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FY18 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 2018.

Table of Contents

Central Processing Unit

The Central Processing Unit (CPU) received 2,306 new referrals for investigation in the 2nd quarter of fiscal year 2018 (FY18) from the following sources:

Source

Number of Referrals

Percentage of Total

Department of Transitional Assistance (DTA)

1,951

84.6%

MassHealth

239

10.4%

Hotline

96

4.2%

Task Force

8

0.3%

Department of Early Education and Care (EEC)

7

0.3%

Data Analytics Unit (DAU)

5

0.2%

The primary sources of the 2,306 new referrals by program are as follows:

Type

Number of Cases

Percentage of Total

Supplemental Nutrition Assistance Program

886

38.4%

Transitional Aid to Families with Dependent Children

666

28.9%

Emergency Aid to the Elderly, Disabled, and Children

398

17.3%

MassHealth

293

12.7%

Classification to Be Determined

56

2.4%

Other

7

0.3%

CPU processed, analyzed, and reviewed 2,393 cases. CPU identified 930 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 1,139 cases administratively with a finding of no fraud after completing a preliminary investigation. CPU designated the remaining 324 cases for assignment to either the MassHealth or DTA Units.

MassHealth Unit

During the 2nd quarter of FY18, there were 130 new cases assigned to the MassHealth Unit, which completed 189 investigations that were assigned in this and previous quarters and identified $460,839.942 in fraud in 131 cases. The remaining 58 cases resulted in findings of no fraud or were closed administratively.

The MassHealth Unit also collaborated with the DTA Unit on 15 investigations, identifying fraud in 8 of those cases, totaling $152,173.95.

The Unit’s ongoing investigative efforts into MassHealth’s Personal Care Attendant (PCA) Program contribute to the safety and wellbeing of individuals receiving care under the program. When suspicions or allegations of abuse and/or neglect arise, the Unit’s fraud examiners immediately contact the Executive Office of Elder Affairs or the Disabled Persons Protection Commission to request a wellness check by a skills trainer from the relevant personal care management agency.

The MassHealth Unit works closely with MassHealth management and meets monthly with MassHealth’s Program Integrity Unit, 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.

Department of Transitional Assistance Unit

For the 2nd quarter of FY18, the DTA Unit completed 172 cases, identifying fraud totaling $2,006,105.19 in 127 cases. One hundred sixteen of those cases were DTA referrals, generating $1,087,080.28 in identified fraud. In the remaining 11 cases, the DTA Unit identified $919,024.91 in additional fraud related to EEC.  In addition, the DTA Unit reached civil settlements in six cases totaling $207,951.16 in identified fraud.

Data Analytics Unit

For the 2nd quarter of FY18, the MassHealth and DTA Units completed 66 cases from DAU-generated referrals from previous quarters and identified fraud totaling $1,718,544.37 in 59 of those cases. The majority (45) of those cases uncovered $97,773.04 in 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. Thirteen cases, totaling $14,590.62 in identified fraud, involved PCAs fraudulently receiving DTA benefits by concealing from DTA the PCA income they received from MassHealth. Finally, DAU referred one case with $1,606,180.71 in identified fraud to the Massachusetts Attorney General’s Office in connection with a MassHealth dental provider’s fraudulent billing practices.

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

Date published: July 5, 2018
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