MassHealth Did Not Ensure That It Had Accurate Information in Its Medicaid Management Information System About Dual-Eligible Members Who Chose To Receive Hospice Services.

MassHealth was not requiring hospice service providers to notify the agency when it began providing services to MassHealth members.

Overview

During our audit period, MassHealth did not ensure that it had accurate information in its Medicaid Management Information System (MMIS) about dual-eligible members who chose to receive hospice services. Specifically, for 223 (56%) of the 400 claims in our sample, although the member had chosen to receive hospice services (according to Medicare information provided to us by the United States Department of Health and Human Services’ Office of Inspector General), either MassHealth did not receive the member’s MassHealth Hospice Election Form and therefore could not update MMIS to reflect that the member had chosen to participate in hospice, or (in at least four instances) MassHealth received the member’s MassHealth Hospice Election Form but did not update MMIS to show that the member had chosen to participate in hospice. Not ensuring that MMIS reflects accurate information for these services creates a higher-than-acceptable risk that the payments for them may be improper. Examples of improper payments that occurred during the audit period and may have been the result of this issue appear in Finding 2, Finding 3, and Finding 4.

Once a member has chosen to receive hospice services, MassHealth enters the code HSPC in MMIS to indicate that the member has chosen hospice care. Subsequently, all claims for services provided to the member are subject to system edits related to hospice care, which are designed to ensure that MassHealth does not pay any claims that should be paid by either the hospice provider or Medicare. Based on our statistical sample of 400 reviewed claims, we estimate that during our audit period, approximately $56,640,242 in non-hospice-provider claims⁹ of the four types tested were for members who had chosen to participate in hospice. However, this information was not reflected in MMIS, so the claims were not subject to the proper MMIS system edits.

Authoritative Guidance

Section 437.412(C) of Title 130 of the Code of Massachusetts Regulations (CMR) states that providers must send hospice election forms to MassHealth:

Each time a MassHealth member . . . seeks to elect hospice services . . . the hospice must complete the MassHealth agency’s hospice form according to the instructions on the form and submit the form to the MassHealth agency.

MassHealth needs to monitor compliance with this requirement so it can ensure that the information in MMIS about dual-eligible members’ choice to participate in hospice is complete and accurate and that MassHealth does not pay for improper bills submitted by non-hospice providers for these services.

Reasons for Issue

MassHealth does not have an effective monitoring process to ensure that hospice providers submit to it a MassHealth Hospice Election Form for every dual-eligible member who chooses to receive hospice services. Further, officials from 46 of the 59 hospice providers we visited told us that they were unaware that they were required to send MassHealth a MassHealth Hospice Election Form for all dual-eligible members who chose to receive hospice services; many stated that they thought they only had to send in this form when they were going to bill MassHealth for services provided to a member.

Recommendations

1. MassHealth should establish an effective monitoring process to ensure that hospice providers send it a MassHealth Hospice Election Form for every dual-eligible member who chooses to receive hospice services.
2. MassHealth should consider collaborating with the Centers for Medicare & Medicaid Services (CMS) to obtain CMS’s hospice election information about dual-eligible members and determine whether all MassHealth’s hospice providers have submitted the required MassHealth Hospice Election Forms.
3. MassHealth should review MMIS for all members who have elected the hospice benefit to ensure that their MassHealth Hospice Election Forms are accurately reflected in MMIS.

Auditee’s Response

Auditee’s Response

In its written response to our draft audit report, the Executive Office of Health and Human Services (EOHHS), in collaboration with MassHealth, provided some general comments, excerpted below.

When MassHealth receives a Member’s MassHealth hospice election form it opens a hospice segment in MassHealth’s Medicaid Management Information System (MMIS) enabling the MassHealth hospice provider to bill MassHealth for the per diem hospice rate intended to cover hospice services provided to the member. In completing and signing the MassHealth hospice election form the member is affirmatively waiving their right to receive other MassHealth covered services related to or for the treatment of their terminal illness, the submission of the MassHealth hospice election form also triggers additional program integrity measures related to the member’s receipt of other MassHealth covered services. Specifically, submission of the MassHealth hospice election form and the establishment of a hospice segment in MMIS activates an MMIS edit (“edit 2018”), that denies claims for other MassHealth covered services that may be related to the member’s terminal illness, such as physician services and inpatient hospital services, during the period the MassHealth hospice segment is in place and active. Importantly, and by design, edit 2018 does not deny payments for MassHealth services categorically unrelated to the member’s terminal illness, such as 1915(c) home and community-based waiver services that enable members with disabilities to live and remain in the community as an alternative to facility settings.

