I don’t guess when I opine on anything. But in writing about events whose parties are not revealed, I am strongly guessing that, collectively, attorneys lose tens of billions a year not understanding the rudiments of shared ride transportation – particularly the corruption of it by non-emergency medical transportation (NEMT) services. This hydra has more heads than one can usually count, since virtually nothing they do is obvious to even most senior members of the public transportation field. But this is also because those in the transportation field have little, if anything, to do with the funding or operations of NEMT service.
But even officials in public agencies giving money for MediCare, Medicaid and VA transportation have no remote clue what they’re doing and haven’t for a long time. 50 years ago the average healthcare agency was getting cheated out of 2/3 or it money (by billing for phantom trips it never provided), and wasted most the last third by driving its certified clients around in circles and running up mileage fees – long before computerized technology emerged at roughly the same time as the Americans with Disabilities Act (ADA), regulations of which only complicated things further, and provided a wealth of new opportunities to steal even more money from our healthcare system. But a valuable lesson should be learned by this: Funding for these healthcare-related transportation services does not flow from a transportation bureaucracy at the Federal level to a transportation bureaucracy at the municipal, county, regional or state level. It flows from a healthcare bureaucracy with no remote understanding of transportation to a healthcare bureaucracy at the state, regional, county or municipal level, with even less of an understanding of how transportation – particularly demand-responsive transportation (the backbone of NEMT service provision) operates – or should operate. As a consequence – if an analogy can be applied — those transporting this vulnerable population are akin to the dead leading the blind, or vice versa. More accurately, we have the ignorant leading the even-more-ignorant. This is no way to operate a game of marbles, much less a transportation service with millions of lives at stake, and hundreds of billions of dollars involved in doing so.
Otherwise, the cheating of the second half of the 20th Century became even easier as we approached the 21st Century, and as healthcare agencies were allowed to hire brokers, around the mid-1990s. With no clue about what intelligible transportation operations involved, and absolutely no understanding of efficiency (and little concern about it), these agencies began hiring brokers as fast as the ink could dry on their childlike contract agreements.
Brokers and Broken The reasons for this speedy transition to brokers is not hard to understand. First, after decades of ignorance by journalists from major newspapers and magazines, a few journalists began to catch onto the shenanigans, and the subterfuges given to public agencies to keep the floodgates open. In the later decades of 20th Century, many or most service providers made money – often a small fortune – by submitting invoices for phantom trips that were never provided, or by driving clients around in circles.
Suddenly, near the end of the Century, brokers emerged who claimed to have the answers, and the skills to put them in place. One of my favorite ruses was the claim that, getting paid by the hour, the service providers were not being held accountable because there was no incentive to provide service efficiently. The notion of actually monitoring its provision never surfaced. The truth is that these service providers could have been held accountable if these agencies had any understanding of monitoring, which they could have picked up from a handful of consultants, as I was, off and on, at the time. Instead, brokers (at least the major two that dominated service) paid their service providers $X per trip and $Y/hour). As a result, the companies that provided the actual service were only paid when the vehicle was moving (with a certified MediCare, Medicaid or VA client on board (and occasionally clients affiliated with other programs). That tens of thousands of wheelchair tipovers likely occurred every day – mostly in NEMT service, transit and paratransit (in that order) should hardly come as a surprise. Not a surprise is that many of these tipovers resulted in little injury, those more severe were not severe enough to attract the attention of an attorney, most of the attorneys who were attracted were lazy, incompetent and crooked, and lied to their clients about why they should take the defendant’s “crummy offer” (because the victims’ attorney would then have little to do), and because genuine expert for those few honest, hard-working attorneys were hard to find, and few and far between. So most of these tipovers remained invisible to those institutions who one assumed were charged with collecting this information. Of course, as perhaps a real surprise to most readers, no such organization existed.
Since brokers often retained most of the transportation budget and handed out the crumbs to those companies that actually provided the service, the “operators” were, understandably, stingy with their money. Drivers were often paid minimum wages. And in some cases, they were paid only a fraction of the income their employers obtained in fares. If that wasn’t enough, some drivers paid for the penalties assessed against their employers when, for example, vehicles arrived a certain amount behind schedule – and when “liquidated damages” were assessed against the service providers, some providers actually made their drivers pay them (withholding the money from their wages).
In one lawsuit in which I was involved, the drivers were paid a flat rate for every trip, irrespective of the time or distance involved in providing it. Of course, drivers did not make the schedules. (Nor did their employes; robots did.) If this arrangement were not absurd enough, these drivers were literally racketeered by their employers’ penalty structure: With drivers paid a flat rate of $25.00 for every trip – irrespective of its length or traffic conditions, even when the trip took hours (including the deadhead time back to the service area from which they were allowed to accept trips from) they eked out a paltry living – which explained the turnover at the driver level, and the difficulty finding drivers. On-time performance meant picking up or dropping off within a 15-minute “window.” (And a client not ready to travel, who held up the vehicle, led to that driver arriving behind schedule at the next pickup. Often, when vehicles were late, clients quickly found other ways to travel – and those would-be trips turned into “no-shows,” for which the drivers were obviously not paid, and further, were fined for a “missed trip.” The broker – which kept all the money not paid to its providers – had little incentive to investigate the reasons for this lateness (including the poor scheduling capabilities of their service providers’ robots, yet another party immune from any penalties, all of which were paid for by the service provider.
