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Audit Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Cozy Corner Adult Day Health

The audit found deficiencies with the provider's’ documentation to support MassHealth claims for adult day health (ADH) services. It examined the period of January 1 2016 through December 31, 2017.

Organization: Office of the State Auditor
Date published: March 15, 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 Cozy Corner Adult Day Health for the period January 1, 2016 through December 31, 2017. During this period, MassHealth paid Cozy Corner approximately $955,587 to provide ADH services for 47 MassHealth members. The purpose of this audit was to determine whether Cozy Corner obtained the required physician orders and clinical authorizations for ADH 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

Cozy Corner did not properly document physician orders and clinical authorizations in member records to support ADH services it billed.

Recommendations
 

  1. MassHealth should determine how much of the $955,587 discussed in this finding should be repaid and seek reimbursement.
  2. If Cozy Corner believes that any of the requirements established by MassHealth regulations are unclear, it should contact MassHealth for guidance and clarification.
  3. Cozy Corner should ensure that completed and authorized physician orders and clinical authorizations are in place before it provides ADH services to MassHealth members. The orders should indicate the assistance with activities of daily living, and/or skilled nursing services, members require and be used to develop members’ individual care plans.

 

A PDF copy of the audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services Provided by Cozy Corner Adult Day Health is available here.

Downloads

Contact

Phone

Fax

(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133
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