An Audit Report On The Medical Transportation Program At .

TxDOT does not conduct monitoring visits as frequently as required by its policies andprocedures. TxDOT does not sufficiently track its contract monitoringspecialists’ (contract specialists) activities or provide the contract specialistswith sufficient guidance to ensure they meet TxDOT’s minimum requirementsfor monitoring transportation providers and drivers. TxDOT’s programmanagement receives e-mails that include calendars of each contractspecialist’s planned monitoring activities for a month. However, TxDOT doesnot review these calendars and compile the information into a usefulmanagement tool to ensure that contract specialists meet minimum monitoringrequirements. Audit testing determined that TxDOT’s contract specialistshad:Provider Monitoring Conducted on-site monitoring visits for 4 of 15 (27 percent)transportation providers since the contracts were issued inJune 2006. TxDOT’s policy requires contract specialists toconduct an on-site visit of each transportation provider everyquarter (see text box for information on TxDOT’s monitoringrequirements). The on-site visits occurred in May 2007 andJune 2007; no documentation of other on-site visits wasprovided to auditors. Conducted on-site observations of transportation driveractivities at health care facilities or eligible recipient homesfor 11 of 24 (46 percent) transportation service areas betweenJune 2006 and March 2007. TxDOT’s policies andprocedures require contract specialists to perform five on-siteobservations for each transportation service area everyquarter; however, contract specialists conducted 5 on-sitevisits each quarter for only 1 of the 11 (9 percent)transportation service areas.TxDOT requires its contract specialiststo perform three types of monitoring oftransportation providers. These are: On-site monitoring. Contractspecialists should conduct a quarterlyon-site review of each transportationprovider. Observation monitoring. Contractspecialists should visit health careproviders or eligible recipients’homes to observe drivers when theypick up or drop off eligible recipientsto ensure that the drivers complywith TxDOT requirements. Thecontract specialist should conduct atleast five quarterly on-siteobservations in each transportationservice area. Ride-alongs. Contract specialistsshould conduct at least one quarterlyride-along with a transportationprovider’s driver in eachtransportation service area. A ridealong occurs when the contractspecialists ride in the vehicle with aneligible recipient to his or herappointment. Conducted a ride-along with drivers in 13 of 24 (54 percent)transportation service areas between June 2006 and March2007. Contract specialists conducted a ride-along withdrivers in each quarter, as required by TxDOT policy, in only1 of the 13 (8 percent) transportation service areas. Not conducted any monitoring activity in 10 of 24 (42 percent)transportation service areas. These transportation service areas includedthe Rio Grande Valley area (Transportation Service Areas 19, 20, and 21)and the San Antonio area (Transportation Service Area 18). (See map oftransportation service areas in Appendix 3.)TxDOT reported that it had conducted an additional 7 on-site monitoringvisits, 77 on-site observations, and 14 ride-alongs as of August 2007. Becausethese reported monitoring activities occurred after auditors completedfieldwork, auditors did not validate or test this assertion.An Audit Report on the Medical Transportation Program at the Texas Department of TransportationSAO Report No. 08-006October 2007Page 2

TxDOT does not have a formal risk assessment process to help it identify high-risktransportation service areas that may need increased monitoring and to help it moreeffectively use its limited resources. In February 2007, TxDOT developedpolicies and procedures for monitoring its transportation providers; however,these procedures do not include a risk assessment process that identifies highrisk transportation providers. The on-site monitoring visits conductedbetween June 2006 and April 2007 did not align with the areas of the state thathad characteristics indicating they may be at high risk due to the number ofeligible recipients served (see Appendix 2 for details on the total number ofeligible recipients served by Transportation Service Area). For example, thelower Rio Grande Valley and San Antonio areas had not received anymonitoring by TxDOT contract specialists; however, these service areasrepresented 27 percent, or 425,534, of the one-way trips made by programdrivers between July 2006 and February 2007 (see Appendix 3 for a map ofmonitoring activity).Current procedures would require TxDOT’s six contract specialists to conducta total of 60 on-site monitoring visits of transportation providers, 480 on-siteobservations at health care facilities or eligible recipient homes, and 96 ridealongs with eligible recipients and drivers annually. TxDOT’s contractspecialists have not been able to maintain the schedule required by TxDOT’sprocedures. Meeting TxDOT’s monitoring timeline may become moredifficult because, according to TxDOT management, contract specialists willbe assigned additional responsibilities for tracking, monitoring, and testingclaims identified as having errors.Contract specialists also are responsible for reviewing and disseminatingcomplaints received by transportation providers from eligible recipients. Thecomplaint handling process is discussed in more detail in Chapter 2.TxDOT is not providing adequate training to its contract specialists.TxDOT’scontract specialists typically work in the field, often in remote locations, andwith minimal supervision or direction. As of April 2007, many of the sixcontract specialists were former call center managers, supervisors, or staffmembers with extensive knowledge of TxDOT’s Medical TransportationProgram. However, none of them had been provided formal training oncontract monitoring.RecommendationsTxDOT should: Track and report all monitoring activities in a format that allowsmanagement to identify trends and track problem areas.An Audit Report on the Medical Transportation Program at the Texas Department of TransportationSAO Report No. 08-006October 2007Page 3

