Completed Audits (March 15, 2020 through March 12, 2021)

An overview of the audits conducted by the Medicaid Audit Unit over the past year, and their findings.

During this reporting period, the Office of the State Auditor (OSA) released 10 audit reports on selected Medicaid service providers’ compliance with state and federal laws, regulations, and other applicable authoritative guidance. These reports identified $1,155,719 in improper payments to eldercare organizations providing unauthorized services, as well as potential cost savings totaling $1,060,470 in the administration of the Adult Foster Care (AFC) Program. The reports also made a number of recommendations to strengthen internal controls and oversight in MassHealth’s program administration. The following is a summary of our Medicaid audit work.

1. Office of Medicaid (MassHealth)—Review of Claims Paid for Services by Old Colony Elder Services

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Audit Number	2020-1374-3M2B
Audit Period	January 1, 2016 through December 31, 2018
Issue Date	June 29, 2020
Number of Findings	1
Number of Recommendations	1
Total Improper Billings	N/A—Operational Issues Identified
MassHealth Recouping Payments	N/A

Background/Reason for Audit

OSA’s Bureau of Special Investigations (BSI) had identified what appeared to be numerous instances of simultaneous billings of AFC and home care services, contrary to MassHealth regulations. Old Colony Elder Services (OCES) was one of the agencies with the most instances of these potentially improper billings.

Summary of Finding and Recommendation

OSA reported one finding in this audit:

1. OCES did not submit required annual prior authorizations (determinations of MassHealth members’ clinical eligibility to receive AFC) for AFC it provided to MassHealth members. Specifically, for 40 of 208 MassHealth members who received AFC, OCES did not submit 55 (58%) of 95 required annual prior authorizations.

Our recommendation to OCES to address this problem was as follows:

1. OCES should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.

The Executive Office of Health and Human Services’ Comments on Behalf of MassHealth: Implementation of Recommendation

On MassHealth’s behalf, the Executive Office of Health and Human Services (EOHHS) responded,

EOHHS agrees with the OSA that OCES should submit annual prior authorizations. EOHHS plans to conduct an audit of OCES to determine compliance with the prior authorization requirement for MassHealth-covered AFC.  

2. Office of Medicaid—Review of Claims Paid for Services by Somerville-Cambridge Elder Services

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Audit Number	2020-1374-3M2C
Audit Period	January 1, 2016 through December 31, 2018
Issue Date	June 29, 2020
Number of Findings	1
Number of Recommendations	1
Total Improper Billings	N/A—Operational Issues Identified
MassHealth Recouping Payments	N/A

Background/Reason for Audit

BSI had identified what appeared to be numerous instances of simultaneous billings of AFC and home care services, contrary to MassHealth regulations. Somerville-Cambridge Elder Services (SCES) was one of the agencies with the most instances of these potentially improper billings.

Summary of Finding and Recommendation

OSA reported one finding in this audit:

1. SCES did not submit required annual prior authorizations for AFC it provided to MassHealth members. Specifically, for 45 of 287 MassHealth members who received AFC, SCES did not submit 48 (53%) of 90 required annual prior authorizations.

Our recommendation to SCES to address this problem was as follows:

1. SCES should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.

EOHHS’s Comments on Behalf of MassHealth: Implementation of Recommendation

EOHHS responded,

EOHHS agrees with the OSA that SCES should submit annual prior authorizations. EOHHS plans to conduct an audit of SCES to determine compliance with the prior authorization requirement for MassHealth-covered AFC.

3. Office of Medicaid (MassHealth)—Review of Claims Paid for Services by Boston Senior Home Care

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Audit Number	2020-1374-3M2E
Audit Period	January 1, 2016 through December 31, 2018
Issue Date	July 20, 2020
Number of Findings	1
Number of Recommendations	1
Total Improper Billings	N/A—Operational Issues Identified
MassHealth Recouping Payments	N/A

Background/Reason for Audit

BSI had identified what appeared to be numerous instances of simultaneous billings of AFC and home care services, contrary to MassHealth regulations. Boston Senior Home Care (BSHC) was one of the agencies with the most instances of these potentially improper billings.

