This is not the official budget document.

Budget Summary FY2014

40000301 - MassHealth Auditing and Utilization Reviews
Data Current as of:  9/11/2013





Account Description FY2013
Spending
FY2014
GAA
4000-0301 MassHealth Auditing and Utilization Reviews
For the costs of MassHealth provider and member audit and utilization review activities, including eligibility verification, disability evaluations, provider financial and clinical audits and other initiatives intended to enhance program integrity; provided, that no expenditures shall be made from this item that are not federally reimbursable; provided further, that notwithstanding any general or special law to the contrary, the state Medicaid office may conduct a trial to determine the effectiveness of various fraud management tools to identify potential fraud at claims submission and validation in order to reduce Medicaid fraud before payment; provided further, that the state Medicaid office may employ strategies to improve systems for detection and may allow for the use of external data sources; provided further, that any such trial may test innovative technologies to improve Medicaid fraud detection and, at the least, evaluate the efficacy of a real-time model to identify and investigate potential Medicaid fraud cases prior to payment; provided further, that the Medicaid office may use actual claims data, in accordance with federal law, to identify specific suspicious provider billing patterns, document the results of any potential fraud findings and estimate anticipated savings and benefits to the commonwealth associated with such a fraud detection system; provided further, that the executive office shall report to the house and senate committees on ways and means not later than January 17, 2014 detailing total audit findings and recoveries in fiscal year 2013 and estimated recoveries in fiscal year 2014; provided further, that the report shall also identify any audits and recoveries referred by the office of the state auditor; provided further, that the executive office shall report to the house and senate committees on ways and means not later than April 1, 2014 on prepayment audit efforts; and provided further, that the report shall include only: (i) the original amount of estimated payments prior to prepayment audit; and (ii) the actual amount of payments made following prepayment audits
1,736,313 4,416,519