Overview
For 1 of the 40 MassHealth members tested, ActiveLife lacked a properly authorized physician order to authorize $34,137 of adult day health (ADH) services provided during our audit period. As a result, there is a higher-than-acceptable risk that ActiveLife may not have provided the appropriate ADH services to this member.
Authoritative Guidance
According to Section 404.406(F)(2) of Title 130 of the Code of Massachusetts Regulations as of March 2010, to initiate ADH services, providers must obtain physician documentation, including physician orders, for the services:
(a) Before the member’s first attendance day, the ADH provider must obtain the necessary documentation from the member’s physician.
(b) The physician’s documentation must include
(i) physician orders for adult day health services.
Reasons for Noncompliance
ActiveLife does not have internal controls (policies and procedures) in place to ensure that physician orders are obtained from members’ physicians before beginning ADH services.
Recommendations
- ActiveLife should collaborate with MassHealth to determine how much of the $34,137 discussed in this finding should be repaid.
- ActiveLife should develop policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.
Auditee’s Response
The State Auditor states in the Report that, for one of the 40 MassHealth members in question, ActiveLife lacked a properly authorized PO to authorize the $34,137 in ADH services that ActiveLife billed during the Audit Period. ActiveLife is certain that it had a properly authorized PO for the member in question at one point because it could not have obtained an ADH Referral from MassHealth without one. It appears that ActiveLife has accidentally deleted this PO, though, as ActiveLife is unable to locate this PO in its filing system. ActiveLife has requested a copy of this PO from the member's primary care physician, which is currently processing the request. Even if the primary care physician is unable to produce a copy of this PO, though, it would be inequitable for MassHealth to recoup $34,137 from ActiveLife due to a one-time, inadvertent administrative error.
MassHealth’s Response
MassHealth agreed with our recommendations and stated that it would follow through with its own audit of ActiveLife.
Auditor’s Reply
As noted above, none of the documentation in the member file in question included a physician order for ADH services. In its response, ActiveLife asserts that there was a properly authorized physician order for the member but implies that it may have been misplaced because ActiveLife could not have obtained an ADH referral from MassHealth without one. However, ActiveLife’s management is responsible for ensuring that a properly authorized physician order is obtained and retained in each member’s file before the first day of service in order to substantiate the need for the service. We believe that the controls over this activity could be strengthened; therefore, we again urge ActiveLife to implement our recommendation to develop policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.
| Date published: | November 14, 2019 |
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