EOHHS and MassHealth (hereafter EOHHS) indicated that they had conducted an analysis of the claims in our sample and, based on all available information, determined that there were no inappropriately paid claims. EOHHS separated the claims in our sample into five categories and explained why they believe they would have paid the claims:

1. Medicare Crossover Claims [64 claims; $74,845]

The claims in Category 1 are appropriately paid Medicare crossover claims. Here, Medicare determined that the claim was not precluded from payment by the dual eligible member’s election of Medicare hospice and therefore Medicare paid the Medicare portion of the claim as primary payor, and the crossover claim was forwarded to MassHealth by Medicare for processing of the remaining patient responsibility (the cost-sharing amount) as secondary payor. . . . The MassHealth program is required to pay any patient responsibility amount for Medicare crossover claims in accordance with Sections 1902(a)(10)(E) and 1902(n)(1) & (2) of the Social Security Act and MassHealth regulations at 130 CMR 450.318.

2. Claims for 1915(c) Home and Community Based (HCBS) Waiver Services [85 claims; $868,810]

The claims in Category 2 are appropriately paid claims for 1915(c) HCBS Waiver services. Claims identified by the auditors in this category include claims for residential habilitation waiver services (group home services) provided through MassHealth’s [Intellectually Disabled / Developmentally Disabled, or ID/DD] Residential Supports Waiver, claims for home health aide, homemaker, and companion services provided through the Frail Elder Waiver, and a claim for acquired brain injury skills training services provided through one of MassHealth’s Acquired Brain Injury waivers. . . .

MassHealth members enrolled in a 1915(c) HCBS Waiver are not required to disenroll from their waiver upon the election of hospice and may continue to receive HCBS waiver services while on hospice. . . .

For all 1915(c) HCBS waiver services the auditors identified as being inappropriately paid, EOHHS disagrees with the auditors’ draft finding that the identified 1915(c) HCBS waiver services may have been duplicative or otherwise unallowable. EOHHS’s review of the subject claims indicates that the claims were for waiver services that were either not related to the member’s terminal illness, and/or were for waiver services not covered by hospice (e.g., residential habilitation services; companion services; homemaker services and home health aide services for the provision of in-home respite). . . .

3. Claims for State Plan Services Categorically Unrelated to Hospice [108 claims; $35,219]

Claims in this category are appropriately paid claims for State Plan services that are categorically unrelated to hospice, as well as claims for Medicaid personal care services for which a hospice election does not apply. Claims for State Plan services in this category include claims for services such as non-emergency medical transportation as well as claims for Adult Foster Care (“AFC”) services, which provide 24/7 personal care provided by a live-in caregiver. . . .

4. Claims Outside the Hospice Election Period [1 claim; $17,215]

This category includes one claim for acute inpatient hospital services after the member had disenrolled from Hospice. EOHHS found that this claim was appropriately paid, where it was for services after the member had disenrolled from Medicare hospice, and therefore, the member was entitled to their full Medicare and MassHealth benefits.

5. Claims for State Plan Services Appropriately Payable If Unrelated to the Terminal Illness [60 claims; $14,290]

Claims in this category are appropriately payable if the provided service was not related to the terminal illness for which the member elected hospice. This category consists of [durable medical equipment, or DME] claims and oxygen and respiratory equipment claims. The claims in this category would require further clinical review to validate whether they were related to the terminal illness; however, based on all information reviewed to date (including all information provided by the auditors), EOHHS has not identified any inappropriately paid claims in this category.

In response to Finding 1, EOHHS provided the following comments.

The audit pertains to dual eligible members receiving Medicare covered hospice services and sub-regulatory guidance from CMS in its Medicare Benefit Policy Manual at Chapter 9, Section 20.3 that Medicare hospice providers must require dual eligible members to waive their right to receive all other Medicare and Medicaid covered services related to their terminal illness for which they would otherwise be eligible to receive via simultaneous election of both the Medicare and Medicaid hospice benefits. The audit identified that some Medicare hospice providers, when providing Medicare covered hospice services to dual eligible members, failed to require such members to simultaneously complete a MassHealth hospice election form with the election of their Medicare hospice benefit. In particular, the auditors found that for 223 out of the 400 MassHealth claims for non-hospice services associated with certain dual eligible members who had elected Medicare hospice and were receiving Medicare covered hospice services, that the Medicare hospice provider had not required the member’s completion of a MassHealth hospice election form through which the member waived their right to receive certain MassHealth covered services related to their terminal illness.¹⁰

EOHHS agrees in part with the auditors’ findings indicating that the audited Medicare hospice providers failed to require dual eligible members to complete a MassHealth hospice election form along with their Medicare hospice election in some of the 223 cases . . . in violation of the sub-regulatory Medicare guidance in the Medicare Benefit Policy Manual at Chapter 9, Section 20.3.11 However as previously discussed and as provided below, EOHHS has not identified any inappropriately paid claims as a result of this deficiency on the part of the audited Medicare hospice providers.

