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Audit

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

This audit of a Hopkinton-based MassHealth provider calls for improvements to documentation to support adult day health services it billed the program. 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 Liberty Adult Day Health for the period January 1, 2016 through December 31, 2017. During this period, MassHealth paid Liberty approximately $1,356,967 to provide ADH services for 72 MassHealth members. The purpose of this audit was to determine whether Liberty 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 findings and recommendations, with links to each page listed.

Finding 1

Liberty did not properly document physician orders in member records to support ADH services it billed, totaling $32,407.

Recommendations

  1. Liberty should collaborate with MassHealth to repay the $32,407 discussed in this finding.
  2. Liberty should develop internal control policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.

Finding 2

Liberty did not always obtain physician orders detailing the assistance with activities of daily living that members required.

Recommendation

Liberty should develop policies and procedures for the review of physician orders to ensure that these orders contain the necessary information to develop adequate care plans for MassHealth members.

 

A PDF copy of the Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Liberty 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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