FY 18 4th Quarter Summary by Unit

A unit-by-unit breakdown of identified fraud by the Bureau of Special Investigations in the fourth quarter of fiscal year 2018.

Central Processing Unit

The Central Processing Unit (CPU) received 2,078 new referrals for processing and investigation in the 4^th quarter of fiscal year 2018 (FY18) from the following sources:

 

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Source	Number of Referrals	Percentage of Total
Department of Transitional Assistance (DTA)	1,354	65.2%
MassHealth	293	14.1%
BSI’s Data Analytics Unit (DAU)	239	11.5%
Hotline	150	7.2%
US Attorney’s Office Public Assistance Task Force	23	1.1%
Department of Early Education and Care (EEC)	19	0.9%

 

 The primary basis for the potential fraud broken down by program type for the 2,078 new referrals is as follows:

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Type	Number of Cases	Percentage of Total
Supplemental Nutrition Assistance Program (SNAP)	650	31.3%
MassHealth	624	30.0%
Transitional Aid to Families with Dependent Children (TAFDC)	507	24.4%
Emergency Aid to the Elderly, Disabled, and Children (EAEDC)	259	12.5%
Other	22	1.0%
Classification to Be Determined	16	0.8%

 In addition to taking in referrals, CPU’s three-person staff processed, analyzed, and reviewed 2,080 cases in the 4^th quarter of FY18. The unit identified 336 (16.1%) as potential Intentional Program Violation cases, where BSI determined that a fraud claim had merit but did not warrant the further deployment of BSI’s resources. BSI returned these cases to DTA for further action based on our evidence. Additionally, CPU closed 1,050 cases administratively (50.5%) with a finding of no fraud after completing a preliminary investigation. CPU recommended the remaining 694 cases (33.4%) for assignment to either BSI’s DTA or MassHealth Units.

MassHealth Unit

During the 4^th quarter of FY18, there were 218 new cases assigned to the MassHealth Unit, including 10 new DTA/EEC cases. The unit completed 141 investigations and identified $887,161.94² in fraud in 77 cases. The remaining 64 cases resulted in findings of no fraud or were closed administratively.

The MassHealth Unit’s fraud examiners also investigated DTA/EEC cases,³ completing eight investigations and identifying fraud totaling $36,377.91 in five cases.

The unit filed two criminal complaints: one in Lowell District Court and the other in Hingham District Court.

The unit continues to meet monthly with MassHealth management and is in frequent contact with its stakeholders within MassHealth, including the Office of Compliance and Program Integrity, the Executive Office of Elder Affairs, the Estate Recovery Unit, and fiscal intermediaries, as well as with the Attorney General’s Office. During this quarter, the unit’s Assistant Director and a senior fraud examiner attended a presentation by MassHealth’s Office of Compliance and Program Integrity regarding its new procedures for calculating fraudulent overpayments and discussed how the agencies could assist each other in streamlining and making the process of obtaining calculations easier and more efficient for both units.

Department of Transitional Assistance Unit

For the 4^th quarter of FY18, the DTA Unit, which investigates public assistance fraud involving DTA and EEC benefits, identified $1,512,097.91 in fraud. The breakdown of identified fraud by public assistance benefit program was $898,536.48 for SNAP; $301,401.93 for EEC; $235,324.87 for TAFDC; and $76,824.63 for EAEDC.

During this quarter, the DTA Unit settled 23 cases via civil recovery. In these cases, the unit executed agreements that disqualified subjects from receiving future benefits and repayment agreements totaling $541,896.44 to be paid back to the Commonwealth. Subjects send both initial and future payments directly to DTA and/or EEC.

The DTA Unit filed criminal complaints against five defendants in various courts throughout the Commonwealth, including Boston Municipal Court, Brockton District Court, Holyoke District Court, and Worcester District Court.

Data Analytics Unit

For the 4^th quarter of FY18, the MassHealth and DTA Units completed four cases based on referrals generated by DAU and identified fraud in all four of those cases. The referrals identified fraud in connection with personal care attendants (PCAs) falsely submitting time sheets for services allegedly provided to members residing in long-term care facilities; MassHealth prohibits PCA services for members who reside in long-term care facilities.

DAU also closed two joint investigations involving home health agencies, totaling $696,305.44 in identified fraud. The investigations targeted impermissible billing practices identified in connection with a home health agency task force that comprised BSI, the Office of the Massachusetts Attorney General, the US Department of Health and Human Services’ Office of the Inspector General, and the Federal Bureau of Investigation.

2. This figure includes referrals from MassHealth and BSI’s DAU.

3. These cases represent cases with collaboration with the DTA/EEC Unit and/or cases with multiple allegations of fraud regarding MassHealth and/or DTA/EEC benefits.

Date published:	October 16, 2018