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Audit Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services by ActiveLife Adult Day Care, Inc.

The audit, which examined the period of January 1, 2016 through December 31, 2017, found the agency did not have a physician order justifying the services it provided to one member. The audit calls on the agency to work with MassHealth to determine how much of the $34,137 in claims should be repaid.

Organization: Office of the State Auditor
Date published: November 14, 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 adult day health (ADH) services paid to ActiveLife Adult Day Care, Inc. for the period January 1, 2016 through December 31, 2017. During this period, MassHealth paid ActiveLife approximately $2,365,604 to provide ADH services for 108 MassHealth members. The purpose of this audit was to determine whether ActiveLife properly billed for ADH services provided to MassHealth members during our audit period.

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 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 findings and recommendations, with links to each page listed.

Finding 1

ActiveLife did not obtain a physician order for $34,137 of services for one MassHealth member.

Recommendations
 

  1. ActiveLife should collaborate with MassHealth to determine how much of the $34,137 discussed in this finding should be repaid.
  2. ActiveLife should develop policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.

 

A PDF copy of the audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by ActiveLife Adult Day Care, Inc. 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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