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Audit Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy (UCP)

UCP is one of approximately 128 providers of DH services in the Commonwealth. During the audit period (April 1, 2015 through July 31, 2018), it provided DH services to 111 MassHealth members and received payments of $4,505,326 for these services.

Organization: Office of the State Auditor
Date published: September 19, 2019

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 claims for day habilitation (DH) services paid to United Cerebral Palsy (UCP) for the period April 1, 2015 through July 31, 2018. During this period, MassHealth paid UCP $4,505,326 to provide DH services for 111 MassHealth members. The purpose of this audit was to determine whether UCP obtained the required authorization from a physician or primary care clinician for DH services for each MassHealth member.

The audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program. Our previously issued audit reports have disclosed significant weaknesses in MassHealth’s claim-processing system and improper billing practices by MassHealth providers, which resulted in millions of dollars in potentially improper claim 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 finding and recommendations, with links to each page listed.

Finding 1
 

UCP did not obtain physician or primary care clinician authorizations to support payment for DH services provided to six MassHealth members.

Recommendations
 

  1. UCP should collaborate with MassHealth to determine how much of the $122,357 discussed in this finding should be repaid.
  2. UCP should update its policies and procedures to require its staff to ensure the completion of physician or primary care clinician authorizations before it provides DH services for MassHealth members.

 

A PDF copy of the audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy is available here.

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Contact

Phone

Fax

(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133
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