject is listed in the national provider registry as an organization in Overland Park, Kansas, with taxonomy three four three nine zero zero zero zero zero X. records 1
2. 02The OIG exclusion list records an exclusion of this provider on January 20, 2010 under section 1128 and subsection 1128b5, with the entry described as a transportation company. records 3
3. 03Medicaid paid 4,441,513 dollars across 31 months after the exclusion list action, spanning January 2018 through July 2020, while payments in the 12 months before the action were zero dollars. Under 42 CFR 1001.1901, no payment is to be made for any item or service furnished by an excluded entity on or after the effective date of the exclusion. records 2, 4
4. 04The gap between the January 20, 2010 exclusion date and payments beginning in January 2018 is relevant to 42 CFR 455.436, which requires states to determine exclusion status through routine checks of the exclusion list upon enrollment and reenrollment and no less frequently than monthly. records 3, 4
5. 05Code A0100 accounts for 3,517,992 dollars paid over 31 months, which is 79 percent of this provider's Medicaid dollars, at 172 dollars per patient month, ranking at the 64th percentile of all providers billing this code against a typical 112 dollars. records 5
6. 06Code T2001 accounts for 464,942 dollars paid over 31 months, which is 10 percent of this provider's Medicaid dollars, at 228 dollars per patient month, ranking at the 85th percentile of all providers billing this code against a typical 90 dollars. records 6
7. 07Code A0130 accounts for 458,579 dollars paid over 31 months, which is 10 percent of this provider's Medicaid dollars, at 201 dollars per patient month, ranking at the 53rd percentile of all providers billing this code against a typical 190 dollars. records 7
8. 08The Verity risk tier is evidence tier one, documented action followed by payment, with dollars at stake of 4,441,513 dollars taken from the detector that set the tier. Claims presented for services furnished by an excluded person are addressed at 42 CFR 1003.200, and payment suspension and referral to the Medicaid Fraud Control Unit are addressed at 42 CFR 455.23(a) and 455.23(d). records 2

Refer to the state Medicaid program integrity unit for review of the paid claims dated January 2018 through July 2020 against the exclusion list entry dated January 20, 2010. Reviewers should first confirm that the excluded entity and the paying provider record are the same legal entity, then quantify any payments that fall under 42 CFR 1001.1901. Reviewers should also examine the monthly exclusion list screening required by 42 CFR 455.436 for the payment period. If the review establishes a credible allegation of fraud, 42 CFR 455.23(a) governs payment suspension and 42 CFR 455.23(d) governs referral to the Medicaid Fraud Control Unit. Remedies under 42 CFR 1003.200 should be considered only after identity and payment facts are verified.

• Identity matching must be verified. The exclusion list entry and the paying provider record may describe different entities that share a similar name or address.
• The exclusion may have been reinstated, waived, vacated or terminated at some point before January 2018, which the evidence here does not address.
• The provider identifier used for the paid claims may have been reassigned, or a successor owner may have acquired the business and enrolled separately, which the evidence here does not address.
• The paid amounts may include payments later recouped, voided, adjusted or denied on appeal, and the evidence does not show net final amounts.
• The 2010 exclusion date paired with payments beginning in 2018 may reflect a data or record linkage artifact rather than continuous payment to an excluded entity, and source claims records should be pulled to confirm.
• High per patient month figures and percentile ranks may reflect legitimate case mix, long distance transports, rural geography or contract rate structures rather than any billing irregularity.
• No finding here asserts fraud, intent or guilt. These are record observations that require investigation before any conclusion.