TL;DR
- Medicaid reimburses loaded miles. The miles a van drives with nobody in it are the operators to absorb.
- Deadhead mileage runs an estimated 30 to 40 percent of total miles in NEMT, and higher in rural service areas.
- Indiana’s Medicaid broker scheduled 36,203 trips in February 2025 and fulfilled 27,249. Member cancellations alone accounted for 10 percent of scheduled rides.
- Every cancelled trip opens a slot in a driver’s day. Whether it gets filled depends on how fast dispatch notices and reassigns the work.
- Providers sent back 11.88 percent of assigned trips that month. Late send backs were reassigned 72.54 percent of the time, against 89.63 percent for send backs filed with more notice.
Ask most NEMT operators to name their biggest expense and the answer is usually vehicles, fuel, or insurance. There is another cost that never appears on an invoice, and it runs every time a van moves down the road with an empty seat behind the driver.
The industry calls these deadhead miles. They are the miles driven between a drop-off and the next pickup, or back to base after the last trip of the day. One industry estimate puts deadhead mileage at 30 to 40 percent of total miles driven by NEMT vehicles, with rural service areas running higher because the distances between stops are longer.
An empty mile still burns fuel, still adds wear to the vehicle, and still shows up in driver payroll. The only thing missing is the revenue.
Medicaid Pays for Loaded Miles Only
Most state Medicaid programs reimburse mileage only while a member is in the vehicle. Montana’s Medicaid program states the rule plainly in its provider guidance, noting that mileage reimbursement is available for loaded miles and that payment is made after the state confirms the appointment was attended. The Centers for Medicare & Medicaid Services covers the same question in its 2023 guidance to state Medicaid directors, which includes a section on no-load and unloaded miles.
So the math on a trip is not the distance the driver covered. It is the distance the driver covered with a passenger on board. Everything else is overhead the operator agreed to carry when they took the trip.
That changes how a day’s schedule should be read. A van that completes eight trips and drives 40 empty miles doing it earns less than a van that completes eight trips and drives 15 empty miles. Same revenue, different cost.
Where the Empty Miles Come From
Indiana publishes monthly NEMT reports from its Medicaid broker under state code, which makes it one of the clearest public windows into how trips move through the system.
In February 2025, the broker received 36,217 trip requests and scheduled 36,203 of them, a scheduling rate of 99.96 percent. Of those, 27,249 were fulfilled, which works out to 75.24 percent. Roughly a quarter of scheduled work did not happen.
| Reason | Trips | Share of scheduled rides |
|---|---|---|
| Member cancelled | 3,634 | 10.0% |
| Member no-show | 708 | 2.0% |
| No provider assigned | 596 | 1.6% |
| Member too sick | 234 | 0.6% |
| Member hospitalized | 167 | 0.5% |
| Provider no-show | 130 | 0.4% |
| All missed trips | 5,627 | 16% |
Member cancellations are the largest single line, at ten percent of everything scheduled. Some arrive a day ahead. Others arrive while the driver is already turning onto the street.
What Happens After a Trip Cancels
The cancellation itself costs very little. The cost builds in the twenty minutes that follow, while a driver sits in a parking lot waiting to hear what comes next.
That van stays expensive while it waits. Insurance is running, the driver is on the clock, and the vehicle keeps depreciating whether it moves or not. None of it is earning.
Filling the opening is dispatch work, and it is time-sensitive. Someone has to see the cancellation come through, check where every driver currently sits, find a will call or a same-day request that fits, and get it assigned before the driver drifts too far from the next rider. Handled quickly, the day mostly recovers. Handled late, the operator has paid for an empty vehicle and the trip that could have covered it goes elsewhere.
This is where the difference between a phone agent and a dispatcher shows up. An agent takes the trip request and captures the details correctly so the trip can be billed. A dispatcher works the board, coordinating with drivers and keeping the schedule productive as conditions change. Smaller operations often run both jobs through one person, which holds until the day gets busy.
Send Backs Have a Clock on Them
When a provider cannot cover a trip they were assigned, they send it back to the broker. In February 2025, providers sent back 2,182 of 18,362 assigned trips, or 11.88 percent. Of those, 437 were filed within 48 hours of the trip, and 72.54 percent of the late ones were reassigned to another provider. Send backs filed with more than 48 hours of notice were reassigned 89.63 percent of the time.
The distance between those two figures is what notice buys. Trips released early find a home more often. Trips released at the last minute leave a rider without a ride, and leave the broker with a record of which provider caused it.
Both directions matter. Filing your own send backs early protects your standing with the broker. Being reachable when another provider’s send back needs a home puts revenue in front of you.
Losing hours to empty vans?
Pac Biz places trained NEMT dispatchers who work inside your dispatch system and reassign trips as the day changes.
What to Check on Your Own Numbers
Most operators have never separated loaded miles from total miles. That is the place to start, before changing anything else.
Pull last month and confirm four things:
- Total miles driven across the fleet, against loaded miles billed
- Cancellations, split between advance notice and same-day
- Average minutes between a cancellation arriving and the replacement trip being assigned
- Your own send back rate, and how much notice you typically give
The last two are usually the ones nobody tracks, and they are often where the money sits. A fleet averaging ten minutes to reassign is running a different business than one averaging an hour, with identical vehicles and identical contracts.
The Short Version
Riders will keep cancelling. Illness, hospital admissions, and appointment changes come with moving people to medical care, and the Indiana numbers show they happen at a steady rate.
What an operator controls is how long the van sits still afterward. Start by separating loaded miles from total miles on last month’s numbers. It is a short piece of work, and it shows how much of the fleet’s running is actually being paid for.