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FY18 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 2018.

Table of Contents

Central Processing Unit

The Central Processing Unit (CPU) received 1,692 new referrals for investigation in the 3rd quarter of fiscal year 2018 (FY18) from the following sources:

Source

Number of Referrals

Percentage of Total

Department of Transitional Assistance (DTA)

1,313

77.6%

Hotline

185

10.9%

MassHealth

174

10.3%

Task Force

11

0.6%

Department of Early Education and Care (EEC)

8

0.5%

BSI’s Data Analytics Unit (DAU)

1

0.1%

 

The primary sources of the 1,692 new referrals by program are as follows:

Type

Number of Cases

Percentage of Total

Supplemental Nutrition Assistance Program (SNAP)

742

43.8%

Transitional Aid to Families with Dependent Children (TAFDC)

425

25.1%

MassHealth

274

16.2%

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

232

13.7%

Other

13

0.8%

Classification to Be Determined

6

0.4%

CPU processed, analyzed, and reviewed 1,601 cases in the 3rd quarter of FY18. The unit identified 258 cases (16.1%) 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 985 cases administratively (61.5%) with a finding of no fraud after completing a preliminary investigation. CPU recommended the remaining 358 cases (22.4%) for assignment to either the DTA or MassHealth Units.

MassHealth Unit

During the 3rd quarter of FY18, there were 85 new cases assigned to the MassHealth Unit, including 24 new DTA cases. The unit completed 110 investigations and identified $605,434.802 in fraud in 67 cases. The remaining 43 cases resulted in findings of no fraud or were closed administratively.

The MassHealth Unit’s fraud examiners also investigated DTA cases, completing 27 investigations and identifying $160,051.83 in 15 cases.

On January 25, 2018, the Assistant Director for the MassHealth Unit and a senior fraud examiner met with directors from the MassHealth Enrollment Center in Quincy to discuss referrals and cases and to answer questions about BSI. This meeting, along with monthly meetings with MassHealth management and its Program Integrity Unit, is part of the MassHealth Unit’s ongoing effort to foster communication, cooperation, and collaboration with MassHealth.

Department of Transitional Assistance Unit

For the 3rd quarter of FY18, the DTA Unit, which investigates public assistance fraud involving DTA and EEC benefits, completed 172 investigations and identified $1,438,396.10 in fraud. The breakdown of identified fraud by public assistant benefit program was $817,856.07 for SNAP; $391,646.68 for TAFDC; $137,150.39 for EAEDC; and $91,742.96 for EEC.

During this quarter, the DTA Unit settled four cases via civil recovery. In these cases, the unit recovered $50,120.56 in fraudulent overpayments and executed agreements that disqualified subjects from receiving future benefits. Subjects send both initial and future payments directly to DTA and/or EEC.

The DTA Unit has 13 new cases with the status of “court”; these cases could end up in the court system or be handled as civil recoveries.

Data Analytics Unit

For the 3rd quarter of FY18, the MassHealth and DTA Units completed 14 cases from referrals generated by DAU and identified fraud in 12 of those cases. The majority of those referrals (11) 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 remaining case identified fraud involving a PCA who allegedly concealed personal income from DTA to fraudulently receive DTA benefits.

Finally, DAU referred a case to the Office of the Attorney General totaling $1,272,865 in identified fraud in connection with a home health care agency’s billing practices.

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

Date published: July 25, 2018
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