Overview
During our audit period, Boston Senior Home Care (BSHC) did not submit required annual prior authorizations (determinations of MassHealth members’ clinical eligibility to receive adult foster care, or AFC) for AFC it provided to MassHealth members. Specifically, for 40 of 107 MassHealth members who received AFC, BSHC did not submit 46 (53%) of 86 required annual prior authorizations. As a result, MassHealth paid for AFC that it did not authorize.
Authoritative Guidance
According to Section 408.417(B) of Title 130 of the Code of Massachusetts Regulations, prior authorizations are required for AFC before the first date of service and annually thereafter.
Reasons for Issue
BSHC officials told us MassHealth did not have a process for providers to submit annual prior authorizations, although MassHealth authorizations were required as of May 5, 2017. MassHealth officials told us the agency could not process annual prior authorizations online until April 16, 2019. They stated that this was because of a two-year delay with the new vendor that was responsible for implementing MassHealth’s Long-Term Services and Supports Provider Portal, an online tool for submitting prior authorizations to MassHealth for AFC.
Recommendation
BSHC should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.
Auditee’s Response
As noted in the [Office of the State Auditor, or OSA] report, MassHealth did not have a process in place for providers to submit annual prior authorizations online until April 16, 2019. Therefore, BSHC was unable to submit annual prior authorizations to MassHealth for the period May 5, 2017 through April 16, 2019. Since the [Long-Term Services and Supports] Provider Portal was implemented on April 16, 2019, BSHC has been submitting prior authorizations as required by AFC regulations. BSHC will continue to maintain compliance with the requirement to submit annual prior authorizations in accordance with AFC regulations.
MassHealth’s Response
The Executive Office of Health and Human Services (EOHHS, MassHealth’s oversight agency) and MassHealth responded,
EOHHS agrees with the OSA that BSHC should submit annual prior authorizations. EOHHS plans to conduct an audit of BSHC to determine compliance with the prior authorization requirement for MassHealth-covered AFC.
| Date published: | July 20, 2020 |
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