Audit of the Office of Medicaid (MassHealth)—Review of Transportation Services Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Office of Medicaid (MassHealth)—Review of Transportation Services.

Overview

In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of certain activities of MassHealth for the period July 1, 2020 through June 30, 2023.

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
Did MassHealth’s nonemergency transportation broker process provide equal opportunity to contracted providers throughout the Commonwealth?	Yes
Did MassHealth determine that nonemergency transportation was properly authorized and documented in accordance with Sections 407.421(D) and 450.205(A) of Title 130 of the Code of Massachusetts Regulations (CMR)?	Not always; see Findings 1 and 2
Did MassHealth ensure that Criminal Offender Record Information (CORI) checks were consistently performed and documented for transportation drivers and attendants in accordance with 130 CMR 407.405(B)?	Yes

To accomplish our audit objectives, we gained an understanding of the internal control environment relevant to our objectives by reviewing MassHealth’s applicable policies, procedures, and internal control plan, and by conducting interviews with MassHealth officials and officials from the two brokers, the Montachusett Regional Transit Authority (MART) and the Greater Attleboro Taunton Regional Transit Authority (GATRA). In addition, to obtain sufficient, appropriate evidence to address our audit objectives, we performed the procedures described below.

Sample Strategy

We obtained data from the Medicaid Management Information System (MMIS)² regarding all claims paid for nonemergency transportation for the audit period. We performed data analytics on the data to only include nonemergency transportation claims for fee-for-service members who did not have a qualifying medical service on the same day. We then selected a random, statistical³ sample of 75 claims, which accounted for 57 unique transportation providers (totaling $2,428) from the population of 8,733,671 claims (totaling $283,336,169) for services. To select the sample, we used a 90% confidence level,⁴ a 50% expected error rate,⁵ and a 20% desired precision range.⁶

For our statistical sample, we projected the error related to claims that did not have a qualifying service and a trip sheet⁷ to the entire population in order to estimate the potential overpayment.

Review of Broker Process

To determine whether MassHealth’s nonemergency transportation broker process provides equal opportunity to contracted providers, we met with officials at both MART and GATRA to gain an understanding of how transportation providers are selected for trips. We requested a list of rates for all transportation providers who were contracted with the brokers (MART and GATRA) during the audit period and Provider Request for Transportation (PT-1) forms for each claim in our sample. We calculated the rate for each claim by determining the miles for each trip from the PT-1 form and multiplying this by the provider’s rate and fees. Next, we determined whether the transportation provider in our sample offered the lowest cost; if it did not, then we contacted the brokers for a reason why some of the providers were chosen when they did not offer the lowest cost.

Based on the results of our testing, we determined that MassHealth’s nonemergency transportation broker process provides equal opportunity to contracted providers throughout the Commonwealth. 

Review of Authorized Transportation and Documentation

To determine whether MassHealth’s nonemergency transportation claims were properly authorized and documented, we requested all PT-1 forms for the claims in our sample from the brokers (MART and GATRA) and gained an understanding of how the broker process works. In addition, we attempted to contact each transportation provider in our sample to gain an understanding of how the broker process works—from its perspective—and requested trip sheets as evidence that each trip occurred from both the broker and the transportation providers.

Based on the results of our testing, all trips were properly authorized; however, not all trips were properly documented. See Findings 1 and 2 for more details. 

Review of Qualified Drivers and Attendants

To determine whether MassHealth ensured that all nonemergency transportation services were provided by qualified drivers, we requested evidence of CORI checks of all drivers and attendants who facilitated a ride within our sample from the brokers (MART and GATRA).

Based on our testing, we determined that CORI checks were completed on all drivers and attendants, in accordance with MassHealth regulations. 

Data Reliability Assessment

We obtained claim data for transportation claims from MMIS. To determine the reliability of the data, we relied on the work performed by the Office of the State Auditor in a separate project, completed in 2023, that tested certain information system controls in MMIS. As part of that work, the Office of the State Auditor reviewed existing information, tested selected system controls, and interviewed knowledgeable MassHealth officials about the data. As part of our current audit, we performed validity and integrity tests on the transportation claim data, including (1) testing for duplicate records, (2) testing for blank fields, (3) testing for values outside of a designated range (e.g., negative paid amounts), and (4) testing for dates outside the audit period. Additionally, we selected 25 claims from the transportation claim data and vouched⁸ these to the hardcopy PT-1 forms and driver logs.

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

2.    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.

3.    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.

4.    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.

5.    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.

6.    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.

7.    According to the Reports and Billing section—Section 8.2(B)(1)—of the contracts MassHealth had with its brokers, “[a] daily trip sheet [identifies] each scheduled One-Way Trip with a check box indicating if the Consumer was transported, canceled or was no-show and signed by the driver (and by program staff, if required). Trip sheets must include the driver’s name and vehicle license plate number listed, the date, the Consumer’s name, pickup location, time of pickup, drop off location, and time of drop off.”

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

Date published:	May 8, 2025