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Audit Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services by City Home Care, LLC

Audit found the provider billed MassHealth for Group Adult Foster Care (GAFC) services given on the same day MassHealth members also received Home Health Program services, which is unallowable under agency guidelines. The audit examined the period January 1, 2016 through December 31, 2018.

Organization: Office of the State Auditor
Date published: September 21, 2020

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 United States 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 group adult foster care (GAFC) paid to City Home Care, LLC for the period January 1, 2016 through December 31, 2018. During this period, MassHealth paid City Home Care $1,079,110 for 4,514 claims to provide GAFC for 76 MassHealth members. The average annual cost for GAFC provided by City Home Care for each member was approximately $7,715.1 The purpose of this audit was to determine whether City Home Care obtained the required prior authorizations, and properly billed, for GAFC provided to MassHealth members during our audit period. In a previous audit (No. 2016-1374-3M2), OSA identified $15 million in improper payments for adult foster care and GAFC provided to MassHealth members. This audit also recommends that MassHealth enact regulations specifically governing the Group Adult Foster Care Program.

This audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program. As with any government program, public confidence is essential to this program’s success and continued support.

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

Finding 1
 

City Home Care was paid as much as $268,494 for group adult foster care services that appear to be unallowable.

Recommendations
 

  1. City Home Care should ensure that it does not bill MassHealth for unallowable GAFC services.
  2. City Home Care should work with MassHealth to determine the amount City Home Care was overpaid for GAFC, and MassHealth should recoup that amount.

In addition to our finding, we identified an issue we believe warrants MassHealth’s attention, which we have disclosed in the “Other Matters” section of this report.

 

A PDF copy of the audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by City Home Care, LLC is available here.

 

1.     To calculate this number, we divided the average annual amount MassHealth paid City Home Care for GAFC during the audit period by the average annual number of members who received GAFC during this period.

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