Develop a formal risk assessment process for monitoring transportationproviders to more effectively use its limited resources and ensure thatthose areas posing a greater risk receive coverage. Ensure that contract specialists receive adequate training for performingtheir job duties. Conduct a staffing analysis to ensure that it has an adequate number ofcontract specialists to perform all required monitoring activities incompliance with TxDOT’s monitoring requirements and schedule.Management’s Response Track and report all monitoring activities in a format that allowsmanagement to identify trends and track problem areas.The department concurs with the recommendation. TxDOT implementednew contract monitoring procedures in February 2007. The monitoringactivities reflect contract monitoring requirements established forTransportation Service Area Providers (TSAPs). In addition, all contractmonitoring activities performed are documented in a contract monitoringdocument. This information is stored on a drive shared with the MedicalTransportation (MTP) Central Office and is monitored by the branchmanager for use in identification of problem areas and opportunities torealign monitoring schedules. Develop a formal risk assessment process for monitoring transportationproviders to more effectively use its limited resources and ensure thatthose areas posing a greater risk receive coverage.The department concurs with this recommendation. There has beenpreliminary research conducted on a risk assessment process focusing onprovider experience, trips volume, number of complaints and paid claims;however, the lead contract specialist will work with the Internal AuditOffice to establish risk assessment protocol that will become a permanentpart of the contract monitoring activities. A risk assessment tool will becompleted by April 1, 2008. The initial assessment at onset of the newcontracts indicated the need for the contract specialists to focus theirefforts on the largest contractor due to the contractor being new to MTP,volume of trips and recipient complaints. Therefore, monitoring activitiesfor other contracts was delayed. Ensure that contract specialists receive adequate training for performingtheir job duties.An Audit Report on the Medical Transportation Program at the Texas Department of TransportationSAO Report No. 08-006October 2007Page 4

The department concurs with this recommendation. The contractspecialists will participate in quarterly training meetings and monthlyteleconferences during the months when training does not occur. Thesesessions will include training and technical assistance for the contractspecialists in addition to receiving ongoing support from the lead contractspecialist. The contract specialists are attending formal training offeredthough TxDOT’s Contract Services Office in the Office of GeneralCounsel. This training is scheduled for October 10 through 12, 2007. Atthe conclusion of this training, contract specialists would haveparticipated in two training activities in FY 08. Conduct a staffing analysis to ensure that it has an adequate number ofcontract specialists to perform all required monitoring activities incompliance with TxDOT’s monitoring requirements and schedule.The department concurs with this recommendation. TxDOT is currentlyassessing the workload of the contract specialists in addition to filling theremaining two positions. We will ensure that adequate staffing levels aremaintained to meet monitoring requirements. If necessary, the sectiondirector and branch manager will request additional staff to conduct theseactivities.Chapter 1-BAlthough TxDOT Has Procedures for Reviewing TransportationProviders, It Does Not Ensure that Transportation ProvidersComply with Contract Requirements for Criminal History Checksand InsuranceCriminal History ChecksTxDOT requires that transportationproviders conduct criminal history checkson all contracted and subcontractedoperators prior to hiring the operators,and it requires these checks be doneannually. Under the terms of thetransportation providers’ contracts withTxDOT, operators who have any criminalrecord—including convictions for anymisdemeanors and/or felony offenses—forseven years prior to their hire date are notto be employed to transport eligiblerecipients in the Medical TransportationProgram.For this audit, criminal history and driver’slicense checks were performed by theSpecial Investigations Unit of the StateAuditor’s Office, which used twodatabases: Accurint and Household DriverReport.Auditors visited four transportation providers. Thesetransportation providers covered 13 transportation service areasand included American Medical Response and Irving Holdings,the largest transportation providers in the state.TxDOT does not consistently monitor criminal history and driver’slicense checks at the transportation providers auditors visited toensure the transportation providers comply with contractrequirements (see text box for information on criminal historychecks). All four transportation providers complied with the levelsof insurance required by their contracts with TxDOT; however, asubstantial number of the transportation providers’ subcontractorsdid not comply with liability or workers’ compensation insurancerequirements.Thirty percent of drivers tested had criminal backgrounds or invalid driver’slicenses. Seventy-one of 239 (30 percent) drivers at the fourtransportation providers auditors visited had an invalid driver’sAn Audit Report on the Medical Transportation Program at the Texas Department of TransportationSAO Report No. 08-006October 2007Page 5