Summary of Finding and Recommendation

OSA reported one finding in this audit:

1. BSHC did not submit required annual prior authorizations 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.

Our recommendation to BSHC to address this problem was as follows:

1. BSHC should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.

EOHHS’s Comments on Behalf of MassHealth: Implementation of Recommendation

EOHHS 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.

4. Office of Medicaid (MassHealth)—Review of Claims Paid for Services by WestMass ElderCare, Inc.

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Audit Number	2020-1374-3M2E
Audit Period	January 1, 2016 through December 31, 2018
Issue Date	July 20, 2020
Number of Findings	1
Number of Recommendations	1
Total Improper Billings	N/A—Operational Issues Identified
MassHealth Recouping Payments	N/A

Reason for Audit

BSI identified what appeared to be numerous instances of simultaneous billings of AFC and home care services, contrary to MassHealth regulations. WestMass ElderCare, Inc. (WMEC) was one of the agencies with the most instances of these potentially improper billings.

Summary of Finding and Recommendation

OSA reported one finding in this audit:

1. WMEC did not submit required annual prior authorizations for AFC it provided to MassHealth members. Specifically, for 45 of 392 MassHealth members who received AFC, WMEC did not submit 63 (57%) of 110 required annual prior authorizations.

Our recommendation to WMEC to address this problem was as follows:

1. WMEC should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.

EOHHS’s Comments on Behalf of MassHealth: Implementation of Recommendation

EOHHS responded,

EOHHS agrees with the OSA that WMEC should submit annual prior authorizations. EOHHS plans to conduct an audit of WMEC to determine compliance with the prior authorization requirement for MassHealth-covered AFC.

5. Office of Medicaid—Review of Claims Paid for Services by Beyond Healthcare Agency, LLC

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Audit Number	2020-1374-3M2E
Audit Period	January 1, 2016 through December 31, 2018
Issue Date	July 20, 2020
Number of Findings	1
Number of Recommendations	2
Total Improper Billings	$887,225
MassHealth Recouping Payments	Yes

Reason for Audit

BSI identified what appeared to be numerous instances of simultaneous billings of AFC and home care services, contrary to MassHealth regulations. Beyond Healthcare Agency, LLC was one of the agencies with the most instances of these potentially improper billings.

Summary of Finding and Recommendations

OSA reported one finding in this audit:

1. Beyond Healthcare Agency 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.  

Our recommendations to Beyond Healthcare Agency to address this problem were as follows:

1. Beyond Healthcare Agency should ensure that it does not bill MassHealth for unallowable GAFC services.
2. Beyond Healthcare Agency should work with MassHealth to determine the amount Beyond Healthcare Agency was overpaid for GAFC, and MassHealth should recoup that amount.

EOHHS’s Comments on Behalf of MassHealth: Implementation of Recommendations

EOHHS 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.

6. Office of Medicaid (MassHealth)—Review of Claims Paid for Services by City Home Care, LLC

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Audit Number	2020-1374-3M2E
Audit Period	January 1, 2016 through December 31, 2018
Issue Date	July 20, 2020
Number of Findings	1
Number of Recommendations	2
Total Improper Billings	$268,494
MassHealth Recouping Payments	Yes

Reason for Audit

BSI identified what appeared to be numerous instances of simultaneous billings of AFC and home care services, contrary to MassHealth regulations. City Home Care, LLC was one of the agencies that had the most instances of these potentially improper billings.

Summary of Finding and Recommendations

OSA reported one finding in this audit:

1. City Home Care billed, and received payments for, 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.

Our recommendations to City Home Care to address this problem were as follows:

1. City Home Care should ensure that it does not bill MassHealth for unallowable GAFC services.
2. City Home Care should work with MassHealth to determine the amount City Home Care was overpaid for GAFC, and MassHealth should recoup that amount.

