Overview
During the audit period, City Home Care, 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 City Home Care 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, City Home Care could have been overpaid as much as $268,494 for 1,231 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, City Home Care 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
City Home Care’s senior management stated that the agency’s previous owner had spoken with MassHealth’s Group Adult Foster Care Program manager, who had said there were no clear guidelines and therefore members could receive both GAFC and home health services on the same day.
In addition, City Home Care had been given prior authorizations for the members to receive GAFC; however, 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
- City Home Care should ensure that it does not bill MassHealth for unallowable GAFC services.
- City Home Care should work with MassHealth to determine the amount City Home Care was overpaid for GAFC, and MassHealth should recoup that amount.
Auditee’s Response
In review of the report summarizing the results of the audit we would like to provide you with additional information for your reconsideration in this matter. Sometime in 2015 the previous owner called [the] then GAFC Program Director . . . asking if both programs can be combined. The GAFC Program Director response was; “yes.” On November 19th of 2019, the agency sent an email to . . . the GAFC Program Director at that time to seek further clarification on the issues regarding the mixed messages regarding the provision of GAFC services and HHA services for a client. To this point we have not [been] provided any clearly written guidance but the clinical director of our GAFC program has provided close [monitoring] of all care in which GAFC and HHA services are being provided to assure we avoid duplication of services. We have [reviewed] client records again . . . and have found there is no duplication. Furthermore there are no black and white regulations stating otherwise.
We respectfully disagree that a repayment should be made on the basis that there are no clear guidelines in place and that as an agency providing said services, services have carefully [been] screened to assure that the GAFC services provided were not the same services that was or could have been provided by the other service program.
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 [Office of the State Auditor] that City Home Care 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 City Home Care 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, City Home Care indicates that it obtained approval from MassHealth to provide both home health services and GAFC to the members in question. However, City Home Care did not provide us 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 City Home Care’s records that indicated that any of the members in question received home health services as part of an approved respite plan, nor did City Home Care’s billing for GAFC indicate that the claims were for respite care.
Based on the issues we identified with City Home Care’s billing practices during this audit, we urge it to implement our recommendations and work with MassHealth to resolve this matter.
| Date published: | September 21, 2020 |
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