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Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services by WestMass ElderCare, Inc. 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 WestMass ElderCare, Inc.

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 payments made by MassHealth for adult foster care (AFC) to WestMass ElderCare, Inc. (WMEC) 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 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 this report.

Objective

Conclusion

  1. Did WMEC obtain prior authorizations from MassHealth for its members receiving AFC?

No; see Finding 1

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 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, (2) scanning for duplicate records, (3) testing for values outside a designated range, (4) looking for dates outside specific periods, (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 WMEC properly billed MassHealth for AFC, we selected a nonstatistical, random sample of 45 of 3923 MassHealth members who received only AFC 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 AFC and whether MassHealth authorized the services. When sampling, we used a nonstatistical sampling method, whose results we could not project to the entire population.

3.     Although WMEC provided AFC to 404 members, we only included the 392 who did not receive both AFC and home health aide services.

Date published: July 21, 2020

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