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FY 19 1st Quarter Summary by Unit

A unit-by-unit breakdown of identified fraud by the Bureau of Special Investigations in the first quarter of fiscal year 2019.

Table of Contents

Central Processing Unit

The Central Processing Unit (CPU) received 1,652 new referrals for investigation in the 1st quarter of fiscal year 2019 (FY19) from the following sources:

Source

Number of Referrals

Percentage of Total

Department of Transitional Assistance (DTA)

1,177

71.2%

MassHealth

289

17.5%

BSI Hotline

170

10.3%

Department of Early Education and Care (EEC)

8

0.5%

Data Analytics Unit (DAU)

5

0.3%

US Attorney’s Office Public Assistance Task Force

3

0.2%

 

The following public assistance programs were the primary basis for potential fraud in the 1,652 new referrals:

Type

Number of Cases

Percentage of Total

Supplemental Nutrition Assistance Program (SNAP)

543

32.9%

Transitional Aid to Families with Dependent Children (TAFDC)

425

25.7%

MassHealth

352

21.3%

Emergency Aid to the Elderly, Disabled, and Children (EAEDC)

254

15.4%

Classification to Be Determined

67

4.1%

Other

11

0.7%

 

CPU team members processed, analyzed, and reviewed 1,633 cases. CPU identified 285 referrals as potential Intentional Program Violation cases, where BSI determined that a fraud claim had merit but returned the case to DTA for further action based on our evidence. Additionally, CPU closed 981 cases administratively with no fraud determined after completing a preliminary investigation. CPU designated the remaining 367 cases for assignment to either the MassHealth Unit or the DTA Unit. Lastly, CPU team members completed 80 DTA investigations, identifying fraud in 71 cases.

MassHealth Unit

During the 1st quarter of FY19, there were 103 new cases assigned to BSI’s MassHealth Unit. The unit completed 185 investigations and identified $784,561.98 in fraud; 174 were MassHealth cases with $586,787.40 in identified fraud and the remaining 11 were DTA/EEC cases with $197,774.58 in identified fraud. Of the 185 completed cases, 140 had a financial amount attached to them, while the remaining 45 cases resulted in a finding of no fraud or were closed administratively.

The MassHealth Unit’s collaboration with BSI’s DAU continues to contribute to the success of investigations into out-of-state residents receiving MassHealth benefits. The DAU’s success at uncovering MassHealth recipients residing out of state has increased the number of completed cases and identified fraud totals.

Department of Transitional Assistance Unit

For the 1st quarter of FY19, the DTA Unit, which investigates public assistance fraud involving DTA and EEC benefits, completed 185 cases and identified fraud totaling $1,607,623.46. The SNAP (food stamp) program had $1,045,592.99 in identified fraud, while the TAFDC cash assistance program had $311,788.95. Additionally, the EEC program had $163,953.29 in identified fraud and the EAEDC program had $86,288.23.

The DTA Unit continued its involvement with the federal Public Assistance Task Force.  In addition, the DTA Unit completed 18 civil recoupments, totaling $472,911.98 in identified fraud monies to be repaid to the Commonwealth.

Data Analytics Unit

During the 1st quarter of FY19, the DAU continued its efforts to uncover suspicious MassHealth provider activity. In some cases, these efforts supported open federal and state investigations. The DAU generated 105 referrals that were investigated by the MassHealth Unit and identified fraud in 103 of those referrals.

The majority of the DAU’s 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.

The DAU identified and referred several instances of improper billing related to dermatology services and evaluation and management services provided within the Medicaid program to the Audit Operations Division for the Office of the State Auditor. These referrals detailed excessive or improper use of claim modifiers used in conjunction with dermatologist evaluation, and management services in violation of MassHealth’s Code of Massachusetts Regulations.

Date published: December 19, 2018
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