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

The audit determined that NADHC did not have proper physician order documentation for adult day health services that were provided to MassHealth members, totaling $92,644. The audit examined the period of January 1, 2016 through December 31, 2017.

Organization: Office of the State Auditor
Date published: June 6, 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 Norwood Adult Day Health Center (NADHC) for the period January 1, 2016 through December 31, 2017. During this period, MassHealth paid NADHC approximately $1,854,494 to provide ADH services for 150 MassHealth members. The purpose of this audit was to determine whether NADHC 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
 

NADHC did not obtain physician orders to support as much as $92,644 of ADH services provided to three MassHealth members.

Recommendations
 

  1. NADHC should collaborate with MassHealth to determine how much of the $92,644 discussed in this finding should be repaid.
  2. NADHC should develop policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.

Finding 2
 

NADHC did not always properly document claims submitted to MassHealth by its billing agents to ensure that the correct ADH location was indicated.

Recommendation
 

NADHC should enhance its policies and procedures to make sure that it properly monitors claims submitted to MassHealth by its billing agents to ensure that all the claims they submit indicate the locations where services were provided.

 

A PDF of the Audit of the Office of Medicaid (MassHealth) -- Review of Claims Paid for Services Provided by Norwood Adult Day Health Center is available here.

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Contact

Phone

Fax

(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133
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