Caught Between the Broker and the Payer: The Real Business of Non-Emergency Medical Transportation

By Danny B.

From the outside, non-emergency medical transportation appears simple.

A driver arrives at a passenger’s home, helps the passenger into the vehicle, drives to a medical appointment, waits or returns later, and brings the passenger home.

But the ride itself is only the visible part of the service.

Behind that trip may be a Medicaid agency, managed-care organization, transportation broker, insurance company, case manager, healthcare provider, billing administrator, transportation company, driver, and patient—each operating under different rules, contracts, responsibilities, and payment systems.

The transportation provider may be the only party the passenger ever meets in person.

It is also the party expected to have the correct vehicle, trained driver, insurance, documentation, authorization, arrival time, mobility equipment, and customer-service response ready when the trip begins.

Yet the operator frequently has the least control over the authorization, reimbursement rate, billing rules, payment timing, and complaint process.

That is the real business of non-emergency medical transportation.

The operator is caught between the broker controlling the trip, the payer controlling the money, and the passenger depending on both.

NEMT Is Not Merely a Ride

Federal Medicaid policy requires states to ensure necessary transportation for beneficiaries who have no other means of reaching covered healthcare services. Congress later reinforced NEMT as a required Medicaid benefit, not simply an optional administrative convenience.

The benefit serves a relatively small share of Medicaid beneficiaries, but its impact is significant.

Milliman estimates that approximately 3 million to 4 million Medicaid beneficiaries used NEMT annually between 2018 and 2021, representing roughly 4% to 5% of all beneficiaries. Those trips helped people access preventive care, treatment for acute and chronic conditions, laboratory and imaging services, behavioral healthcare, and substance-use treatment.

That distinction matters.

A missed airport transfer is inconvenient.

A missed dialysis treatment, chemotherapy appointment, behavioral-health visit, physical-therapy session, or specialist consultation can affect someone’s health.

NEMT is therefore not simply transportation associated with healthcare.

It is part of the healthcare delivery system.

But the businesses providing the transportation are often treated as though they are supplying a basic commodity ride.

The Passenger Sees One Company—But the Trip May Involve Several

A passenger may believe the transportation company scheduled the trip, approved it, and will be paid for completing it.

That is frequently not how the system works.

States can administer NEMT through several structures, including direct state programs, statewide or regional brokers, managed-care organizations, or combinations of those models. CMS guidance specifically allows states to use NEMT brokerage programs, while state Medicaid programs retain broad flexibility in how transportation is organized.

A typical trip may involve:

A healthcare provider determines that an appointment is needed.
A beneficiary or case manager requests transportation.
A health plan or broker verifies eligibility.
The trip is authorized—or denied.
The broker assigns the trip to a transportation provider.
The operator schedules a vehicle and driver.
The driver documents pickup, mileage, destination, assistance, and completion.
The operator submits the required trip information or claim.
The broker, managed-care organization, or payer reviews the documentation.
Payment is approved, reduced, delayed, denied, or returned for correction.

To the passenger, it still looks like one ride.

To the operator, it is a transportation movement combined with a healthcare-administration process.

The Broker Controls the Trip

The transportation broker may control:

Eligibility verification
Trip authorization
Scheduling
Assignment of the provider
Approved vehicle level
Mileage
Pickup windows
Documentation standards
Complaint intake
Provider credentialing
Payment submission
Trip denial and appeal processes

The operator controls the vehicle and driver.

That division creates an immediate imbalance.

The broker can determine whether the trip enters the system, how it is categorized, which provider receives it, and what documentation will be accepted.

The transportation company must then determine whether the assigned rate can support the trip after accounting for the real operational cost.

That calculation is not limited to loaded mileage.

It may include:

Travel to the passenger
Passenger loading and mobility assistance
Waiting for the passenger
Travel to the appointment
Facility delays
Return travel without a passenger
A second pickup later in the day
Cleaning and sanitizing
Driver downtime between trips
Dispatch and administrative labor
Claim preparation
Resubmission or dispute work

This is where NEMT economics begin to break down.

A broker may view a trip as twelve payable miles.

The operator may experience it as two hours of labor, twenty-eight miles of vehicle use, a wheelchair securement process, a thirty-minute facility delay, and several layers of documentation.

The Payer Controls the Money

The second source of pressure is the reimbursement system.

The operator can complete the transportation properly and still encounter payment problems if the authorization, service classification, mileage, coding, destination information, or supporting documentation does not match the payer’s requirements.

NEMT billing is not uniform across the country.