EOHHS’s Comments on Behalf of MassHealth: Implementation of Recommendations

EOHHS 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.

7. Office of Medicaid—A Review of MassHealth Member Eligibility at the Tewksbury Enrollment Center

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Audit Number	2018-1374-3M6
Audit Period	January 1, 2017 through December 31, 2018
Issue Date	October 9, 2020
Number of Findings	0
Number of Recommendations	0
Total Improper Billings	N/A
MassHealth Recouping Payments	N/A

Reason for Audit

In its 2016 Comprehensive Annual Financial Report (CAFR) on the Commonwealth, the audit firm KPMG found issues related to MassHealth’s eligibility offices:

1. Finding 2016-011: KPMG found a problem where too many users of the MA-21 system had administrative access allowing them to access more functionality and bypass controls. 
2. Finding 2016-041: KPMG found that MassHealth did not investigate exception reports for members who did not appear to be eligible or were no longer eligible (e.g., those whose dates of death were before the eligibility start and end dates).
3. Finding 2016-048: KPMG found that enrollment center managers did not use exception reports to manage eligibility processes and ensure that employees were redirected.

8. Office of Medicaid—A Review of MassHealth Member Eligibility at the Chelsea Enrollment Center

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Audit Number	2018-1374-3M7
Audit Period	January 1, 2017 through December 31, 2018
Issue Date	October 9, 2020
Number of Findings	0
Number of Recommendations	0
Total Improper Billings	N/A
MassHealth Recouping Payments	N/A

Reason for Audit

In its 2016 CAFR on the Commonwealth, KPMG found issues related to MassHealth’s eligibility offices:

1. Finding 2016-011: KPMG found a problem where too many users of MA-21 had administrative access allowing them to access more functionality and bypass controls.
2. Finding 2016-041: KPMG found that MassHealth did not investigate exception reports for members who did not appear to be eligible or were no longer eligible (e.g., those whose dates of death were before the eligibility start and end dates).
3. Finding 2016-048: KPMG found that enrollment center managers did not use exception reports to manage eligibility processes and ensure that staff members were redirected.

9. Office of Medicaid—A Review of MassHealth Member Eligibility at the Taunton Enrollment Center

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Audit Number	2018-1374-3M8
Audit Period	January 1, 2017 through December 31, 2018
Issue Date	October 9, 2020
Number of Findings	0
Number of Recommendations	0
Total Improper Billings	N/A
MassHealth Recouping Payments	N/A

Reason for Audit

In its 2016 CAFR on the Commonwealth, KPMG found issues related to MassHealth’s eligibility offices:

1. Finding 2016-011: KPMG found a problem where too many users of MA-21 had administrative access allowing them to access more functionality and bypass controls.
2. Finding 2016-041: KPMG found that MassHealth did not investigate exception reports for members who did not appear to be eligible or were no longer eligible (e.g., those whose dates of death were before the eligibility start and end dates).
3. Finding 2016-048: KPMG found that enrollment center managers did not use exception reports to manage eligibility processes and ensure that staff members were redirected.

10. Office of Medicaid—Review of MassHealth Member Eligibility at the Springfield Enrollment Center

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Audit Number	2018-1374-3M9
Audit Period	January 1, 2017 through December 31, 2018
Issue Date	October 9, 2020
Number of Findings	0
Number of Recommendations	0
Total Improper Billings	N/A
MassHealth Recouping Payments	N/A

Reason for Audit

In its 2016 CAFR on the Commonwealth, KPMG found issues related to MassHealth’s eligibility offices:

1. Finding 2016-011: KPMG found a problem where too many users of MA-21 had administrative access allowing them to access more functionality and bypass controls. 
2. Finding 2016-041: KPMG found that MassHealth did not investigate exception reports for members who did not appear to be eligible or were no longer eligible (e.g., those whose dates of death were before the eligibility start and end dates).
3. Finding 2016-048: KPMG found that enrollment center managers did not use exception reports to manage eligibility processes and ensure that staff members were redirected.

Date published:	March 11, 2021