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Audit Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by Somerville-Cambridge Elder Services (SCES)

Audit found SCES provided adult foster care (AFC) services to MassHealth members without required prior eligibility authorization. The audit examined the period of January 1, 2016 through December 31, 2018.

Organization: Office of the State Auditor
Date published: June 29, 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 adult foster care (AFC) paid to Somerville-Cambridge Elder Services (SCES) for the period January 1, 2016 through December 31, 2018. During this period, MassHealth paid SCES $13,237,054 for 7,597 claims to provide AFC for 287 MassHealth members. The average annual cost for AFC provided by SCES for each member was approximately $21,115.1 The purpose of this audit was to determine whether SCES properly billed for AFC 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. 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 recommendation, with links to each page listed. 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.

Finding 1
 

SCES provided AFC to MassHealth members without submitting annual prior authorizations.

Recommendation
 

SCES should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.

 

A PDF copy of the audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services by Somerville-Cambridge Elder Services is available here.

 

Post-Audit Action

SCES officials told us that SCES began submitting annual prior authorizations on April 16, 2019, the day MassHealth’s Long-Term Services and Supports Provider Portal became operational.

 

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

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Contact

Phone

Fax

(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133
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