Occasionally (although typical of one of the two major brokers), the punitive damages assessed for late trips was excessive: When a vehicle arrived late (e.g., 15 minutes beyond the end of the scheduling “window”), its company was not only not paid for the trip but fined an additional $100 for it. When a second company was assigned the trip because the first one was either too late or never showed up at all, that second company – paid the same $25 to provide it, had to arrive no more than 30 minutes late. If that “rescues” provider was late, it was not only not paid for the trip but was fined $500. Within this arrangement, the broker was allotted 93 percent of the roughly $250,000,000 for operating this “system,” but kept as much of the seven percent otherwise paid to the service providers that actually provided the trips for their lateness through their racketeering practice – a lateness that could not even be verified because the service providers had no drivers’ logs onto which they would enter their pickup and drop-off times. The “monitoring” on which the broker based its “punitive damages” was a combination of the complaints from the passengers’ relatives or program officials at the destinations.
Evidence of the service providers’ dissatisfaction with this approach was documented by the shrinkage of the broker’s “network” of service providers from which it was supposed to whittle down to a small core of the best and most safe and reliable providers from a list of the providers licensed to perform this type of service by the healthcare agency theoretically in charge. During the span of time during which various service providers operated (which encompassed the incident I was engaged to evaluate the cause of), this network – which would have been served best and most easily by a small handful the best providers with reasonably sized fleets – this “network shrank from 225 to 27 providers – and after shrinking to 25, was enlarged only by adding Uber and Lyft to it, which I found in other cases to be among the most crooked and treacherous service providers I had ever come across in the 44 years I was in the transportation field when hired to evaluate th mess that this particular lawsuit encompassed. Most of the $250,000,000 this broker received was only for the Medicaid clients to whom it provided service. Providing service also to MediCare patients (which usually exceeded the number of Medicaid clients – although this has likely change since President Trump took over), VA patients and a small group of developmentally disabled individuals whose trip costs were 28 times the size of each of this broker’s Medicaid clients likely yielded the broker in excess of $1B. As noted, of this estimated $1B, seven percent (at most) of it went to the actually providers of the service, but otherwise covered the cost of 19 staffpersons – 11 of whom were effectively receptionists: They fielded phone calls from those needing the trips, and assigned them to the various service providers (by some methodology never explained to me, but which translated into an enormous number of late trips, and many trips not provided at all). In another service area in which that same broker worked, despite the numbers “doctored” from month to month in reports submitted (none whatsoever were submitted during the first 21 months of service), the number of late trips by the two largest service providers was roughly 25 percent, while the number of missed trips altogether was a lesser amount – but still significant.
The two largest brokers in these two networks operated in all or part of 45 states and the District of Columbia – complete phonies that knew zero about this mode of transportation. Judging from the magnitude of funds effectively stolen from the local or state healthcare agencies, my sloppy guess is that together, they have been stealing close to $100B a year from our nation’s healthcare industry. The waste from neither the brokers nor the lion’s share of service providers assigned trips by hapless brokers who did nothing to “design” a system, with the right number of service providers in various parts of the service area added to the enormous sum of money lost. But few attorneys wished to go after them because they think perhaps, that these huge broker had armies of legal experts at their disposal. As both a plaintiff’s and one odd defendant’s expert in two cases in particularly, I found this not to be true – although the attorney on the defendant’s side in the one case I did on behalf of a defendant (a nursing home!) was excellent. In that case, an unqualified pawn of a service provider with no knowledge or experience, with only four vehicles, and who received no training from the brokers, was effectively eliminated the day after a wheelchair tipped over and killed its client: The broker immediately stopped assigning any trips to that service provider, effectively putting it out of business, whereby the owner was forced to liquidate her tiny fleet at fire sale prices. But the decedent’s attorney failed to file suit again the broker. Instead, he filed against the “pawn” (which had obtained only $250,000 of insurance coverage when its contract with the broker required $3M of coverage) and the nursing home, which I helped defend. My client was sued on the ridiculous theory that a nurse’s assistant should have secured the wheelchair – an act that virtually no service provider in the country would have allowed a “civilian” not even working for them to perform.
All this was not exactly a surprise to me. I had been involved in a couple dozen NEMT or paratransit cases involving one of these two giant brokers. But only a few rare attorneys bothered to file suit against the brokers involved. This cadre of ignorant and lazy attorneys, for the most part, operated at the chimpanzee level because they had no remote understanding of how this form of transportation worked, and even in mostly unlosable cases (where their experts’ expenses would eventually be paid out of the 2/3rds of the settlement or judgment which the plaintiff or is or her estate received) settled for maybe 10 cents on the dollar (a complete guess) because only a handful of experts in the country have a clue how this form of transportation should be provided – and how poorly trips were scheduled by the robots employed by the intelligentsia of the service providers who had been hired to provide it – hired by brokers who, as noted, knew nothing about this form of service, which in turn, were hired by a nationwide patchwork quilt of local, state and regional service providers held accountable by no one, indemnified for any damages by their brokers, and which considered themselves lucky to get this confusing and time-consuming nightmare out of their hair, and to “wipe their hands” of any responsibility for providing it.
While our hapless President was actually correct that there really is a “deep state” squandering an enormous amount of money (eve a broken clock is correct twice a day), he had no remote clue where it was, but instead of seeking out genuine experts to identify it, engaged a complete phony zillionaire who initially addressed the problem by eliminating agencies like the U.S. Agency for International Development (USAIR) and starving to death half a million Africans (mostly babies and children) before his power was taken away – a simple task as this individual was never a government employee to begin with, and thus his confirmation was never approved by the congressional branch of our government.
So the carnage continues to go on, and these brokers continue to grow exponentially richer – except when, recently, one of them was forced to declare bankruptcy in two different states, a feat that literally floors me when viewed against the ease with which they accumulate profits and the total lack of accountability to which they are held when doing so. But this is America, where corporations and the public agencies that engage them are free to do whatever they wish, and to do as little work as they wish to ensure that they and their companies actually accomplish the missions described for them by the enabling legislation that created them.
#Modivcare #MTM #nemtservice #nonemergencymedicaltransportaton #transalt