Different states, plans, and service models may use different billing procedures and HCPCS codes based on the type of vehicle, passenger mobility level, base trip, mileage, and additional service. Colorado, for example, instructs providers to use HCPCS code S0215 for certain ambulatory or mobility-vehicle mileage, while other plans publish different code sets and documentation rules.

One health plan warns that when multiple trips are provided to the same member on the same day, the time and destination information must be entered correctly or subsequent trips may be denied as duplicates.

Think about what that means operationally.

The vehicle arrived.

The driver performed the trip.

The passenger reached the appointment.

Fuel was consumed.

The employee was paid.

The vehicle accumulated mileage.

The insurance exposure existed.

But payment may still be delayed because the information entered into a billing system did not meet a technical requirement.

Transportation companies do not receive refunds on fuel, payroll, or insurance simply because a claim is returned.

The Operator Finances the System While Waiting to Be Paid

Most NEMT operators must pay their expenses before receiving reimbursement.

Drivers expect payroll on schedule.

Insurance premiums are due regardless of claim status.

Fuel is purchased every day.

Vehicle payments, repairs, tires, licensing, dispatch software, phones, office expenses, and compliance costs continue whether the broker has approved payment or not.

This makes cash flow one of the most misunderstood risks in NEMT.

A company may show substantial trip volume while still experiencing financial distress.

The schedule may be full.

Vehicles may be moving.

Drivers may be working overtime.

Yet the company can still struggle if:

Rates are inadequate
Claims are denied
Payment cycles are extended
Trips require excessive unpaid mileage
No-shows are not compensable
Facility waiting time is unpaid
Driver utilization is inefficient
Administrative expenses are not included in pricing

Revenue is not the same as cash.

Trip volume is not the same as profitability.

In NEMT, a company can become busier while becoming financially weaker.

Deadhead Mileage Is Not Free

The rural NEMT problem makes this particularly clear.

Health Management Associates found that provider shortages are especially severe in rural areas. It also noted that providers accepting rural trips typically receive no payment for lengthy unloaded—or deadhead—travel to reach the passenger or return after drop-off.

A provider may drive thirty miles to collect a passenger, transport the passenger fifteen miles, and then travel another thirty miles without a passenger.

The paid portion may represent only a fraction of the vehicle’s actual movement.

The operator still incurs:

Driver wages
Fuel
Maintenance
Tire wear
Depreciation
Insurance exposure
Dispatch time
Opportunity cost

The rural passenger may have few alternatives, while the operator may lose money by accepting the trip.

That is not a sustainable network.

It is a system depending on transportation companies to subsidize access to healthcare through uncompensated vehicle use.

Rates Must Reflect the Cost of Maintaining a Real Provider Network

State agencies and managed-care organizations often focus on whether enough providers are technically enrolled.

That does not necessarily mean enough providers are financially capable of accepting trips.

A network may appear adequate on paper while passengers experience:

Long pickup windows
Repeated cancellations
Limited wheelchair capacity
Few providers in rural counties
Inability to secure long-distance transportation
Drivers arriving late because schedules are overloaded
Providers declining low-paying assignments

The 2025 HMA review of state Medicaid NEMT contracts recommended that states ensure broker rates allow adequate payment to transportation providers, particularly in rural areas, and that rates be reevaluated as utilization and market conditions change.

North Carolina offered a recent example of how consequential reimbursement decisions can become. NEMT rate reductions that took effect in October 2025 were later reversed, with the state directing that the prior rates be restored for qualifying services.

Rate policy is not merely an accounting decision.

If the payment does not support the trip, providers withdraw, reduce capacity, delay vehicle replacement, or stop accepting difficult assignments.

Eventually, the passenger feels the effect.

Insurance Treats the Operator as a Transportation Risk

Healthcare systems may view NEMT as a support benefit.

Commercial insurers view it as passenger transportation involving vulnerable individuals.

That difference matters.

The operator may be transporting passengers who:

Use wheelchairs or mobility devices
Require physical assistance
Have limited balance
Have cognitive or behavioral conditions
Are medically fragile
May be more vulnerable during boarding and unloading
Depend on the driver for more than curb-to-curb service

The company must manage vehicle accidents as well as loading injuries, wheelchair securement, slips and falls, passenger abandonment allegations, driver conduct, and failures to follow assistance procedures.

Yet insurance is rarely reimbursed as a separate expense.

It must be absorbed within the trip rate.

The operator is therefore expected to maintain healthcare-sensitive service standards while purchasing commercial transportation insurance from a market that prices the company according to its exposure.

The Driver Is Not “Just a Driver”

NEMT driver recruitment is different from ordinary delivery or rideshare work.

