NEMT business losing money: finding the payers, trips, and hours that cost more than they pay

When a NEMT company loses money month after month, the cause can sit in a few kinds of work that cost more to run than they pay, hidden inside totals that look fine. Revenue per van and the overall margin, covered in what NEMT companies earn and keep, tell you that you are losing. They do not tell you where.

This guide finds the where. It works through one sample month, trip type by trip type, using a real state fee schedule and published wage and fuel figures. The break-even calculator then turns your fixed costs into the number of trips of each kind you need.

What does each trip leave after its own costs?

Each trip should be judged by what it leaves after the costs that exist only because you ran it. Accountants call this the contribution margin. For a NEMT trip, those costs are the driver’s paid minutes plus fuel and wear for all the miles driven, counting the empty ones to reach the rider and to get back.

Everything else is fixed for the month: insurance, van payments, the dispatcher, the office, software. Those bills arrive whether a van runs 10 trips a day or 4. A trip with a positive contribution pays part of them. A trip with a negative contribution adds to the loss every time you accept it.

Compare trips per driver hour, not per trip. Your real limit is the hours a van and driver have in a day. A $57 trip that ties up a van for 90 minutes can be worth less than a $32 trip that takes 40.

The inputs for a sample Indiana wheelchair van

The example below is a five-van wheelchair company in central Indiana, paid at the state’s Medicaid fee schedule. The figures are real; the company and its trip counts are an example.

• Revenue. Since January 1, 2026, Indiana’s maximum fee for a wheelchair van base (A0130) has been $31.79. Loaded mileage (A0425 with the U5 modifier) pays $1.67 a mile, but Indiana pays it only on legs longer than 10 miles and subtracts the first 10 from each. An ambulatory trip pays a $12.71 base (T2003).
• Driver time. In the Indianapolis metro area, shuttle drivers and chauffeurs had median pay of $15.77 an hour in May 2025. That federal category includes nonemergency medical transporters. With the employer’s Social Security and Medicare taxes (6.2 and 1.45 percent), each paid hour comes to about $16.98, before workers’ compensation and unemployment insurance.
• Fuel. EIA’s weekly survey put regular gasoline in the Midwest at $4.291 per gallon in the week beginning September 28, 2026. Assuming 16 miles per gallon, fuel runs 26.8 cents a mile.
• Wear. AAA’s 2026 driving cost study puts maintenance at 12.16 cents a mile for a medium SUV. Lift service comes on top of that.

Together, the van costs about 39 cents for every mile it moves. The full yearly picture for one lift van, fixed lines included, is in the guide to wheelchair van operating costs.

Four kinds of trip, side by side

With those inputs, an ordinary in-town wheelchair trip carries the company, and two common kinds of work lose money every time. The in-town and ambulatory trips are 7 miles loaded and 5 empty. The specialist trip is 25 miles each way with an empty drive home and 3 empty miles to the pickup. Miles below include the empty ones.

The specialist trip brings in the most money but leaves less than a third as much per hour as the in-town trip, because the van drives 25 miles home empty and the first 10 loaded miles are not paid. The ambulatory trip loses money because Indiana’s rate follows what the rider needs, not the vehicle. A rider who can walk earns the ambulatory rate even when the trip runs in a lift van.

The no-show is a pure loss. Under CMS guidance, Medicaid gets no federal match for a member who never comes out, and empty miles are generally not paid as a service in their own right. See billing Medicaid for no-shows for what states and private contracts do instead.

A sample month that loses $3,400

Here is the example company’s month. Five drivers each work 22 days of 9.5 paid hours, which is 1,045 paid hours. The vans run 900 in-town trips, 120 specialist trips, 150 ambulatory trips, and 50 no-shows.

1. The in-town trips leave $14,211 after their own costs.
2. The specialist trips leave $1,286.
3. The ambulatory trips lose $281.
4. The no-shows lose $542.
5. The trips use 892.5 driver hours. The other 152.5 paid hours, mostly midday gaps between runs, carry no trips and cost $2,589.

