Report  Annual Report Medicaid Audit Unit for March 15, 2019 through March 14, 2020

The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit (the Unit) for the purposes of preventing and identifying fraud, waste, and abuse in the MassHealth system and making recommendations for improved operations. The state’s fiscal year 2020 budget (Chapter 41 of the Acts of 2019) requires that OSA submit a report to the House and Senate Committees on Ways and Means by no later than March 14, 2020 that includes (1) “all findings on activities and payments made through the MassHealth system;” (2) “to the extent available, a review of all post-audit efforts undertaken by MassHealth to recoup payments owed to the commonwealth due to identified fraud and abuse;” (3) “the responses of MassHealth to the most recent post-audit review survey, including the status of recoupment efforts;” and (4) “the unit’s recommendations to enhance recoupment efforts.”

For fiscal year 2020, the appropriation for the Unit was $1,234,674. This amount represents an approximately 3% increase over the Unit’s fiscal year 2019 appropriation of $1,198,713. OSA submits all costs (direct and indirect) associated with running the Unit to the Executive Office of Health and Human Services (EOHHS) to be included in its in quarterly filings with the Centers for Medicare & Medicaid Services for federal cost sharing. In federal fiscal year[1] 2019, OSA submitted a total of $1,470,381 to EOHHS for consideration for the state’s program integrity, allowing the state to obtain a 50%, or $735,190, reimbursement of these costs.

This report, which is being submitted by OSA in accordance with the requirements of Chapter 41, provides summaries of three performance audits of MassHealth involving the following:

• billing methods and treatment plans for methadone and buprenorphine users
• payments for prescription refills
• management of accounts receivable

It also provides summaries of five MassHealth provider audits involving the following:

• a provider of day habilitation services (one audit)
• a provider of physical therapy (one audit)
• providers of adult day health services (two audits)
• a provider of vision care (one audit)

The report also summarizes OSA’s objectives for MassHealth audits that are currently underway. Finally, it details the corrective measures and related outcomes reported by the auditees, including MassHealth, in relation to our findings and recommendations for six audits.

This report details findings that identified improper payments totaling $1,901,051, as well as deficiencies in MassHealth’s administration of millions of dollars in uncollectible accounts receivable and treatment for members with opioid use disorders. It also describes corrective actions MassHealth is taking as a result of six audits whose findings were issued at least six months ago for which follow-up surveys have been completed and MassHealth has taken actions, including recouping funds. MassHealth and its providers reported action or planned action on approximately 15 (52%) of our 29 audit recommendations, which will improve operational efficiency and effectiveness.

A PDF copy of the annual report for the Medicaid Audit Unit is available here.

1. The 2019 federal fiscal year is October 1, 2018 through September 30, 2019.