license or a criminal history that would disqualify them from driving forTxDOT’s Medical Transportation Program. Of the 239 drivers tested, 16percent had criminal backgrounds and 14 percent had invalid driver’s licenses.The invalid driver’s licenses were either (1) not found in databases containingdriver’s license information or (2) were issued to someone other than thedriver listed on the rosters provided to auditors by the transportationproviders. Twenty of the 33 (61 percent) invalid driver’s licenses identifieddid not belong to the driver listed on the roster (see Table 1 on the next page).The highest number of drivers with criminal histories or invalid driver’slicenses was identified at American Medical Response.Thirty-five percent of driver files tested at American Medical Response had an invaliddriver’s license or criminal history—the highest number among transportation providerstested. The number of drivers with invalid driver’s licenses or criminalhistories could be higher than the number identified by auditors becauseAmerican Medical Response (AMR) was unable to provide a list of drivers forfive of its subcontractors. Also, 9 of 43 (21 percent) AMR subcontractorswere not on TxDOT’s list of approved contractors. Another transportationprovider, Irving Holdings, also was unable to provide a list of drivers for twoof its subcontractors. The other two transportation providers visited—LeFleurTransportation and East Texas Support Services—provided complete andapproved lists of all of their subcontractors’ drivers.Table 1Number of Drivers Who Had Criminal History or Invalid Driver’s LicensesAt Four Transportation ProvidersTotal Numberof DriversTransportation ProvideraDriverswithCriminalHistoryPercent ofDrivers withCriminalHistoryDrivers withInvalidDriver’sLicensesPercent ofDrivers Drivers’RecordsTestedAmerican Medical Response854Irving Holdings194LeFleur Transportation (Lower RioGrande)1631800%211%East Texas Support e totals are not complete. American Medical Response and Irving Holdings were unable to furnish auditors a complete list of drivers for theirsubcontractors.TxDOT’s requirement that any criminal history disqualifies a person from being a drivermay be too stringent. As a result, the pool of available drivers may be reducedand leave the transportation providers and subcontractors with a drivershortage. Twenty of the 38 (52 percent) drivers with criminal backgroundsAn Audit Report on the Medical Transportation Program at the Texas Department of TransportationSAO Report No. 08-006October 2007Page 6

had convictions for offenses that were misdemeanors, non-violent, and notrelated to drugs or alcohol. Auditors reviewed other states’ criminal historyrequirements but did not identify any specific, detailed requirements forsimilar programs.All four transportation providers visited complied with the levels of insurance requiredby their contracts with TxDOT. However, AMR and East Texas Support Serviceshad a substantial number of subcontractors that did not comply with liabilityor workers’ compensation insurance requirements. TxDOT’s contracts withthe transportation providers require that subcontractors maintain the samelevel of coverage required of its contracted transportation providers.Specifically: 15 of 64 (23 percent) subcontractors did not have the required levels ofcomprehensive general liability insurance. 38 of 64 (59 percent) subcontractors did not have the required level ofworkers’ compensation and employer liability insurance. 5 of 64 (8 percent) subcontractors did not have the required level ofbusiness auto liability coverage.RecommendationsTxDOT should: Ensure that its transportation providers maintain complete information onall drivers and supporting documentation demonstrating that transportationproviders and their subcontractors conduct required criminal history anddriver’s license checks. Ensure that all transportation provider subcontractors are approved and onthe approved list. Ensure that all transportation provider subcontractors carry specifiedlevels of insurance, as required by their contracts. Consider reviewing its contract requirement for conducting criminalbackground checks to determine whether it is too restrictive and preventsotherwise qualified drivers from transporting eligible recipients.Management’s Response Ensure that its transportation providers maintain complete information onall drivers and supporting documentation demonstrating thatAn Audit Report on the Medical Transportation Program at the Texas Department of TransportationSAO Report No. 08-006October 2007Page 7

transportation providers and their subcontractors conduct requiredcriminal history and driver’s license checks.The department concurs with this recommendation. TxDOT will develop acontractor-certification form for Transportation Service Area Providers(TSAP) to complete and submit to the contract specialists to ensure thatTSAPs are complying with contract requirements. The contract specialistswill implement the new form and process by January 2008. TSAPsrequesting approval for a new subcontractor will be required to submit asigned certification stating that the TSAP has reviewed all the contractrequirements and that the subcontractor is in compliance with theserequirements. The contract specialists will continue to monitor a randomsample for each TSAP. Ensure that all transportation provider subcontractors are approved andon the approved list.The department concurs with this recommendation. TxDOT is responsiblefor approving all subcontracts. The lead contract specialist will implementa process to ensure that approved subcontractors are maintained on anofficial subcontractor list by January 2008. Contract specialists willmonitor listed subcontractors as a part of their regular monitoringactivities. Ensure that all transportation provider subcontractors carry specifiedlevels of insurance, as required by their contracts.The department concurs with this recommendation. TxDOT hasimplemented a process where the TSAP has to submit copies of insurancepolicies, in the required coverage amounts for all subcontractors prior tothem being approved. The TSAP will be responsible for ensuring that allof their subcontractors are in compliance and will be monitoredaccordingly. Consider reviewing its contract requirement for conducting criminalbackground c

Transportation for Indigent Cancer Patients, Children with Special Health Care Needs, and Medicaid (the largest of the three programs). The Medical Transportation Program is responsible for providing non-ambulance transportation services to eligible recipients