Overview
The Commonwealth annually awards contracts totaling more than $3 billion to human-service providers, and the Office of the State Auditor (OSA) has an ongoing program of conducting audits of these providers. Since March 15, 2017, OSA’s Division of Contract Audits has issued audit reports on four human-service providers certified by MassHealth to provide group adult foster care (GAFC) services to its members. Although these audits were not conducted by the OSA Medicaid Unit, they identified a significant issue that involved Medicaid funds. Specifically, in these four reports, OSA disclosed as an “Other Matter”—an issue outside the scope of these audits, but substantial enough to be disclosed in the reports—that MassHealth had allowed the four providers to bill a cumulative total of more than $12 million for unallowable adult foster care (AFC). OSA determined these payments to be duplicative because these human-service providers provided AFC in-home care on days when the patients also received skilled nursing services. This is contrary to the GAFC guidelines and MassHealth regulations. The table below lists the four providers and the amounts our audits questioned as duplicative for the period July 1, 2011 through June 30, 2016.
|
Audit Number |
Human-Service Provider |
Questioned Amount |
|---|---|---|
|
Report No. 2016-4596-3C |
Medical Community Services, Inc. |
$1,434,256 |
|
Report No. 2016-4593-3C |
Community Connection Healthcare LLC |
1,814,810 |
|
Report No. 2016-4598-3C |
SafetyNet Solutions Inc. |
1,848,082 |
|
Report No. 2016-4595-3C |
Nizhoni Community Care LLC |
7,821,600 |
|
Total |
|
$12,918,748 |
OSA recommended that these four human-service providers collaborate with MassHealth to prevent duplicative payments for duplicative member services.
In these four audits, we also found that MassHealth may be able to realize significant savings by changing how it administers medications to GAFC members. Currently, when a GAFC member cannot manage his/her own medications, the GAFC provider notifies the member’s physician, who writes a referral for medication management and sends it to the GAFC provider. The GAFC provider typically contracts with a visiting nurse association to provide the needed services and then bills MassHealth directly for the services. GAFC providers use registered nurses (RNs) to manage medication because the home health agencies they use to provide services under the Group Adult Foster Care Program are not qualified to manage medication according to MassHealth regulations. However, medication could be managed by certified nursing assistants (CNAs) who are certified in medication management.
We believe there appears to be an opportunity for significant savings if MassHealth, rather than paying directly for skilled nursing from RNs, directs GAFC providers to use CNAs who are certified in medication.
| Date published: | March 15, 2018 |
|---|