Current Initiatives March 14, 2021 - March 1, 2022

A preview of audits currently in progress by the Medicaid Audit Unit.

Overview

During this reporting period, the Office of the State Auditor (OSA) began or continued work on four audits of MassHealth’s administration of the Medicaid program and of Medicaid service providers’ compliance with state and federal laws, regulations, and other authoritative guidance. These audits were selected based on our research and applied data analysis to identify areas of risk in the state’s Medicaid program. We anticipate that the audits will identify a significant number of improper payments as well as deficiencies in MassHealth’s administration of program services. When applicable, the audits will include recommendations to strengthen internal controls and oversight in MassHealth’s program administration. The following is a summary of our Medicaid audit work in process.

• OSA is working with the US Department of Health and Human Services and Office of Inspector General (Boston office) on a review of improperly paid capitation payments⁹ for MassHealth members with concurrent eligibility in another state for the period July 1, 2019 through June 30, 2021. We will determine whether MassHealth made capitation payments for Massachusetts Medicaid beneficiaries who lived and were enrolled in Medicaid in another state. As applicable, we will identify the reasons this occurred and make recommendations to resolve the problems.
• OSA will conduct a review of MassHealth’s telehealth services for the period July 1, 2019 through June 30, 2021. This audit will determine whether MassHealth ensures the program integrity of its telehealth services, in accordance with federal and state requirements, after the rapid implementation necessitated by the 2019 coronavirus.
• OSA will conduct a review of MassHealth’s Delivery System Reform Incentive Payment (DSRIP) Program for the period July 1, 2018 through December 31, 2020. This audit will determine whether MassHealth ensured that DSRIP funds allocated to its accountable care organizations were in accordance with applicable protocols.
• OSA will conduct a review of MassHealth’s continuity of operations plan (COOP) for the period January 1, 2020 through June 30, 2021. This audit will determine whether MassHealth’s COOP ensured that the more than 1.8 million members to whom MassHealth provides coverage receive continual coverage through emergencies.
• OSA will conduct a review of MassHealth claims submitted by Dr. Nicholas Franco for the period July 1, 2015 through December 31, 2020. This audit will determine whether dental services provided to MassHealth members were properly supported by documentation and allowable in accordance with certain MassHealth regulations.
• OSA will conduct a review of MassHealth claims submitted by Dr. Melissa Hamilton for the period July 1, 2015 through December 31, 2020. This audit will determine whether dental services provided to MassHealth members were properly supported by documentation and allowable in accordance with certain MassHealth regulations.

 

9. Capitation payments are set payments to a managed care organization (MCO) from MassHealth to provide healthcare for its members. These payments are paid monthly for each MassHealth member enrolled in the MCO.