Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Office of Medicaid (MassHealth)—Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy.

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 certain activities of United Cerebral Palsy (UCP) for the period April 1, 2015 through July 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 finding and conclusions based on our audit objective.

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

Objective	Conclusion
Did UCP properly bill MassHealth for day habilitation (DH) services provided to MassHealth members?	No; see Finding 1

Auditee Selection

During our audit period, MassHealth paid approximately $567 million for DH services. To identify the DH services that represented the highest risk, we (1) performed data analytics on all DH service claims paid during the audit period to identify the frequency of complex billings compared to basic and intermediate billings by all providers, (2) reviewed the highest billings for each location compared to overall billings to isolate any unusually high billings at the locations, and (3) isolated providers with 100% complex billings. Based on the results of this analysis, we selected UCP for audit.

Methodology

We obtained claim data from MassHealth’s Medicaid Management Information System (MMIS) for testing. These data contained information about fee-for-service claims, which DH providers bill directly to MassHealth. 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, which is maintained by the Executive Office of Health and Human Services. As part of the work performed in this separate project, OSA reviewed existing information, tested selected system controls, and interviewed knowledgeable agency officials about the data. Additionally, we performed validity and integrity tests on claim data, including (1) testing for missing data, (2) scanning for duplicate records, (3) testing values outside a designated range, (4) looking for dates outside specific time periods, and (5) tracing a sample of claims queried to source documents and confirming the type and severity of each individual’s disability for claims paid. Based on these procedures, we determined that the data obtained were sufficiently reliable for the purposes of this report.

We evaluated the design of UCP’s billing processes for DH services and the related internal controls over these processes that we deemed significant to our audit objective.

Effective September 7, 2018, MassHealth revised Chapter 419 of Title 130 of the Code of Massachusetts Regulations. For the purpose of our audit, OSA used the prior regulations that were in effect during the audit period. 

Because UCP provided DH services to only 111 MassHealth members during the audit period, we evaluated all 111 members’ files to determine whether UCP properly billed for services it provided. To do so, we reviewed information in all members’ medical records. This included reviewing active member binders on site and looking through archived inactive member folders. We recorded and verified the following for each member: (1) the date s/he started the program; (2) a physical examination record in the file; (3) a physician or primary care clinician authorization, as well the date the form was signed and the physician’s or primary care clinician’s name, address, and phone number on the form; (4) a service-needs assessment; (5) a severity profile; (6) a member service plan; and (7) a Preadmission Screening and Resident Review (PASRR)² if the member lived at a nursing facility.

We performed the following audit procedures:

• We examined member files to determine whether a physician or primary care authorization approving DH services was included in each member’s records.
• We reviewed the dates of physician or primary care clinician authorizations against the dates members started the program. We then reviewed a PASRR on record for “approval of need,” if applicable.
• We compared the dates that the first claims were paid for each member to their physician or primary care clinician authorizations to determine whether claims were paid after the authorizations were signed.
• We sent physician signature confirmations to a judgmental sample of 21 out of 63 doctors whose signatures appeared on one or more physician authorizations within the audit period to verify that their signatures were authentic. We used nonstatistical sampling; therefore, we did not project our results to the population.

Additionally, we ran queries from MMIS of all the services received by each member to determine whether they also received personal care or nursing facility services from providers. From this analysis, we determined that no personal care or nursing facility services were provided at the same time DH services were provided.

2.    According to medicaid.gov, “Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care.”

Date published:	September 19, 2019