In particular, all of the claims identified in Finding 1 fall into one of the MassHealth Categories of appropriately paid claims as follows:

• Category 1 (Medicare Crossover Claims): 45 Claims; $59,622
• Category 2 (1915[c] HCBS Waiver Claims): 77 Claims; $813,099
• Category 3 (State Plan Services Unrelated to Hospice): 48 Claims; $23,628
• Category 4 (Claims Outside Hospice Election Period): 1 Claim; $17,215
• Category 5 (Claims Payable if Unrelated to Terminal Illness): 52 Claims; $12,029

Accordingly, while EOHHS agrees that the audited Medicare hospice providers failed to require the dual eligible member to complete a MassHealth hospice election form in some cases, EOHHS strongly disagrees with the auditors’ finding of any “improper payments” arising out of this issue. Notably, MassHealth’s Third Party Liability (TPL) edits deny claims for services covered under Medicare to ensure that MassHealth is the payer of last resort. Via TPL edits, MassHealth is able to ensure that it only pays for services that are not covered under Medicare, which includes all of the claims identified by the auditors (i.e. Medicare cross-over claims, claims for Medicaid 1915(c) HCBS waiver services, claims for AFC services, etc.). Any asserted “risk that the payments for these services may be improper” arising out of this issue (i.e. the absence of a MassHealth hospice election form in certain situations in which a dual eligible member was receiving Medicare covered hospice services) does not rise to the level of “approximately $56,640,242” as asserted by the auditors, as EOHHS analysis of the claims at issue revealed that many of the services identified by the auditors are categorically unrelated to hospice and were appropriately payable regardless of whether there was a MassHealth hospice election on file. . . .

EOHHS agrees with [Recommendation 1] and in October 2020 took action. EOHHS issued MassHealth Hospice Provider Bulletin 15 as a reminder to MassHealth enrolled hospice providers of the federal sub-regulatory guidance that requires dual-eligible members to simultaneously elect their hospice benefit under both Medicare and Medicaid, and that hospice providers need to submit a MassHealth hospice election form for these members regardless of whether MassHealth is paying for the hospice services. MassHealth will continue to follow up and provide education and training for MassHealth hospice providers on their responsibility to comply with this requirement when providing Medicare covered hospice services to dual-eligible members.

In addition, EOHHS is developing additional measures to ensure it receives MassHealth hospice election forms from MassHealth enrolled hospice providers providing Medicare covered hospice services to dual-eligible members:

• additional program integrity processes to identify when a dual eligible member has elected Medicare covered hospice services via Medicare data and confirming there is an associated MassHealth hospice election on file for the member; and
• administrative sanctions on MassHealth enrolled Medicare hospice providers will be imposed when they fail to submit a MassHealth hospice election form for a dual-eligible member simultaneous to the member’s completion of a Medicare hospice election form, as required by federal sub-regulatory guidance and as set forth in MassHealth’s Hospice Bulletin 15 issued in October of 2020. . . .

EOHHS agrees with [Recommendation 2] and is developing program integrity processes to confirm there is a MassHealth hospice election on file in instances where the MassHealth member is receiving Non-MassHealth Medicare covered hospice services, and as described above under Recommendation 1. . . .

EOHHS agrees with [Recommendation 3] and is developing program integrity processes to ensure MassHealth enrolled providers of Medicare covered hospice services submit a MassHealth hospice election form for dual eligible members receiving Medicare covered hospice services, as described above in EOHHS’s response to Recommendations 1 and 2. In addition, as described in the initial section of this audit response, EOHHS has an effective process for ensuring that there is a MassHealth Hospice election form in place for MassHealth members receiving MassHealth covered hospice services. Specifically, EOHHS requires submission of a MassHealth hospice election form as a prerequisite for a hospice provider to bill MassHealth for MassHealth covered hospice services. Through this process, MassHealth is able to deny the provider’s claims for MassHealth covered hospice services until the provider submits the Member’s MassHealth hospice election form, which ensures compliance with this requirement in situations in which MassHealth is the payor of the hospice services. . . .

EOHHS appreciates this audit of Medicare hospice providers’ compliance with the federal sub-regulatory guidance on hospice election for dual eligible members and appreciates the opportunity to utilize these findings as a vehicle towards improving MassHealth’s oversight of MassHealth enrolled hospice providers that provide Medicare covered hospice services to dual eligible members.

