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FY 19 2nd Quarter Summary by Unit

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

Table of Contents

Central Processing Unit

Central Processing Unit

The Central Processing Unit (CPU) received 1,415 new referrals for investigation in the 2nd quarter of fiscal year 2019 (FY19) from the following sources:

 

Source

Number of Referrals

Percentage of Total*

Department of Transitional Assistance (DTA)

988

69.8%

MassHealth

295

20.8%

Hotline

113

8.0%

Task Force

12

0.8%

Department of Early Education and Care (EEC)

4

0.3%

Data Analytics Unit (DAU)

3

0.2%

*    Percentages do not total 100 due to rounding.

 

The primary sources of fraud in these 1,415 new referrals, based on the number of cases, are as follows:

Type

Number of Cases

Percentage of Total

Supplemental Nutrition Assistance Program (SNAP)

429

30.3%

Transitional Aid to Families with Dependent Children (TAFDC)

308

21.8%

MassHealth

300

21.2%

Classification to Be Determined

220

15.5%

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

153

10.8%

Other

5

0.4%

CPU processed, analyzed, and reviewed 1,367 cases. CPU identified 189 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 811 cases administratively with a finding of no fraud after completing a preliminary investigation. CPU designated the remaining 367 cases for assignment to either the MassHealth Unit or the DTA Unit. CPU team members also completed 66 DTA investigations, identifying fraud in 56 of those cases.

MassHealth Unit

During the 2nd quarter of FY19, there were 117 new cases assigned to the MassHealth Unit, which completed 163 investigations that were assigned in this and previous quarters and identified $629.944.082 in fraud in 116 cases. The remaining 47 cases resulted in findings of no fraud or were closed administratively.

The MassHealth Unit also completed 13 civil recovery cases, totaling $160,724.37.

The unit’s ongoing investigative efforts into MassHealth’s Personal Care Attendant (PCA) Program contributed to the filing of two criminal complaints during this quarter. The first case, in Pittsfield District Court, involved an individual who allegedly submitted timesheets for payment for providing personal care services while the consumer was an inpatient at a nursing facility. The total amount paid for services not rendered was $14,946.47. The second case, filed in Ayer District Court, involved an individual who allegedly submitted timesheets for payment for providing personal care services while married to the consumer. The individual allegedly used her maiden name as PCA, but acted as the consumer’s surrogate under her married name. The total amount paid for fraudulent services was $457,253.52, as she was also charged with receiving MassHealth benefits for a period when she underreported her employment.  

The MassHealth Unit continues to work closely with MassHealth management and meets monthly with MassHealth’s Program Integrity Unit. The MassHealth Unit maintains constant contact with stakeholders, including the Executive Office of Elder Affairs, fiscal intermediaries, UMass Medical Center, and the Attorney General’s Office, resulting in increased referrals to BSI. In addition, BSI regularly schedules trainings for the directors and staff of the four MassHealth Enrollment Centers located throughout the Commonwealth in order to foster greater communication and shared goals between the agencies.

DTA Unit

For the 2nd quarter of FY19, the DTA Unit completed 1,073 cases, identifying fraud totaling $2,080,050.82 in 150 cases. In total, the DTA Unit identified the following fraud: $995,829.58 in SNAP benefits, $653,726.01 in EEC benefits, $352,749.39 in TAFDC benefits, and $77,745.84 in EAEDC benefits.

In addition, the DTA Unit filed charges on four subjects in various courts and conducted 13 civil recoveries for $367,060.92 fraudulently obtained from the Commonwealth.

Data Analytics Unit

For the 2nd quarter of FY19, the MassHealth and DTA Units completed 87 cases from DAU-generated referrals from previous quarters and identified fraud totaling $215,957.46 in 85 of those cases. The majority of the cases identified fraud in connection with PCAs falsely submitting timesheets for services allegedly provided to MassHealth members residing in long-term care facilities; MassHealth prohibits PCA services for long-term-care facility residents.

DAU continued its efforts to uncover suspicious activity related to providers participating in the MassHealth program. These efforts led to DAU entering several joint investigations with federal law enforcement partners that participate in the Public Benefits Fraud Federal Task Force.

2. The figure includes referrals from MassHealth and DAU.

Date published: May 1, 2019
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