Overview
Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth annually provides access to healthcare services for approximately 2.5 million eligible children, families, seniors, and people with disabilities, all of whom have low or moderate incomes. In fiscal year 2023, MassHealth paid healthcare providers more than $17.1 billion in total, of which approximately 35% was funded by the Commonwealth. These Medicaid program expenditures represented approximately 33% of the Commonwealth’s total fiscal year 2023 budget.
Durable Medical Equipment
Durable medical equipment (DME) refers to medical devices that can withstand repeated use and are primarily used to serve a medical purpose. Some examples of DME covered by MassHealth include the following:
- ambulatory equipment, such as crutches or canes;
- mobility equipment, such as wheelchairs and scooters;
- nutritional supplements;
- glucose monitors and other diabetic supplies; and
- personal emergency response systems, such as Life Alert.
DME must be ordered by a provider for medically necessary purposes for MassHealth members. When a DME provider bills MassHealth, it must also include the name and national provider identifier (NPI) of the ordering provider on the MassHealth claim.
MassHealth Payments After Member Death
Before paying a claim, MassHealth uses the Department of Public Health’s (DPH’s) Vital Statistics File to flag any claims where the associated MassHealth member has a date of death occurring before the date of service listed on the claim. After an investigator reviews this file, if the claim is found to be for a member who was deceased before the date of service, MassHealth denies the claim. This procedure relies on DPH’s Vital Statistics File being complete and up to date when the MassHealth claim is processed. Once claims are processed and paid, MassHealth’s vendors perform additional procedures by running reports every one to two years on claims data, with the purpose of identifying claims paid for members who are deceased. Previously, MassHealth’s process for identifying improper payments made for services occurring after a member’s death only used DPH’s Vital Statistics File. However, in January 2024, MassHealth updated its procedures for member death verification to include multiple data sources; the agency no longer relies solely on DPH’s Vital Statistics File. This update was in response to a previous audit of MassHealth (Audit No. 2023-1374-3M1), in which we used a variety a death data sources and found that MassHealth paid providers $11,797 for 109 claims for services allegedly rendered to 31 members who were proven to be deceased at the time services were rendered.
Medicaid Provider Exclusions
Pursuant to Section 1128 of the Social Security Act, the US Department of Health and Human Services Office of the Inspector General (HHS OIG) has the authority to exclude individuals and entities from federally funded healthcare programs. Providers can be excluded for several reasons, including being found guilty of Medicare or Medicaid fraud; having recorded instances of misconduct with patients, including abuse or neglect; unlawfully prescribing controlled substances; and providing unnecessary or substandard services.
HHS OIG maintains the List of Excluded Individuals and Entities (LEIE), which is available for download on its website. The LEIE is updated monthly with providers who have become ineligible to participate in Medicare or Medicaid. The HHS OIG website also provides guidance to state Medicaid agencies about how they should use the LEIE to prevent improper payments.
| Date published: | October 30, 2025 |
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