Audit of the Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Day Health Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Day Health.

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 MassHealth for the period January 1, 2020 through December 31, 2021.

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 the audit findings.

Objective	Conclusion
1. Did MassHealth pay for telehealth adult day health (ADH) in accordance with Section 404.414 of Title 130 of the Code of Massachusetts Regulations (CMR) and MassHealth’s ADH Bulletins 18 and 20?	No; see Finding 1
2. Did MassHealth pay for ADH transportation services in accordance with 130 CMR 404.414, 130 CMR 404.416, 130 CMR 450.205, MassHealth’s All Provider Bulletin 327, and MassHealth’s ADH Bulletins 18 and 20?	No; see Finding 2
3. Did MassHealth ensure that it did not pay for ADH provided to members after their dates of death, in accordance with 130 CMR 450.235?	No; see Finding 3

To accomplish our audit objectives, we gained an understanding of the aspects of the internal control environment relevant to our objectives by reviewing applicable policies and procedures and MassHealth’s internal control plan and by interviewing MassHealth officials.

To obtain sufficient, appropriate evidence to address our audit objectives, we performed the procedures described below.

ADH Telehealth Services

To determine whether MassHealth properly paid for ADH, we selected a random, statistical¹ sample of 71 out of 1,134 MassHealth members who received ADH from the 10 providers that were paid the most for telehealth ADH, totaling $665,064 for 12,716 telehealth claims. To select our sample, we used a 90% confidence level,² a 50% expected error rate,³ and a 20% desired precision range.⁴

We reviewed supporting documentation for the 12,716 telehealth ADH claims, totaling $665,064, for the 71 members in our sample. The supporting documentation included prior authorization letters for ADH; plans of care that detailed each member’s qualifying needs for ADH and how those needs would be met through ADH; attendance logs that showed each day that each member received ADH in person; Remote Services Log entries that showed each day that each member received telehealth ADH; and service notes, which detail the extent of services that were provided to each member for each day on which that member received ADH.

We determined whether each member in our sample had prior authorization from MassHealth to receive ADH by cross-referencing prior authorization letters from the ADH providers with prior authorization information from the Medicaid Management Information System (MMIS). We also determined whether services were paid by MassHealth at the appropriate level of care (e.g., basic or complex level of care) that was authorized by MassHealth by cross-referencing the modifier codes⁵ attached to each claim with prior authorization forms.

We reviewed plans of care, service notes, attendance logs, and Remote Services Logs from the providers for each member in our sample to determine whether the provided services had supporting documentation that detailed the services provided each day and how they supported the goals on each member’s plan of care.

MassHealth allowed providers to bill ADH telehealth a maximum of three times per week per member during 2020. Therefore, we filtered claims data to identify all ADH telehealth that exceeded three times per week for each of the members in our sample. We then reviewed billing documentation to determine whether these services were billed to and paid for by MassHealth. We also filtered claim data to identify all claims coded as telehealth that were not billed using the partial per diem rate that MassHealth requires. We then reviewed Remote Services Logs, attendance logs, and billing documentation to determine whether these services were actually provided through telehealth and whether they were billed to and paid for by MassHealth.

Based on the result of our testing, we determined that MassHealth did not pay for ADH in accordance with 130 CMR 404.414 and MassHealth’s ADH Bulletins 18 and 20. See Finding 1 for more information.

Transportation and Telehealth ADH

We identified the five providers that were paid the most by MassHealth for transportation and telehealth ADH on the same day. We then identified a population of 53 MassHealth members who received telehealth ADH from these providers and who may have received telehealth ADH and transportation on the same day.

We reviewed supporting documentation for 2,582 telehealth ADH and transportation claims, totaling $180,750, for the 53 MassHealth members (100%) in our population. The supporting documentation that was provided to us by each member’s ADH provider included prior authorization letters for ADH and transportation, plans of care, transportation logs showing each day that each of the 53 members were transported to an ADH center, attendance logs, Remote Services Logs, and service notes for each day that each member received ADH.

We examined attendance logs, Remote Services Logs, and each member’s service notes, to determine whether each claim was for telehealth ADH. We then cross-referenced each verified telehealth claim with transportation logs to identify all transportation services that were paid for by MassHealth for days when the corresponding member did not attend ADH in person.

