Audit of the Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Foster Care and Group Adult Foster Care Objectives, Scope, and Methodology

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

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 our audit objective, indicating the question we intended our audit to answer, the conclusion we reached, and where the objective is discussed in the audit findings.

Objective	Conclusion
Did MassHealth monitor adult foster care (AFC) and group adult foster care (GAFC) providers to ensure that they complied with Section 408 of Title 130 of the Code of Massachusetts Regulations (CMR), 130 CMR 450, and MassHealth Adult Foster Care Bulletins 18 and 21?	No; see Findings 1, 2, and 3

To accomplish our audit objective, we gained an understanding of the aspects of the internal control environment relevant to our objective by reviewing applicable MassHealth policies and procedures and by conducting inquiries with MassHealth officials who are responsible for the oversight of AFC and GAFC programs. In addition, to obtain sufficient, appropriate evidence to address our audit objective, we performed the following procedures.

Sample Strategy

We obtained data from the Medicaid Management Information System (MMIS)⁴ of all the claims paid by MassHealth to AFC and GAFC providers for the audit period. We filtered these claims to include only AFC and GAFC service codes. We further filtered for claims that only contained the service code for telehealth services. This gave us a population of 310,831 claims, totaling $22,979,654, corresponding to 1,002 members.

We selected a random, statistical sample⁵ of 119 out of these 1,002 members using a 90% confidence level,⁶ a 50% expected error rate,⁷ and a 15% desired precision range.⁸

Next, to include members who did not receive AFC and GAFC services rendered through telehealth during the audit period, we filtered the AFC and GAFC claims from MMIS to exclude claims that contained the service code for telehealth services. This population contained 5,897 members who had 2,730,400 claims, totaling $190,782,589. We selected a random, statistical sample of 128 out of these 5,897 members from the 10 providers who were paid the most for AFC and GAFC services, using a 90% confidence level, a 50% expected error rate, and a 15% desired precision range.

For the 119 members in our telehealth sample and 128 members in our non-telehealth sample, we contacted the 5 telehealth AFC and GAFC and 10 non-telehealth AFC and GAFC providers related to the claims from these members to request supporting documentation for these members. The supporting documentation, which included care manager and nursing notes, prior authorizations, and caregiver / direct care aide logs,⁹ indicated whether AFC and GAFC services were being provided in accordance with MassHealth regulations during the audit period.

Based on the results of our testing, we determined that, during the audit period, MassHealth paid for AFC and GAFC caregiver / direct care aide services that were coded as telehealth services, even though the services were provided in person. See Finding 3 for more information.

Oversight Visits

For our telehealth and non-telehealth member samples, we inspected prior authorizations first to determine what level of service each member was authorized to receive. Next, we reviewed the care managers’ and registered nurses’ / licensed practical nurses’ notes from both our telehealth and non‑telehealth samples to determine whether they conducted and documented oversight visits at the regulated intervals.

Based on the results of our testing, we determined that, during the audit period, MassHealth did not ensure that required oversight visits by AFC and GAFC care managers and registered nurses / licensed practical nurses were conducted in accordance with 130 CMR 408. See Finding 1 for more information.

Caregiver/ Direct Care Aide Logs

For both our telehealth and non-telehealth member samples, we reviewed each claim associated with each member in our samples and inspected caregiver / direct care aide logs given to us by the AFC and GAFC providers. To determine whether these providers had supporting caregiver / direct care aide log documentation that corresponded with the billed service, we tested the following attributes:

• whether the provider received logs from caregivers / direct care aides;
• whether caregivers / direct care aides documented activity of daily living codes;
• whether caregivers’ / direct care aides’ initials were present on the log for each day;
• whether caregivers’ / direct care aides’ signatures were present on each log;
• whether care managers’ or registered nurses’ / licensed practical nurses’ signatures were present on each log;
• whether care managers or registered nurses / licensed practical nurses reviewed each log every 30 days; and
• whether the modifier codes¹⁰ included on the claim matched caregiver / direct care aide logs.

Based on the results of our testing, we determined that, during the audit period, MassHealth paid AFC and GAFC providers that did not have sufficient supporting caregiver / direct care aide log documentation. See Finding 2 for more information. In addition, although all of the claims in our telehealth sample were coded and billed as telehealth, we were able to determine through caregiver / direct care aide logs that some of these claims were incorrectly coded and billed as telehealth. 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 claim data from the audit period, including (1) testing for blank fields, (2) scanning for duplicate records, and (3) looking for dates outside of the audit period. We also selected a random sample of 20 claims from each of our telehealth and non-telehealth member populations, and traced the dates of service, member names, and procedure codes to MMIS.

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. 

4.    MMIS is the claim processing and data warehouse system that MassHealth uses. MMIS contains various types of information, such as healthcare information about services provided to MassHealth members and billing submission data. It is used for processing data, verifying eligibility, and running reports that identify medical treatments.

5.    Auditors use statistical sampling to select items for audit testing when a population is large and contains similar items. Auditors generally use a statistics software program to choose a random sample when statistical 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.

6.    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.

7.    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.

8.    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.

9.    Caregiver / direct care aide logs document the care delivered (e.g., assistance with eating, dressing, or housework) by a qualified AFC caregiver in accordance with each member’s written plan of care.

10.    Modifier codes provide MassHealth with additional information about medical services, such as when a member takes vacation and does not need services during that time.

Date published:	September 4, 2024