| Organization: | Office of the State Auditor |
|---|---|
| Date published: | September 4, 2024 |
Executive Summary
The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to help 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 foster care (AFC) and group adult foster care (GAFC) services for the period January 1, 2020 through December 31, 2021. During this period, MassHealth paid $771,112,638 for 7,099,054 AFC and GAFC claims, of which, $22,979,654 was paid for 310,831 telehealth AFC and GAFC claims. The purpose of this audit was to determine whether MassHealth monitored telehealth practices for AFC and GAFC services to ensure compliance with its regulations.
The 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 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 that their dollars are spent prudently and that there is a system of continuous improvement to support improved efficiency and service over time.
Below is a summary of our findings, the effects of those findings, and our recommendations, with links to each page listed.
| Finding 1 | MassHealth did not ensure that AFC and GAFC registered nurses / licensed practical nurses and care managers conducted required oversight visits. |
| Effect | The absence of required oversight visits, whether on-site or through telehealth, calls into question whether the proper quality of care was given to each member who received AFC or GAFC. Because these oversight visits also assist caregivers and direct care aides in the work they do to care for AFC and GAFC members, this also calls into question whether each caregiver / direct care aide was adequately supported in the work they provided. |
| Recommendation | MassHealth should establish effective monitoring controls to ensure that AFC and GAFC providers conduct the required oversight visits for MassHealth members and caregivers / direct care aides. To establish effective monitoring controls, we believe MassHealth should establish a goal for the number of AFC / GAFC providers it will audit each year. |
| Finding 2 | MassHealth paid AFC and GAFC providers for services that did not have supporting caregiver / direct care aide log documentation. |
| Effect | The lack of adequate documentation calls into question whether all of the services from caregivers and direct care aides were delivered and makes it impossible to determine whether services were necessary or appropriate for members. |
| Recommendation | MassHealth should establish an effective monitoring process to ensure that caregivers / direct care aides of AFC and GAFC providers properly document care in their logs. |
| Finding 3 | MassHealth paid for AFC and GAFC caregiver / direct care aide services that were incorrectly coded as telehealth. |
| Effect | If MassHealth pays for services billed incorrectly without verifying how the services are provided, it may pay for unallowable services. By paying for unallowable services, MassHealth will have less money available to pay for allowable services for other MassHealth members. |
| Recommendation | MassHealth should add a system control in the Medicaid Management Information System to deny AFC and GAFC caregiver / direct care aide services in a telehealth setting. |