| Organization: | Office of the State Auditor |
|---|---|
| Date published: | October 1, 2024 |
Executive Summary
The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to 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 and 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 a performance audit of MassHealth’s payments for telehealth adult day health (ADH) for the period January 1, 2020 through December 31, 2021. During this period, MassHealth paid $41,809,653.67—for 718,902 claims—to its providers for telehealth ADH provided to MassHealth members. The purpose of this audit was to determine whether MassHealth monitored telehealth practices for ADH to ensure compliance with its regulations.
This audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program. Several of our previously issued audit reports disclosed weaknesses in MassHealth’s claim processing system and improper billing practices by MassHealth providers, which identified millions of dollars in potentially improper payments. As with any government program, public confidence is essential to the success of and continued support for public expenditures, such as the state’s Medicaid program. Our audit is designed to identify issues that will help improve the Medicaid program, so taxpayers know their dollars are spent prudently and that there is a system of continuous improvement of efficiency and service over time.
Below is a summary of our findings, the effects of our findings, and our recommendations, with links to each page listed.
| Finding 1 | MassHealth paid providers for ADH that it did not authorize and/or that did not have supporting documentation. |
| Effect | When ADH providers do not fully document the services provided to MassHealth members, MassHealth cannot ensure that its members receive services that are consistent with members’ plans of care. Additionally, by not authorizing ADH before making payments to providers, MassHealth risks paying providers for unnecessary services. |
| Recommendations |
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| Finding 2 | MassHealth paid providers for transportation to ADH that it did not authorize and/or that did not have supporting documentation. |
| Effect | When providers submit claims for ADH without maintaining documentation to support how the service was performed, MassHealth risks paying for services that are not appropriate for a member’s needs, or that may not have been provided at all. By not ensuring that telehealth claims are adequately documented by providers, MassHealth limits its capabilities to detect potential fraud. |
| Recommendations |
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| Finding 3 | MassHealth paid providers $11,797 for 109 claims for services allegedly rendered to 31 members who were proven to be deceased. |
| Effect | By not always identifying deceased members, MassHealth risks paying fraudulent claims or overpaying its providers for services that were not rendered. |
| Recommendations |
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Post-audit Action
On December 26, 2023, MassHealth officials told us that, in response to this audit, it revised its policy on date of death matching to include certain data sources other than the Department of Public Health’s Registry of Vital Records and Statistics. The registry collects, tracks, and manages vital records such as the births and deaths of Massachusetts residents. MassHealth officials further stated that, when pursuing recoupments for potential overpayments, it must balance the risk of missing such potential overpayments with the risk of relying on alternate sources of data that MassHealth does not consider to be as reliable as the registry.
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