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Audit Audit of the Office of Medicaid (MassHealth)—Payments for Hospice-Related Services for Dual-Eligible Members

Audit led to improvements in MassHealth's program integrity and oversight of claims and payments for dual-eligible members. The audit examined the period January 1, 2015 through July 31, 2019 and was performed in collaboration with the U.S. Department of Health and Human Services (HHS) Office of Inspector General’s (OIG) Boston office.

Organization: Office of the State Auditor
Date published: July 20, 2021

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 (CMS), within the United States Department of Health and Human Services (HHS), regulate Medicaid services and work with state governments to administer their Medicaid programs. Additionally, CMS administers the Medicare program, which is a federally funded health insurance program for individuals over the age of 65, individuals under the age of 65 with certain disabilities, and people of all ages with end-stage renal (kidney) disease.

In collaboration with the HHS Office of Inspector General’s Boston office, OSA has conducted an audit of claims paid by MassHealth for dual-eligible members (members who are enrolled in both the federal Medicare program and the state’s Medicaid program) who were receiving hospice care for the period January 1, 2015 through July 31, 2019. During this period, MassHealth paid $620,584,171 in claims for hospice-related services to non-hospice providers1 for dual-eligible members. The purpose of this audit was to determine whether MassHealth effectively administered payments for hospice-related services in accordance with applicable state and federal requirements, including ensuring that Medicaid was the payer of last resort (i.e., that it only paid for covered services if no other payer existed) for hospice services. The audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program.

Below is a summary of our findings and recommendations, with links to each page listed.

Finding 1
 

MassHealth did not ensure that it had accurate information in its Medicaid Management Information System (MMIS) about dual-eligible members who chose to receive hospice services.

Recommendations
 

  1. MassHealth should establish an effective monitoring process to ensure that hospice providers send it a MassHealth Hospice Election Form for every dual-eligible member who chooses to receive hospice services.
  2. MassHealth should consider collaborating with CMS to obtain CMS’s hospice election information about dual-eligible members and determine whether all MassHealth’s hospice providers have submitted the required MassHealth Hospice Election Forms.
  3. MassHealth should review MMIS for all members who have elected the hospice benefit to ensure that their MassHealth Hospice Election Forms are accurately reflected in MMIS.

Finding 2
 

MassHealth paid for professional services that were not coordinated by hospice providers.

Recommendations
 

  1. MassHealth should ensure that its hospice providers coordinate professional services with non-hospice providers for dual-eligible members to ensure proper service coordination and billing.
  2. MassHealth should update its system edits in MMIS to detect and deny claims for dual-eligible members in hospice care that might be duplicative of services that should be paid for by hospice providers.

Finding 3a

MassHealth paid for durable medical equipment (DME) that was included in members’ plans of care.

Finding 3b

MassHealth paid for DME that should have been included in members’ plans of care.

Recommendations
 

  1. MassHealth should ensure that information in MMIS about hospice election by dual-eligible members is accurate.
  2. MassHealth should ensure that the system edits in MMIS for claims for hospice services for dual-eligible members are effective in detecting and rejecting improper claims.

Finding 4
 

MassHealth unnecessarily paid for ambulance and inpatient services for dual-eligible members.

Recommendations
 

  1. MassHealth should ensure that its hospice providers explain to its members and their families that the members and families are required to inform any non-hospice providers that the members have elected the hospice benefit to ensure service coordination and billing.
  2. MassHealth should ensure that the system edits in MMIS for claims for hospice services for dual-eligible members are effective in detecting and denying improper claims.

 

Post-Audit Action

In response to the issue raised in Finding 1, in October 2020 MassHealth issued Hospice Bulletin 15. This bulletin reminded hospice providers that they were required to submit both a MassHealth Hospice Election Form and a Medicare Hospice Election Form at certain times. Specifically, according to Section 437.412 of Title 130 of the Code of Massachusetts Regulations, the forms must be submitted when a dual-eligible member chooses to receive hospice services (referred to in the regulation and this report as “electing the hospice benefit”) or chooses to end them (referred to as “revoking the hospice benefit”).

 

A PDF copy of the audit of the Office of Medicaid (MassHealth)—Payments for Hospice-Related Services for Dual-Eligible Members is available here.

 

1.     Non-hospice providers deliver medical or other services to members who have chosen to receive hospice care. They can enter into contracts with hospice providers to render these services.

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