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Audit of the Office of Medicaid (MassHealth)—A Review of MassHealth Member Eligibility at the Springfield Enrollment Center Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Office of Medicaid (MassHealth)—A Review of MassHealth Member Eligibility at the Springfield Enrollment Center.

Table of Contents

Overview

In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor (OSA) has conducted a performance audit of MassHealth’s Springfield enrollment center for the period January 1, 2017 through December 31, 2018.

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Below is our audit objective, indicating the question we intended our audit to answer and the conclusion we reached regarding the objective.

Objective

Conclusion

  1. Did the Springfield enrollment center verify the income of MassHealth walk-in applicants and revoke benefits from MassHealth members who were found not to be eligible according to Section 502.003 of Title 130 of the Code of Massachusetts Regulations?

Yes

Methodology

We gained an understanding of the internal controls we deemed significant to our audit objective through inquiries. In addition, we performed the following procedures to obtain sufficient, appropriate audit evidence to address our audit objective.

  • We selected a statistical, random sample of 176 out of 6,236 walk-in applicants from the audit period, using an expected error rate of 50%, a desired precision of 15%, and a confidence level of 95%, to determine whether MassHealth properly verified applicant income during the eligibility process. The expected error rate is the anticipated rate of occurrence of the error of members being placed in the wrong benefit plan; 50% is the most conservative. Desired precision is a measure of how precise the actual error rate is. Confidence level is the numerical measure of how confident one can be that the sample results reflect the results that would have been obtained if the entire population had been tested.
  • To achieve our objective, we reviewed each applicant’s verified income and percentage of the federal poverty level used to determine eligibility. Once we determined the income used to decide eligibility, we reviewed recent paystubs, tax returns, or affidavits that had been provided by applicants and scanned into MassHealth’s MyWorkStation system (MWS). We also calculated each applicant’s income based on the documentation provided and compared it to the income MassHealth used to determine eligibility.
  • We requested and received wage information for the 176 applicants in our test sample from the Massachusetts Department of Revenue (DOR). Using the data provided by DOR, we verified that the income MassHealth used to determine eligibility did not exceed the amount DOR had on record.
  • For applicants that MassHealth found not to be eligible for benefits based on income, we reviewed records in the agency’s Medicaid Management Information System (MMIS) of all the services received, to verify that MassHealth had revoked benefits.
  • From the sample of 176 applicants tested, we noted one exception. Although eligible, the applicant was placed in the wrong benefit plan. We did not report this exception as a finding, and the projected monetary value was below the expected error rate used in our sampling strategy.
  • MassHealth gave us a list of all walk-in applicants from the Springfield enrollment center from January 1, 2017 through December 31, 2018, which it obtained from MWS. We performed validity and integrity tests on the data provided, including (1) testing for blank fields, (2) scanning for duplicate records, (3) testing each person who applied at the Springfield enrollment center, and (4) looking for dates outside the audit period. In addition, we tested a sample of the walk-in applicants to verify that the documentation (recent paystubs, tax returns, or affidavits from the applicant and/or the applicant’s employer) was related to the name given to us by MassHealth, the number of pages matched what was in the system, and the Springfield enrollment center had received the documents. Based on these procedures, we determined that the data obtained were sufficiently reliable for the purposes of this report.
  • In addition, we obtained data from MMIS for testing purposes. To test the reliability of these data, we relied on the work performed by OSA in a separate project that tested certain information system controls in MMIS. As part of that work, OSA reviewed existing information, tested selected system controls, and interviewed knowledgeable agency officials about the data. Additionally, we performed validity and integrity tests on all claim data, including (1) testing for blank fields, (2) scanning for duplicate records, (3) testing for dates outside the audit period, and (4) tracing a sample of claims queried to source documents. Based on these procedures, we determined that the data obtained were sufficiently reliable for the purposes of this report.

Conclusion

Our audit revealed no significant instances of noncompliance that must be reported under generally accepted government auditing standards.

Date published: October 9, 2020
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