A qualified driver must do more than operate the vehicle.

Depending on the service, the driver may need to:

Assist passengers with mobility limitations
Properly secure wheelchairs
Operate ramps and lifts
Understand passenger-assistance boundaries
Communicate with caregivers and facilities
Protect confidential information
Document arrivals, mileage, and trip completion
De-escalate stressful situations
Recognize when a passenger may require emergency assistance
Maintain patience during delays
Keep the vehicle clean and presentable

The driver is often the human face of a system the passenger already finds confusing.

When authorization fails, the passenger may blame the driver.

When a facility delays discharge, the driver waits.

When a return trip is missing, the driver or dispatcher tries to solve it.

When the payer and broker disagree, the driver still has a passenger standing at the curb.

Recruiting safe, compassionate, dependable people for this role is difficult.

Retaining them under low-margin contracts is even harder.

Compliance Is Necessary—But It Has a Cost

NEMT has legitimate program-integrity risks.

GAO found that investigations by state Medicaid Fraud Control Units resulted in nearly 200 criminal convictions, civil settlements, and judgments involving NEMT providers across 25 states from fiscal years 2015 through 2020. Cases included billing for trips that never occurred and using unauthorized vehicles or drivers.

Oversight is necessary.

Taxpayer money must be protected, passengers must be transported safely, and fraudulent providers should not remain in the system.

That is why many programs increasingly rely on:

GPS trip verification
Electronic visit or trip records
Driver credential monitoring
Vehicle inspections
Prior authorization
Pickup and drop-off timestamps
Passenger signatures
Appointment verification
Call-center monitoring
Complaint reporting
Claims analysis

The problem arises when the cost of implementing these controls falls almost entirely on legitimate providers without corresponding rate adjustments or administrative support.

A small transportation company may need multiple systems simply to receive, dispatch, document, invoice, and defend a trip.

Compliance becomes another unfunded operating requirement.

The industry needs strong oversight—but it also needs rules that distinguish between deliberate fraud and correctable administrative error.

Technology Can Improve the System—or Create Another Layer

Technology can make NEMT more efficient.

Good systems can help with:

Route optimization
Driver assignments
Credential expiration
GPS validation
Trip status
Passenger notifications
Mileage documentation
Claims preparation
Exception reporting
Provider performance

But technology is only helpful when systems communicate.

A broker portal that does not integrate with the operator’s dispatch platform creates duplicate data entry.

A healthcare facility using one scheduling system, a managed-care organization using another, and a broker using a third can create more fragmentation—not less.

Technology should reduce the number of times the same trip must be entered, reviewed, corrected, and verified.

It should not turn the operator into an unpaid data-entry department.

The Patient Is Caught in the Middle

The most important person in the system is also the person with the least ability to resolve its failures.

The passenger may be told:

The trip was never authorized.
The broker assigned the wrong vehicle.
The health plan has no record of the request.
The provider canceled.
The return trip was not scheduled.
The driver cannot wait.
The appointment address is incorrect.
The transportation company has not been paid.
The case manager must submit another request.

Each organization may have a legitimate explanation.

None of those explanations gets the patient to the appointment.

The passenger does not care which contract provision failed.

The passenger needs reliable transportation.

This is the fundamental weakness of a fragmented system: responsibility can be distributed so widely that no one appears fully accountable.

The operator blames the broker.

The broker blames the plan.

The plan blames the authorization.

The facility blames scheduling.

The passenger remains at home—or at the clinic waiting for a ride.

Brokers Are Not Automatically the Enemy

Just as in charter and limousine transportation, not every broker is the problem.

A capable NEMT broker can provide real value by:

Creating one scheduling system
Maintaining provider networks
Verifying eligibility
Coordinating difficult trips
Monitoring performance
Handling complaints
Preventing fraud
Supporting patients
Managing statewide transportation capacity

A broker can also give smaller operators access to steady trip volume they could not acquire independently.

The question is whether the broker is managing the network or merely transferring pressure through it.

A healthy broker relationship should not depend on operators accepting rates that fail to cover the true cost of service.

It should not reward the cheapest provider while ignoring reliability, safety, accessible-vehicle capacity, driver quality, and payment performance.

The broker’s responsibility should extend beyond assigning trips.

It should include maintaining a provider network that can survive.

What Reform Should Look Like

The NEMT system does not need less accountability.

It needs accountability applied to every level.

Rates based on actual operating conditions

Reimbursement should account for labor, insurance, vehicle type, accessibility equipment, fuel, maintenance, rural distance, waiting time, and administrative requirements.

