How to Reduce NEMT No-Shows: Prevention, Door Procedure, and Proof

Three kinds of missed trip

“No-show” gets used for three different events, and each one is handled differently.

Virginia’s fee-for-service program (Modivcare member handbook, October 2025) asks members to cancel with 24 hours’ notice, or as soon as possible. If a driver arrives and the member did not cancel, a no-show complaint may be documented against the member. When the driver makes the trip for nothing, it is also called a dry run.

What Medicaid rules say

CMS set out the federal position in its Medicaid Transportation Coverage Guide (SMD 23-006, September 2023). Every provider running Medicaid trips should know these points:

• No denial. States may not deny transportation because of beneficiary no-shows or lateness, even when they happen often.
• No charge. States and providers may not charge a beneficiary for a no-show.
• No federal payment for the no-show. Federal matching funds are not available for transportation to a beneficiary who does not appear for the ride.
• Extra steps are allowed. For chronic no-shows or lateness, states may use counseling, require the rider to confirm the morning of or the night before, assign a single provider with a confirmation shortly before the ride, or let the rider arrange their own transportation for reimbursement.
• The cost can go into the rate. States may build the cost of no-shows and the empty miles they cause into their payment methodology.

States apply this in their own rules. Rhode Island’s Medicaid transportation regulation (210-RICR-20-00-2) says riders who miss more than three regularly scheduled trips in a month without cancelling at least 24 hours ahead may have to schedule each trip separately, at least two days in advance. After 60 days, they can ask to have standing-order pickups reinstated, subject to state approval.

The practical result for a provider: prevention and documentation are the only tools you control. You cannot bill the rider, and the broker needs your records to act on a pattern.

Measure your no-show rate

No-show rate = legs where the rider was not there ÷ legs still scheduled on the day × 100

Take out legs cancelled with proper notice before you divide, since those never reached the road. Track late cancellations as their own number. For a sense of scale, Indiana holds its statewide broker to rider no-shows of no more than 1.5% of scheduled pickups over three months, and the broker came in between 1.19% and 1.68% by quarter in its first contract year (FSSA NEMT Commission, August 2025). That is a broker-wide figure, not a provider target.

Here is a worked example for one hypothetical month:

Each no-show costs you the drive out and back plus the driver’s time. Assume 12 empty miles per no-show at the IRS business rate of 76 cents per mile for the second half of 2026, and 25 minutes of driver time at $22 an hour. That is about $18.30 per no-show, or roughly $860 a month for this fleet, before counting the paid trip the van could have run instead. The IRS rate is a tax figure, not your actual cost per mile, so swap in your own when you have it. The no-show cost calculator runs this math on your own numbers.

Split the rate by rider, by facility, and by day and time. Look for concentration: a handful of riders, one facility, or one time slot. That is where prevention pays first.

Prevention that works

Reminders are well studied. A 2013 Cochrane review of randomized trials on healthcare appointments found that text message reminders raised attendance compared with no reminder, and worked about as well as phone call reminders. Attendance in the pooled trials was 67.8% with no reminder, 78.6% with text reminders, and 80.3% with phone call reminders. A 2016 systematic review by McLean and colleagues found reminder systems effective across healthcare settings, and noted they may also increase cancellations and rescheduling. That is a win for dispatch, because an early cancellation frees a van. These studies measured appointments, not rides, but a NEMT ride and its appointment are the same event for the rider.

Put that to work with a routine:

1. Confirm the day before. Call or text every rider with tomorrow’s pickup time, and make cancelling a one-step reply or call.
2. Remind again close to pickup. A short text when the driver is about 15 minutes away helps the rider be at the door when the van pulls up.
3. Keep two contact numbers. Add a caregiver, group home, or facility contact to every rider profile.
4. Fix the pickup spot. Note the entrance, gate code, and where the rider waits. A driver at the wrong door produces a false no-show.
5. Work with facilities. Ask dialysis centers and care homes to tell you when a rider is hospitalized or a schedule changes.
6. Keep standing orders current. Recurring rides for a rider who is in the hospital turn into a string of no-shows. The standing orders guide covers pauses and renewals.
7. Call ahead when you are late. A rider who gives up on a late van and finds another ride looks like a no-show on your records. Under the Medi Trans manual, a rider may cancel at no charge if the van arrives after the appointment time.
8. Report patterns to the broker. The state or broker, not you, decides on the extra confirmation steps CMS allows, and it needs your documented history to act.

The door procedure

When the rider is not there, the driver’s next few minutes decide whether you have a clean, defensible no-show. Wait times differ by contract:

The procedure for drivers:

1. Arrive inside the window, not before it. CareOregon does not allow pickups before the scheduled time or window, so an early arrival does not start the no-show clock.
2. Make your presence known at the door or front desk.
3. Call the rider, then the caregiver or facility contact.
4. Call dispatch. Dispatch tries the rider and the facility from the office.
5. Wait the full contract time, counted from the scheduled pickup time.
6. Get the OK to leave from dispatch, and from the broker if your contract requires it.
7. Record everything: arrival time, departure time, location, and each contact attempt.
8. Report it by the broker’s deadline.

The free no-show policy template turns these steps into a one-page policy you can hand every driver.

After a no-show

• Recover the van. Pull the next pickup forward, take a waiting will-call, or pick up a fill-in trip.
• Settle the return leg. Do not assume the return is cancelled. Confirm it with the broker or facility and close it the way they say.
• Update the rider’s record if this is part of a pattern, and flag it for the broker.

Provider no-shows are the costly kind

A rider no-show costs you a trip. A provider no-show can cost you the contract. CMS guidance says federal matching funds are not available for no-show providers and expects states to monitor provider performance. Mississippi’s 2024 broker contract lets the state fine its broker $1 to $5,000 per incident for trips a transportation provider did not fulfill, and the Medi Trans manual requires zero missed trips a month and lets the broker pass its fines for missed trips on to the provider. CareOregon asks for a full incident report on every provider no-show.

The cure is capacity honesty. Accept only the trips you can cover, return trips early when a driver calls out, and never leave a rider waiting on a trip you know you cannot make. The NEMT KPIs guide shows how to track missed trips alongside no-shows.

Where software helps

HealthRide records wait times on no-shows, so the proof sits on the trip when a broker asks. Drivers update each leg from the driver app, and you can turn on rider text reminders the day before and shortly before pickup.