Fraud, waste, and abuse prevention is part of how we protect access to care.
Fraud, waste, and abuse prevention is part of how we protect access to care.
At Modivcare, we help connect people to medically necessary transportation, in-home personal care, and monitoring services. That work carries an important responsibility: helping ensure services are appropriate, documented, compliant, and delivered in a way that supports members, clients, providers, caregivers, and public programs.
Strong program integrity is not just about compliance. It is about making sure resources are used responsibly and members can continue receiving the care and support they need.
Healthcare access programs operate in complex environments. Non-emergency medical transportation, personal care services, and monitoring programs can involve high service volume, decentralized networks, multiple delivery models, licensing requirements, credentialing requirements, and varied state rules.
That complexity requires a layered approach.
Modivcare’s program integrity model brings together technology, process, governance, and human judgment to help prevent, detect, investigate, and address potential fraud, waste, and abuse across the care access lifecycle.
Our approach includes:
Program integrity starts before a trip, visit, or service occurs.
Our teams and systems support pre-service validation that may include:
The goal is to validate services without creating unnecessary barriers to care.
For urgent, same-day, rural, recurring, or access-constrained situations, workflows can be adapted to reflect local realities while maintaining appropriate oversight. This helps ensure the right service reaches the right member at the right time.
Where available, service data helps create a stronger record of what occurred.
Depending on the service model and contract requirements, verification may include:
These tools help create an auditable record and support faster identification of discrepancies.
Post-service review is essential to a strong program integrity model.
Modivcare uses claims review, audit processes, reporting, data analytics, and operational oversight to identify patterns that may require additional review. These may include:
When concerns are identified, they are reviewed through established workflows. Appropriate actions may include education, corrective action plans, claims denial or recovery, provider or caregiver escalation, payment suspension, network action, or referral to clients, regulators, Medicaid Fraud Control Units, Offices of Inspectors General, or other oversight agencies as required.
Technology helps scale detection. Human expertise ensures fairness, context, and accountability.
Modivcare’s Special Investigations Unit supports enterprise program integrity by reviewing allegations, analyzing data, gathering documentation, coordinating with internal teams, and preparing referrals when appropriate.
Our SIU works with Compliance, Operations, Claims, Credentialing, Analytics, Field Services, Legal, clients, and oversight partners to support a consistent investigative process.
This includes:
Every concern is reviewed with discipline, documentation, and respect for the members and partners involved.
Non-Emergency Medical Transportation
Non-emergency medical transportation (NEMT) connects members to medically necessary care. It also requires strong oversight because of its high volume, decentralized provider networks, and varied delivery models.
Modivcare supports NEMT program integrity through provider screening, eligibility validation, trip authorization, driver and vehicle data, GPS-supported records where available, claims reconciliation, anomaly detection, and SIU-led review.
Prior authorization, where required, is part of a broader program integrity approach. It helps validate eligibility, medical appropriateness, transportation need, and documentation before service occurs, reducing the need for recovery efforts after payment.
Personal Care Services
Personal care services require strong controls because care is often delivered in the home.
Modivcare supports PCS program integrity through Electronic Visit Verification, caregiver onboarding and screening, service validation, manual timesheet controls where EVV is not used, centralized service verification, enterprise reporting, Quality oversight, and Compliance review.
Our PCS quality model also supports broader risk mitigation through:
These controls help strengthen service validation, support client safety, and reduce financial, operational, licensure, and regulatory risk.
Monitoring Services
Monitoring services help identify needs early and support members in the home and community. Program integrity in this area depends on strong licensing, credentialing, enrollment, and governance controls.
Modivcare supports Monitoring program integrity through:
These controls help maintain compliance, reduce operational risk, and support consistent oversight across Monitoring programs.
Mileage reimbursement can be an important access option, especially when a member has a trusted driver or limited provider availability.
Program integrity controls may include facility verification, mileage documentation, driver review, reporting that identifies impossible travel patterns, and escalation when attendance cannot be confirmed.
Claims controls help prevent inappropriate payments before they occur and support recovery when issues are identified.
These controls may include matching claims to authorized trips, validating required signatures and documentation, enforcing contract rates, applying denial codes, reviewing late submissions, sampling claims for quality assurance, and reconciling certain expense categories.
Rideshare and transportation network partners
For rides delivered through transportation network partners, real-time and post-service data can support review of trip timing, trip distance, pickup and drop-off location, fare changes, short trips, long trips, and route anomalies.
These controls help identify issues such as trips that did not occur, routes that materially differ from the approved trip, or fares that require adjustment.
Fraud prevention should not make it harder for eligible members to access covered care.
That is why Modivcare’s approach is designed to balance validation with access. Routine and recurring transportation can often be handled through streamlined workflows. Same-day and urgent needs can be prioritized. Rural and limited-provider markets may require tailored processes that reduce unnecessary friction while maintaining oversight. Personal care and monitoring programs require similarly practical controls that protect members while supporting compliance.
The goal is simple: protect the program while supporting the member.
Fraud, waste, and abuse risks change over time. So do our controls.
Modivcare uses audit findings, service data, complaint trends, incident reporting, EVV performance, licensing and credentialing reviews, training completion, and operational performance metrics to identify opportunities for improvement.
These insights help teams strengthen workflows, improve documentation, address training gaps, escalate risk, and support corrective action before issues become larger program concerns.
Program integrity works best when expectations are clear and partners are aligned.
Modivcare supports stronger baseline standards across Medicaid-funded access programs, including:
By aligning access with accountability, healthcare programs can reduce fragmentation, improve oversight, and better protect the sustainability of critical services.
Fraud, waste, and abuse concerns can come from many places: members, families, providers, caregivers, facilities, clients, teammates, and community partners.
If you suspect fraud, waste, or abuse involving Modivcare services, please report it.
Report online: ethicshotline.modivcare.com
Call: 855-818-6929
Email: [email protected]
Reports may be made anonymously where permitted by law. Modivcare prohibits retaliation against anyone who reports a concern in good faith.