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Audit Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services by WestMass ElderCare, Inc.

Audit found WMEC 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: July 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 adult foster care (AFC) paid to WestMass ElderCare, Inc. (WMEC) for the period January 1, 2016 through December 31, 2018. During this period, MassHealth paid WMEC $20,296,251 for 11,709 claims to provide AFC for 404 MassHealth members. The average annual cost for AFC provided by WMEC for each member was approximately $16,746.1 The purpose of this audit was to determine whether WMEC 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
 

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

Recommendation
 

WMEC 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 WestMass ElderCare, Inc. is available here.

 

Post-Audit Action

WMEC officials told us that WMEC 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 WMEC for AFC during the audit period by the average annual number of members who received AFC during this period.

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