Organization: | Office of the State Auditor |
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Date published: | July 27, 2018 |
Executive Summary
The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to help prevent and identify fraud, waste, and abuse in the Commonwealth’s Medicaid program. This program, known as MassHealth, is administered under Chapter 118E of the Massachusetts General Laws by the Executive Office of Health and Human Services through the Division of Medical Assistance. Medicaid is a joint federal-state program created by Congress in 1965 as Title XIX of the Social Security Act. At the federal level, the Centers for Medicare & Medicaid Services, within the US Department of Health and Human Services, administer the Medicare program and work with state governments to administer state Medicaid programs.
OSA has conducted an audit of MassHealth’s drug tests for the period July 1, 2012 through June 30, 2016. During this period, MassHealth paid laboratories approximately $39,771,152 to provide drug tests for 240,711 MassHealth members. The purpose of this audit was to review the drug tests that MassHealth paid for during the audit period and determine whether the nature and frequency of testing complied with MassHealth regulations, which allow authorized prescribers treating MassHealth members to order and use drug tests for diagnosis, treatment, or otherwise medically necessary purposes.
The audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program. A previously issued OSA audit report (No. 2012-1374-3C) disclosed significant weaknesses in MassHealth’s claim-processing system for drug tests, which resulted in millions of dollars in potentially improper payments. As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.
Below is a summary of our findings and recommendations, with links to each page listed.
MassHealth may have paid as much as $6.2 million for unnecessary drug tests. |
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MassHealth may have paid for improper drug tests provided to members residing in sober homes. |
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MassHealth paid $21,073 for drug tests that were not supported by proper documentation. |
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List of Abbreviations
BSAS |
Bureau of Substance Abuse Services |
CMR |
Code of Massachusetts Regulations |
CMS |
Centers for Medicare & Medicaid Services |
DPH |
Department of Public Health |
E/M |
evaluation and management |
MASH |
Massachusetts Alliance for Sober Housing |
MMIS |
Medicaid Management Information System |
NPI |
National Provider Identifier |
OSA |
Office of the State Auditor |
SAMHSA |
Substance Abuse and Mental Health Services Administration |
SUD |
substance use disorder |
Table of Contents
Contact
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Room 230
Boston, MA 02133