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FY 19 3rd Quarter Summary by Unit

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

Table of Contents

Central Processing Unit

The Central Processing Unit (CPU) received 1,095 new referrals for investigation in the 3rd quarter of fiscal year 2019 (FY19) from the following sources:

Source

Number of Referrals

Percentage of Total

Department of Transitional Assistance (DTA)

539

49.2%

MassHealth

334

30.5%

Hotline

143

13.1%

Data Analytics Unit (DAU)

64

5.8%

Task Force

12

1.1%

Other

3

0.3%

 

The primary sources of fraud in these 1,095 new referrals based on the number of cases are as follows:

Type

Number of Cases

Percentage of Total

Supplemental Nutrition Assistance Program (SNAP)

447

40.8%

MassHealth

332

30.3%

Classification to Be Determined

178

16.3%

Transitional Aid to Families with Dependent Children (TAFDC)

106

9.7%

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

23

2.1%

Other

9

0.8%

CPU processed, analyzed, and reviewed 1,064 cases. CPU identified 99 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 649 cases administratively with a finding of no fraud after completing a preliminary investigation. CPU designated the remaining 316 cases for assignment to either the MassHealth Unit or the DTA Unit. CPU team members also completed 82 DTA investigations, identifying fraud in 72 of those cases.

CPU continued to assist with ongoing investigations conducted by BSI units by requesting outstanding leads as they pertain to the allegation type. To substantiate allegations, CPU sent out electronic requests for information to various agencies, completing 253 Massachusetts Department of Revenue (DOR) tax return document transcriptions, 53 DOR child support record requests, and 83 Department of Unemployment Assistance benefit claim record reviews.  

MassHealth Unit

During the 3rd quarter of FY19, there were 91 new cases assigned to the MassHealth Unit, which completed 147 investigations assigned in this and previous quarters, and identified $500,148.852 in fraud in 82 cases. The remaining 65 cases resulted in findings of no fraud or were closed administratively.

The MassHealth Unit also completed eight civil recovery cases, totaling $183,016.14.

The MassHealth Unit filed three criminal complaints during the 3rd quarter of FY19. The first case, filed in Newburyport District Court, involved a couple that was residing out of state and allegedly received $49,305 in MassHealth benefits. In that case, both subjects were charged. The second case, also filed in Newburyport District Court, involved an individual who allegedly failed to report his income to MassHealth accurately and as a result improperly received $14,700 in MassHealth benefits. The third case, filed in North Attleboro District Court, involved a couple that lived together, but the defendant allegedly failed to disclose their correct household composition and earnings, which resulted in their unlawfully receiving $58,548 in MassHealth benefits.   

The MassHealth Unit works closely with MassHealth management and meets monthly with MassHealth’s Program Integrity Unit, while maintaining 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, the MassHealth Unit will be participating in the Personal Care Attendant (PCA) Task Force along with MassHealth and the Attorney General’s Medicaid Fraud Control Unit, where the collaborative goals are to identify fraud in the PCA program, avoid duplicative investigations, and foster greater communication and productivity between the agencies.

Department of Transitional Assistance Unit

For the 3rd quarter of FY19, the DTA Unit completed 199 cases, identifying fraud totaling $1,957,684.36 in 168 cases. In total, the DTA Unit identified the following fraud: $1,043,850.32 in SNAP benefits, $436,875.37 in EEC benefits, $289,346.15 in TAFDC benefits, and $133,021.86 in EAEDC benefits.

The DTA Unit conducted seven civil recoveries totaling $116,948 fraudulently obtained from the Commonwealth.

The DTA Unit filed criminal charges in four cases during the 3rd quarter of FY19. In the first case, filed in the Boston Municipal Court, the subject allegedly failed to report to DTA that her dependents did not reside with her while she was in receipt of $17,159 in SNAP and $14,491.71 in TAFDC benefits. The second case, also filed in the Boston Municipal Court, involved a subject who allegedly failed to report to DTA that a non-custodial parent (NCP) was residing in the home and failed to report the NCP’s income to DTA, which led to her unlawful receipt of $40,277 in SNAP benefits. The third and fourth cases involved similar allegations of an NCP in the home; the subject charged in Pittsfield District Court received $22,175 in SNAP and 21,100.52 in EEC benefits, while the subject charged in Lynn District Court received $14,389 in SNAP benefits.

Data Analytics Unit

For the 3rd quarter of FY19, the MassHealth and DTA Units completed 23 cases from DAU-generated referrals from previous quarters and identified fraud totaling $47,687.60 in 20 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.

The DAU continued its efforts to uncover suspicious activity related to providers participating in the MassHealth program. In addition to opening an investigation into a MassHealth provider following a complaint made via BSI’s fraud hotline, the DAU also joined three joint investigations with federal law enforcement partners that participate in the Public Benefits Fraud Federal Task Force. Like the MassHealth Unit, the DAU will be participating in the PCA Task Force. The DAU also referred 54 cases to the DTA Unit after identifying individuals who failed to disclose, or attempted to conceal, their earned income while they were in receipt of cash assistance or SNAP benefits from DTA.  

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

Date published: June 25, 2019
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