Auditor’s Reply

As noted above, for the majority of the claims, 223 (56%) of the 400 claims in our sample, for which the members had elected the hospice benefit, either MassHealth did not receive the member’s MassHealth Hospice Election Form and therefore could not update MMIS to reflect that the member had elected the benefit, or (in at least four instances) MassHealth received the member’s MassHealth Hospice Election Form but did not update MMIS to show that the member had elected the benefit. Although EOHHS  faults hospice providers for failing to require the MassHealth members in question to complete a Medicare Hospice Election Form, MassHealth, as the state purchasing agency, should have had an effective monitoring process in place that ensured that hospice providers submit to it a MassHealth Hospice Election Form for every dual-eligible member who chose to receive hospice services. EOHHS agrees that for 184 of the 223 claims, the information in MMIS did not accurately reflect that the member had elected the hospice benefit. For the remaining 39 claims, EOHHS asserts that there was evidence that the member had elected the benefit; however, EOHHS did not provide this evidence, so we cannot comment on the assertion.

In its response, EOHHS states that it agrees with our finding which it believes is: “Medicare hospice providers failed to require the dual eligible member to complete a MassHealth hospice election form in some cases.” However, to be clear, our finding was not with the hospice providers we reviewed but with the fact that in the majority of the cases, MassHealth did not ensure that it had accurate information in MMIS about dual-eligible members who chose to receive hospice services. Since MassHealth regulations require the submission of the MassHealth Hospice Election Form, in the Office of the State Auditor’s (OSA’s) opinion, the agency is responsible for having monitoring and other controls in place to ensure compliance with this requirement, especially because this information is used in MMIS as a control to prevent improper payments. EOHHS further states that it had “not identified any inappropriately paid claims as a result of this deficiency on the part of the audited Medicare hospice providers.” Since we were not provided with any documentation regarding EOHHS’s analysis of the claims in our sample, we cannot comment on the accuracy of this assertion. However, our concern is not with the dollar value of the claims that may or may not be improper but with the fact that MassHealth failed to ensure that it had the necessary information in MMIS to prevent improper payments from occurring regardless of the amounts.

In their response, EOHHS states that the third-party liability (TPL) edits deny claims for services covered under Medicare, such as those cited in our report, to ensure that MassHealth is the payer of last resort. Although this TPL edit process may be effective for some claim types, OSA questions how it can be effective for all hospice claim types if, as EOHHS states,  MassHealth is not ensuring that it has accurate information in MMIS about all dual-eligible members who elect the hospice benefit.

Our projection of the amount of the claims that were not subject to MassHealth’s system edits for members in hospice ($56,640,242) was based on sound statistical analysis. This analysis was not designed to determine what amount, if any, of these paid claims was improper, but rather what amount was at risk of being improper because MassHealth had not identified all members who had elected the hospice benefit in MMIS. EOHHS asserts that it has determined that many of the claims in our sample may have been properly paid, but we do not believe this mitigates the fact that MassHealth did not properly ensure that it collected and maintained complete and accurate information on its members who had elected the hospice benefit so that it could effectively administer the claims. It should be noted that this $56,640,242 is only a projection of the amount of the payments that were at risk of being improper from the four hospice claim types in our sample during our audit period. We separately analyzed claims paid for all hospice services during the audit period and found that hundreds of millions of dollars in hospice claims may have been paid for members who had elected the hospice benefit although this information was not accurately reflected in MMIS; this means these claims are at risk of being improper.

Based on its response, EOHHS is taking measures to address our concerns on this matter.

9.     This number represents the sum of all four sample types. The professional claim sample totaled $55,766,857, the inpatient claim sample totaled $182,461, the durable medical equipment claim sample totaled $638,475, and the transportation claim sample totaled $52,449. We are 90% confident that the lower limit for professional claims is $51,674,262 and the upper limit is $59,859,452; that the lower limit for inpatient claims is $156,381 and the upper limit is $208,541; that the lower limit for durable medical equipment claims is $566,381 and the upper limit is $710,568; and that the lower limit for transportation claims is $35,729 and the upper limit is $69,169.

 

10.                A member’s completion of the MassHealth hospice election form (through which the member waives their right to MassHealth coverage of certain medical services) is required in order for MassHealth to appropriately deny non-hospice provider claims that are for the treatment of or related to the member’s terminal illness.

11.                MassHealth’s analysis revealed that MassHealth election forms were absent for 184 out of 223 cases alleged by the auditors where there should have been such a form present. For the remaining 39 cases (approximately 17%), MassHealth disagrees with the finding that MassHealth election forms were missing where they should have been present, based on discrepancies between the auditors’ findings and the Medicare and MassHealth hospice election data in MMIS. For example, in some cases there was a MassHealth hospice election form present, and in other cases the claims were outside of the hospice election period and therefore no form was required for the dates of service on the underlying claim.

Date published:	July 20, 2021