FY 19 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 2019.

Central Processing Unit

The Central Processing Unit (CPU) received 1,147 new referrals for investigation in the 4^th quarter of fiscal year 2019 (FY19) from the following sources:

Source	Number of Referrals	Percentage of Total
Department of Transitional Assistance (DTA)	740	64.5%
MassHealth	261	22.8%
Hotline	124	10.8%
Task Force	11	0.9%
Data Analytics Unit (DAU)	6	0.5%
Other	3	0.3%
Department of Early Education and Care (EEC)	2	0.2%

 

The primary sources of fraud in these 1,147 new referrals based on the number of cases are as follows:

Type	Number of Cases	Percentage of Total
Supplemental Nutrition Assistance Program (SNAP)	458	39.9%
Classification to Be Determined	299	26.1%
MassHealth	246	21.5%
Transitional Aid to Families with Dependent Children (TAFDC)	114	9.9%
Emergency Aid to the Elderly, Disabled and Children (EAEDC)	26	2.3%
Other	4	0.3%

 

CPU processed, analyzed, and reviewed 1,117 cases. It identified 161 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 703 cases administratively with a finding of no fraud after completing a preliminary investigation. CPU designated the remaining 253 cases for assignment to either the MassHealth Unit or the DTA Unit. CPU team members also completed 52 DTA investigations, identifying fraud in 47 of those cases. The five remaining cases contained no fraud.

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 87 Massachusetts Department of Revenue (DOR) tax return document transcriptions, 9 DOR child support record requests, and 11 Department of Unemployment Assistance benefit claim record reviews.

MassHealth Unit

During the 4^th quarter of FY19, there were 108 new cases assigned to the MassHealth Unit, which completed 117 investigations assigned in this and previous quarters and identified $460,906.32² in fraud in 56 cases. The remaining 61 cases resulted in findings of no fraud or were closed administratively.

The MassHealth Unit also completed six civil recovery cases, totaling $49,456.49.

The MassHealth Unit filed two criminal complaints during the 4^th quarter of FY19. The first case, filed in the Boston Municipal Court (BMC), involved an individual who was residing out of state but unlawfully received $54,411.57 in MassHealth benefits. The second case, also filed in the BMC, involved a couple who allegedly resided together and failed to report their income to MassHealth accurately and, as a result, received $60,063.31 in MassHealth benefits.

Also during the 4^th quarter of FY19, the MassHealth Unit resolved a case in Quincy District Court involving a MassHealth recipient who was allegedly residing out of state. The case was continued without a finding for one year, and the subject was ordered to complete 100 hours of community service.

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 continues to participate 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 4^th quarter of FY19, the DTA Unit completed 813 cases, identifying fraud totaling $1,139,119.00 in 131 cases. In total, the DTA Unit identified the following fraud: $735,065.16 in SNAP benefits, $28,236.73 in EEC benefits, $282,813.80 in TAFDC benefits, and $98,469.31 in EAEDC benefits.

The DTA Unit conducted 13 civil recoveries, totaling $233,479.13 fraudulently obtained from the Commonwealth.

The DTA Unit filed criminal charges in four cases during the 4^th quarter of FY19. In the first case, filed in Springfield District Court, the subject allegedly failed to report to DTA that his dependents did not reside with him while he was in receipt of $6,824.00 in SNAP benefits and $7,707.40 in TAFDC benefits. The second case, filed in New Bedford District 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 $24,391.82 in SNAP benefits and $69.82 in EAEDC benefits. The third case, filed in Brockton District Court, came to BSI as an allegation that the subject was living above her means, with eight children and one adult reportedly living in a household without any income. Following BSI’s investigation, it was determined that the subject allegedly failed to report to DTA that an NCP was residing in the home and failed to report his income to DTA, which led to her unlawful receipt of $67,155.00 in SNAP benefits. The fourth case, filed in the BMC, involved another subject who allegedly failed to report that her dependents did not reside with her while she was in receipt of $8,629.00 in SNAP benefits and $12,634.00 in TAFDC benefits.

Data Analytics Unit

For the 4^th quarter of FY19, the MassHealth and DTA Units completed 35 cases and identified fraud totaling $1,301,218.37 in 20 of those cases. These cases were DAU-generated referrals from the previous quarter’s DTA referral project, which resulted in 54 new referrals for BSI’s DTA Unit. Out of the 54 new referrals, the DAU completed 19 cases, identifying fraud in 14 of them. The majority of the cases identified fraud in connection with 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.

The DAU also generated and referred six cases to BSI’s MassHealth Unit. These referrals identified individuals who were employed as PCAs and failed to report their incomes to the MassHealth program.

The DAU identified and referred several instances of improper billing related to home health care and adult foster care services provided within the Medicaid program. The DAU’s findings, which detailed claim violations by five Medicaid providers, were referred to the Audit Operations Division for the Office of the State Auditor (OSA).

The DAU continued its efforts to uncover suspicious activity related to providers participating in the MassHealth program. The DAU opened an investigation into a MassHealth provider following a complaint received from OSA’s Audit Operations Division; that investigation is active and ongoing. The DAU also continued its work on the three joint investigations with federal law enforcement partners that participate in the Public Benefits Fraud Federal Task Force, and, like the MassHealth Unit, the DAU continues to participate in the PCA Task Force.

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

Date published:	August 20, 2019