Compensation for unavoidable deadhead and waiting

Operators should not be expected to subsidize rural access or facility delays indefinitely.

Clear and consistent billing standards

Providers need accessible rules explaining authorization, documentation, coding, mileage, denial, correction, and appeal requirements.

Faster dispute resolution

A completed trip should not remain unpaid for months because responsibility is moving between a broker, managed-care organization, and billing administrator.

Transparent broker contracts

Operators should know how rates are established, when payment is due, how complaints are investigated, and what documentation supports denials.

Accountability for network adequacy

A broker should not be considered successful merely because trips were assigned. Performance should consider completed trips, on-time service, accessible capacity, passenger complaints, rural access, and provider retention.

Better coordination with healthcare facilities

Medical offices, dialysis centers, treatment programs, hospitals, and rehabilitation facilities affect transportation schedules. Their delays and discharge procedures must be part of the solution.

Protection for passengers during disputes

The patient should not lose access to care because two organizations disagree over authorization or payment.

What Operators Must Do

Operators also have responsibilities.

NEMT is not a business that should be entered because someone heard Medicaid provides guaranteed work.

The work may be consistent, but it is not guaranteed to be profitable.

Operators should know:

The actual cost per vehicle hour
The cost per loaded and total mile
Driver utilization
Deadhead percentage
Average waiting time
Denial rate
Payment cycle
Revenue by broker and payer
Profitability by trip type
Wheelchair-vehicle utilization
Administrative cost per claim

They should review contracts carefully, maintain organized documentation, monitor credential expiration, track denied trips, and avoid becoming dependent on a single broker or payer.

Most importantly, operators must be willing to decline work that cannot be performed safely and sustainably.

A full schedule does not save a company when every trip loses money.

Final Thoughts

Non-emergency medical transportation is one of the most important and least understood segments of ground transportation.

It combines the operational risks of passenger transportation with the administrative complexity of healthcare reimbursement.

The operator buys and maintains the vehicle.

The operator hires and trains the driver.

The operator carries the insurance.

The operator assists the passenger.

The operator absorbs the fuel, payroll, maintenance, waiting time, and liability.

But the broker often controls the trip, and the payer controls the money.

That structure can work only when each party recognizes that transportation providers are not disposable vendors.

They are part of the healthcare-access network.

When providers are underpaid, passengers lose options.

When billing systems are fragmented, completed trips go unpaid.

When responsibility is divided among too many organizations, patients fall through the gaps.

NEMT may begin with a vehicle arriving at someone’s home.

But the real service is access—to treatment, prevention, recovery, independence, and care.

A system that depends on transportation operators must make it possible for responsible operators to survive.

Because when the transportation company fails, the loss is not limited to a business.

Someone may lose the ride that connects them to healthcare.

Sources

Centers for Medicare & Medicaid Services — Medicaid Transportation Coverage Guide and federal assurance-of-transportation requirements.
Medicaid and CHIP Payment and Access Commission — NEMT benefit requirements, delivery models, financing, and program findings.
Milliman — The Road to Care: An Analysis of Non-Emergency Medical Transportation.
U.S. Government Accountability Office — Medicaid NEMT fraud, compliance, and oversight findings.
Health Management Associates — State Medicaid Non-Emergency Medical Transportation Contracts: Key Provisions, Standards, and Considerations.
North Carolina Medicaid — reversal and restoration of 2025 NEMT reimbursement-rate reductions.
Colorado Department of Health Care Policy and Financing — NEMT billing manual and HCPCS mileage guidance.
Health Plan of San Joaquin — NEMT billing, coding, documentation, and duplicate-trip requirements.

About the Author

Danny B. is a transportation-industry executive and the principal behind BTE Group LLC, a business management and operational consulting company serving motorcoach, charter bus, limousine, non-emergency medical transportation, automotive, logistics, and passenger-transportation businesses.

His work spans financial leadership, fractional CFO support, transportation operations, fleet planning, project management, vehicle sourcing, maintenance and refurbishment oversight, logistics, compliance coordination, sales development, customer communication, and business-process improvement. His experience gives him a practical view of transportation from the financial office to the dispatch desk, maintenance facility, customer relationship, and final delivery of service.

Through The Motorcoach Insider, Danny provides an independent, operator-focused perspective on the issues shaping ground transportation—including insurance, regulation, tourism, brokerage, healthcare transportation, fleet economics, workforce conditions, technology, and the realities facing privately owned operators.

BTE Group LLC helps transportation businesses improve financial visibility, strengthen operational control, organize fleet activity, and build practical systems for sustainable growth.

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