Overview
During the audit period, Beyond Healthcare Agency, LLC billed, and received payments for, group adult foster care (GAFC) services that appear to be unallowable. These services included home health services, such as personal care and assistance with hygiene, bathing, dressing, walking, and medication, that Beyond Healthcare Agency had already provided to members in their homes on the same day under the Home Health Services Program also funded by MassHealth. As a result, Beyond Healthcare Agency could have been overpaid as much as $887,225 for 1,348 GAFC claims.
Authoritative Guidance
MassHealth does not have regulations governing the Group Adult Foster Care Program and relies on a set of sub-regulatory guidelines it has promulgated to communicate program standards and requirements to GAFC providers. The Group Adult Foster Care Guidelines require GAFC providers to ensure “that all regulations and guidelines of [MassHealth] for the Adult Foster Care Program are met” for the Group Adult Foster Care Program as well.
For adult foster care, MassHealth’s Adult Foster Care Manual, Section 408.437 of Title 130 of the Code of Massachusetts Regulations, states, “The MassHealth agency does not pay an [adult foster care] provider when . . . the member receives home health aide services provided by a home health agency.” (In the cases in question, Beyond Healthcare Agency was classified as both a GAFC provider and a home health agency.)
In addition, according to Section 13(H) of MassHealth’s sub-regulatory Group Adult Foster Care Guidelines, home health services are disallowed while a member is receiving GAFC:
The participant is not eligible to receive home health aide services while participating in foster care, unless this service is part of [an] approved respite plan.
Reasons for Issue
Beyond Healthcare Agency’s senior management stated that because they had obtained prior authorizations from MassHealth for members who received GAFC, they believed that the services in question were authorized. Although prior authorizations had been given for the members to receive GAFC, billing for GAFC must be in accordance with MassHealth’s sub-regulatory guidelines, which only allow GAFC members with approved respite care plans to receive home health services. There was no indication that any of the services in question were for respite care.
Recommendations
- Beyond Healthcare Agency should ensure that it does not bill MassHealth for unallowable GAFC services.
- Beyond Healthcare Agency should work with MassHealth to determine the amount Beyond Healthcare Agency was overpaid for GAFC, and MassHealth should recoup that amount.
Auditee’s Response
With its response to this report, Beyond Healthcare Agency provided the Office of the State Auditor (OSA) with copies of emails between itself and MassHealth. In these emails, at Beyond Healthcare Agency’s request, MassHealth outlined the process for prior authorization for a member who was receiving GAFC and, according to Beyond Healthcare Agency, needed 8 hours of home health services. In its emails, Beyond Health Agency also pointed out to MassHealth that there is currently no GAFC training available to providers.
In addition to these emails, Beyond Healthcare Agency provided OSA with the following comments:
Beyond Healthcare Agency has ceased all operation of GAFC as of October 2019. One of the reasons for closing the program was that it did not generate any revenue, nor did it ever turn a profit.
We like to exclaim our sincerest frustration as we have not only communicated verbally to representatives of MassHealth, but in writing, the request of process and approval for allowing our GAFC participants to also receive Home Health Care. We feel that we are able to demonstrate our honest interpretation of the guidelines provided below and attached, in our detailed communication with representatives of MassHealth. Furthermore, in our communication you will see that we asked for training.
Not only did our agency receive prior authorization from MassHealth in every instance, the GAFC Regulations (from 1991) state the following:
Section 4 Provider Responsibility—that the Provider shall notify the department when a recipient requires “respite,” i.e. home health, [adult day health,] or placement out of their home.
Section 13B Respite Care—that respite care may be provided if the recipient meets other eligibility criteria for those services.
Section 13H Other Health and Social Services—that participation in this Program will not preclude the participant from receiving any other needed health or social services, except for those specifically included in the adult foster care agreement. The participant is not eligible to receive home health aide services while participating in foster care, unless this service is part of the approved respite plan.
Not only did we notify the department, but we also have approvals of these services. . . .
In conclusion, the guidelines from 1991 ask that we contact the department when a member needs home health services and not only did we contact the department, we followed their instructions getting the required authorization. We also pointed out the unclear regulations, asked if there was anything new in the past 10 years, and asked for provider training to which we were told, that none existed. . . .
Furthermore, regardless of our liabilities, $40.33 per day GAFC reimbursement multiplied by 1,945 GAFC Claims equals $78,441.85, not one tenth of $887,225.
MassHealth Response
The Executive Office of Health and Human Services (MassHealth’s oversight agency) and MassHealth responded,
[The Executive Office of Health and Human Services] agrees with the OSA that Beyond Healthcare should ensure that it does not bill MassHealth for duplicative services. [The Executive Office of Health and Human Services] plans to conduct an audit of Beyond Healthcare to determine compliance with requirements to not bill for duplicative services.
Auditor’s Reply
As noted above, MassHealth regulations do not allow payment for GAFC for a member who also receives home health services unless the member is part of an approved respite plan. In its response, Beyond Healthcare Agency indicates that it obtained approval from MassHealth to provide both home health services and GAFC to the members in question. However, Beyond Healthcare Agency did not provide OSA with any documentation to substantiate that it had obtained such approval, nor did MassHealth indicate in its response to our report that it had provided any. Further, there was no documentation in Beyond Healthcare Agency’s records that indicated that any of the members in question received home health services as part of an approved respite plan, nor did Beyond Healthcare Agency’s billing for GAFC indicate that the claims were for respite care.
In its response, Beyond Healthcare Agency questions OSA’s calculation of the potential overpayment for GAFC. As noted in the “Audit Objectives, Scope, and Methodology” section of this report, OSA calculated this potential overpayment using the paid claim data in the Medicaid Management Information System. This is MassHealth’s system of record for all claims submitted by, and payments made to, MassHealth service providers, and OSA determined that the information therein was reliable for the purposes of our audit. It should be noted that each of the 1,348 claims we are questioning represents as many as 31 days of GAFC received by a MassHealth member. Therefore, the total overpayment cannot be calculated by multiplying 1,348 by the $40.33 daily rate of reimbursement per member. Based on this, we again recommend that Beyond Healthcare Agency work with MassHealth to determine the amount Beyond Healthcare Agency was overpaid for GAFC during the audit period.
| Date published: | September 21, 2020 |
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