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Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Cozy Corner Adult Day Health Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Cozy Corner Adult Day Health.

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 certain activities of Cozy Corner Adult Day Health for the period January 1, 2016 through December 31, 2017.

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 objective. We believe that the evidence obtained provides a reasonable basis for our findings 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

  1. Did Cozy Corner properly bill for medical services provided to MassHealth members?

No; see Finding 1

Methodology

We obtained claim data from MassHealth’s Medicaid Management Information System (MMIS) for testing. These data contained information for both fee-for-service claims, which adult day health (ADH) centers bill directly to MassHealth, and encounter claims, which represent services provided by other MassHealth plans, such as senior care organization (SCO) and accountable care organization (ACO) plans. 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, 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 for values outside a designated range, (4) looking for dates outside specific time periods, and (5) 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.

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

Effective July 27, 2018 MassHealth revised Chapter 404 of Title 130 of the Code of Massachusetts Regulations. For the purpose of our audit, MassHealth officials instructed OSA to use the prior regulations that were in effect during the audit period, January 1, 2016 through December 31, 2017.

Because Cozy Corner provided ADH services to only 47 MassHealth members during the audit period, we evaluated all 47 members’ records to determine whether Cozy Corner properly billed for the services it provided. We performed the following audit procedures:

  • We examined member medical records to determine whether a physician order approving ADH services was included in each member’s records.
  • We determined whether each physician order indicated that the member required assistance with specific activities of daily living and/or skilled nursing services.
  • We reviewed signed physician orders to determine whether their dates were on or before the members’ first dates of ADH services, since MassHealth does not pay for ADH services before the ADH provider receives a signed physician order.
  • We reviewed members’ records to determine whether Cozy Corner obtained written clinical authorizations from MassHealth or the members’ SCO or ACO health plans and whether the authorizations’ dates were on or before the members’ first dates of service.

We performed a data analysis to identify all MassHealth members who received services from Cozy Corner and may have received duplicate services based on an isolated risk factor: receiving both six hours of ADH services and six hours of personal care attendant (PCA) services on the same day. For these members, we evaluated PCA timesheets, ADH attendance logs, and care plans to determine whether MassHealth paid for duplicate services.

Date published: March 15, 2019

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