That leaves $12,086 toward fixed costs. Say insurance, van payments, a dispatcher, and the office come to $15,500 a month for this company. It loses about $3,414 a month while bringing in $37,338. Nothing in the revenue line warns you. The loss sits in 152 idle hours, 200 trips that cost more than they pay, and 120 trips that pay far less per hour than the rest.

Which fix to try first

Start with the losses you control without anyone’s permission, then move outward to payers.

1. Paid hours with no trips. In the example this is the biggest leak, $2,589 a month. Match shifts to the morning and afternoon peaks with split shifts or part-timers. Federal wage rules count time spent waiting on call as work. For a midday break to be unpaid, the driver must be released before it starts, given a firm return time, and have enough hours to do something of their own (29 CFR 785.16). Pay rules for waiting are in overtime for NEMT drivers.
2. Trips the rate cannot cover. Stop putting ambulatory riders paid at $12.71 into a lift van on a short trip unless it fits between wheelchair trips you already have. If you run a sedan or ambulatory van, send those trips there.
3. No-shows and the empty miles behind them. Confirmation calls and a door procedure cut both. See reducing NEMT no-shows.
4. Empty return legs. Chain the specialist trips with pickups near the clinic, or have the van wait when the appointment is short. Indiana’s module pays for waiting only when the rider travels at least 50 miles one way, and never for the first half hour, so a wait on a 25-mile trip is unpaid driver time. Rural NEMT covers the wait or return decision, and cutting deadhead miles covers chaining.
5. Private-pay and facility prices. These are the only rates you set yourself. If a facility contract is priced below your cost per hour, raise it with proper notice, as in raising NEMT prices.

Cutting the idle hours, dropping the losing ambulatory trips, and halving the no-shows recovers about $3,140 of the $3,414 in this example.

When the rate is statewide and your wages are not

A statewide fee schedule pays the same in every county, but the drivers you hire do not cost the same everywhere. Median pay for the same occupation in May 2025 was $14.03 an hour around Evansville and $18.41 in the Chicago metro area, which takes in northwest Indiana. That is 31 percent more per driver hour for the same $31.79 trip. Rerun the in-town trip at the Chicago-area wage and it leaves $20.85 per driver hour instead of $23.69. The specialist trip drops to $4.30.

A company in a high-wage area on a low statewide rate needs more trips per driver hour, more private-pay work, or both. Shorter empty legs help most there, which is where zone dispatching earns its keep. How ambulatory, wheelchair, and stretcher work compare on rate and cost is in the most profitable NEMT service.

Should you drop a payer or contract?

Drop a payer only when the hours it uses can earn more elsewhere. A payer whose trips leave a small positive amount per hour is still paying part of your fixed costs, and dropping it makes the loss larger unless something better fills the gap.

Run this test before sending any notice:

1. Work out what that payer’s trips leave per driver hour over the last three months, empty miles and waits included.
2. List which fixed costs would actually go away. A van you can sell or a driver you no longer need counts. Insurance minimums, the dispatcher, and the office usually stay.
3. Decide whether the freed hours can be refilled. In the example, dropping the specialist trips loses $1,286 a month if the 180 hours sit idle. Refilled with in-town trips at $23.69 an hour, the same hours would earn about $4,264, a gain of about $2,978.
4. Check the exit terms. Under MTM’s standard agreement, either party can walk away on 30 days’ written notice, but you still owe every trip already assigned in that window, and MTM holds unpaid claims until it has audited your records. Ending a broker contract covers notice and final payments.
5. Check what is left. If one payer would then carry most of your revenue, read NEMT payer mix first.

Seeing it trip by trip in HealthRide

This check needs numbers by payer and by trip, not a monthly total. In HealthRide, the payer summary lists every payer with its completed trips, cancellations, billed revenue, and the amount still owed, over any period you pick. Every trip also carries GPS-recorded miles and timestamps, so the inputs for this test are there each month without rebuilding them in a spreadsheet. See reports.