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Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services by City Home Care, LLC Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Office of Medicaid (MassHealth)—Review of Claims Paid for Services by City Home Care, LLC.

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 City Home Care, LLC for the period January 1, 2016 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 a list of our audit objectives, indicating each question we intended our audit to answer; the conclusion we reached regarding each objective; and, if applicable, where each objective is discussed in this report.

Objective

Conclusion

  1. Did City Home Care bill for group adult foster care (GAFC) in accordance with MassHealth’s sub-regulatory Group Adult Foster Care Guidelines?

No; see Finding 1

  1. Did City Home Care obtain prior authorization from MassHealth for its members who received GAFC?

Yes

Methodology

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

  • We obtained data from MassHealth’s Medicaid Management Information System (MMIS) for testing purposes. To test the reliability of the 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 missing data fields, (2) scanning for duplicate records, (3) testing for values outside a designated range, (4) looking for dates outside the audit period, (5) testing for data validity errors, and (6) 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.
  • To determine whether City Home Care provided GAFC in accordance with MassHealth’s sub-regulatory Group Adult Foster Care Guidelines, we used data analytics on 100% of paid claims and identified a population of potentially unallowable claims. These claims included all payments made to City Home Care for GAFC provided to members on dates for which MassHealth also paid the agency for home health services provided to the same members. From this population of potentially unallowable claims, we examined whether any paid claims were for care provided to MassHealth members enrolled in the Executive Office of Elder Affairs’ Frail Elder Waiver Program2 because members in that program are allowed to receive both GAFC and home health services on the same day. We also determined through review of MMIS records whether members in this population had respite care plans that allowed them to receive both GAFC and home health services on the same day.
  • MassHealth’s sub-regulatory Group Adult Foster Care Guidelines prohibit GAFC providers from being paid for GAFC they provide to members on the same day the members receive home health services. Therefore, we used the paid claim data in MMIS to determine all instances of these unallowable payments at City Home Care during the audit period and based our conclusion on this analysis.
  • To determine whether City Home Care obtained prior authorization from MassHealth for its members who received GAFC, we selected all 76 (100%) of the MassHealth members who received GAFC during the audit period. We then reviewed physician summary forms and prior authorizations for these members to determine whether their physicians approved the need for GAFC and whether MassHealth authorized the services.

2.     The Frail Elder Waiver Program is a MassHealth program that went into effect in January 1990. It provides home- and community-based services to Massachusetts residents who require a nursing-home level of care, allowing them to receive healthcare and ongoing support services in their homes or community-living residences instead of in nursing homes.

Date published: September 21, 2020
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