Based on the result of our testing, we determined that MassHealth did not pay for ADH transportation services in accordance with 130 CMR 404.414, 130 CMR 404.416, 130 CMR 450.205, MassHealth’s All Provider Bulletin 327, and MassHealth’s ADH Bulletins 18 and 20. See Finding 2 for more information.

Date of Death

We provided the US Department of the Treasury’s Do Not Pay (DNP)⁶ with MassHealth enrollment records for all 7,234 members who received ADH during the audit period. These records included the members’ full names, dates of birth, Social Security numbers or tax identification numbers, street addresses, and cities and states of residence. DNP matched names that were exactly the same and names that were similar to each other and then determined a level of confidence that the MassHealth member was the same as the person listed within one or more of the death data sources below. DNP also determined a level of confidence that the MassHealth member was truly deceased. The data sources used by DNP included the following:

• DNP Portal Adjudication data, which consists of data regarding whether a payment is proper, improper, or under review and provides comments associated with the determination;
• the Social Security Administration’s Public Death Master File;
• the American InfoSource⁷ Commercial Obituary Search, which contains obituary data from funeral homes, news sources, and probate records;
• the American InfoSource Commercial Probate Search;
• the US Department of Defense’s public death data;
• the US Department of State’s public death data; and
• the National Association for Public Health Statistics and Information Systems’ Electronic Verification of Vital Events: Fact of Death database.

DNP produced match results for 491 members out of the 7,234 members who received ADH during the audit period using the death data sources above. We queried MMIS for all Medicaid-covered claims associated with these 491 members who were flagged by DNP. We then filtered the data to identify 35 members with claims paid by MassHealth where services were rendered after the date of death found by DNP. We then reviewed obituary records that we obtained through internet searches for 31 out of the 35 members to verify that these members were deceased.

Based on the result of our testing, we determined that MassHealth did not ensure that it did not pay for ADH provided to members after their dates of death, in accordance with 130 CMR 450.235. See Finding 3 for more information.

Data Reliability Assessment

To test the reliability of the claim data obtained from MMIS, we relied on the work performed by OSA in a separate project, completed in 2023, that tested certain information system controls in MMIS. As part of that work, OSA reviewed existing information, tested selected system controls, and interviewed knowledgeable MassHealth officials about the data. Additionally, as part of our current audit, we performed validity and integrity tests on all ADH claim data to identify any of the following:

• duplicate member identification numbers;
• blank fields;
• duplicate records;
• values outside of a designated range (e.g., negative paid amounts);
• dates outside of the audit period;
• gaps in sequential data (e.g., missing dates, weeks, or months); and
• data validity errors (specifically, character fields that contained invalid printable characters and date and time fields that contained invalid dates or times).

Additionally, we selected 20 claims from the ADH claim data and vouched⁸ to the hardcopy patient records. We also selected 20 hardcopy patient records and traced them to the ADH claim data.

Based on the results of the data reliability assessment procedures described above, we determined that the information obtained was sufficiently reliable for the purposes of our audit.

1.   Auditors use statistical sampling to select items for audit testing when a population is large and contains similar items. Auditors generally use a statistical software program to choose a random sample when sampling is used. The results of testing using statistical sampling, unlike those from judgmental sampling, can usually be used to make conclusions or projections about entire populations.

2.    Confidence level is a mathematically based measure of the auditor’s assurance that the sample results (statistic) are representative of the population (parameter), expressed as a percentage.

3.    Expected error rate is the number of errors that are expected in the population, expressed as a percentage. It is based on the auditor’s knowledge of factors such as prior year results, the understanding of controls gained in planning, or a probe sample.

4.    Desired precision range is the range of likely values within which the true population value should lie; also called confidence interval. For example, if the interval is 90%, the auditor will set an upper confidence limit and a lower confidence where 90% of transactions fall within those limits.

5.    Modifier codes provide MassHealth with additional information about medical services, such as a change to the level of service.

6.    DNP is a service provided by the US Department of the Treasury’s Bureau of Fiscal Service that is designed to detect and prevent improper payments. It is authorized by the Payment Integrity Information Act of 2019.

7.    American InfoSource is a private professional services and technology company that maintains a proprietary index of deceased individuals.

8.    Vouching is the inspection of supporting documentation to corroborate data.

Date published:	October 1, 2024