MassHealth Unnecessarily Paid for Ambulance and Inpatient Services for Dual-Eligible Members.

MassHealth unnecessarily paid as much as $203,135 for ambulance and inpatient services for dual-eligible members without the members’ hospice providers’ knowledge that these services had been provided.

Overview

During our audit period, MassHealth unnecessarily paid as much as $203,135 for ambulance and inpatient services for dual-eligible members without the members’ hospice providers’ knowledge that these services had been provided.²² The non-hospice providers billed MassHealth directly instead of billing the members’ hospice providers. Consequently, the hospice providers did not have the chance to review the claims and determine who was responsible for paying them. In 63 of 100 sampled claims for ambulance transportation for dual-eligible hospice members, MassHealth paid for the transportation without the hospice provider reviewing the claim and determining who should have paid for the service: the hospice provider, MassHealth, or Medicare.²³ Similarly, in 7 of 100 sampled claims for inpatient services for dual-eligible hospice members, MassHealth paid for the services without the hospice providers reviewing the claim. During our audit, we reviewed some of the claims with the applicable hospice providers, and hospice provider personnel indicated that the providers would probably have paid them. MassHealth could have used this money to provide additional services to other MassHealth members.

Authoritative Guidance

According to 42 CFR 418.56(e), hospice providers must “[maintain] responsibility for directing, coordinating, and supervising the care and services provided.” Effective coordination of services would include ensuring proper billing.

Further, 130 CMR 437.421(D)(3) requires hospice providers to pay providers for services that are included in members’ plans of care:

The hospice is responsible for paying contract personnel who have provided hospice-approved services according to the member’s plan of care.

To comply with this regulation, hospice providers must be able to review each claim and determine whether they should pay for the services provided.

Section 40.1.9 of CMS’s Medicare Benefit Policy Manual states,

Ambulance transports of a hospice patient, which are related to the terminal illness and which occur after the effective date of election, are the responsibility of the hospice.

In addition, the CMS document Medicare Learning Network: Official CMS Information for Medicare Fee-for-Service Providers states that Medicare may pay for the following type of ambulance transportation:

Covered care in an emergency room, hospital, or other inpatient facility; outpatient services; or ambulance transportation, unless these services are either arranged by the Hospice or are unrelated to the terminal illness.

Reasons for Issue

MassHealth did not ensure that its hospice providers explained to the members and their families that the members and families were required to inform any non-hospice providers that the members had elected the hospice benefit to ensure service coordination and billing. Some hospice providers told us that, in many instances, members’ relatives requested the services without the hospice providers’ knowledge and consent. As a result, the non-hospice providers submitted their claims directly to MassHealth instead of to the hospice providers. In addition, MassHealth’s claim processing system, MMIS, does not have system edits in place to ensure that these claims are properly denied and that non-hospice providers bill hospice providers directly.

Recommendations

1. MassHealth should ensure that its hospice providers explain to its members and their families that the members and families are required to inform any non-hospice providers that the members have elected the hospice benefit to ensure service coordination and billing.
2. MassHealth should ensure that the system edits in MMIS for claims for hospice services for dual-eligible members are effective in detecting and denying improper claims.

Auditee’s Response

EOHHS and MassHealth responded,

EOHHS disagrees with Finding 4. The audit team provided 73 claims totaling $26,037 that fall under Audit Finding 4. EOHHS‘s review of these claims revealed that 12 of the 73 claims were appropriately paid Medicare Crossover Claims for transportation and acute inpatient hospital services (MassHealth Category 1), and the remaining 61 claims were appropriately paid claims for non-emergency medical transportation provided under an HCBS waiver service (MassHealth Category 2) or as a State Plan service unrelated to hospice (MassHealth Category 3). Accordingly, EOHHS disagrees with the auditors’ finding that MassHealth made $203,135 in unnecessary payments, as MassHealth’s analysis of the 73 claims at issue revealed $0 in improper payments. . . .

EOHHS agrees with [Recommendation 1]. EOHHS will continue to provide education to MassHealth enrolled hospice providers on their responsibilities to provide education to members and their families when providing services to dual-eligible members. In particular, EOHHS will continue to provide clarification that even when such providers are providing Medicare covered hospice services, they still have a responsibility to require the dual-eligible member to complete a MassHealth hospice election form waiving their right to receive other MassHealth covered services for the related to their terminal illness. . . .

EOHHS agrees with [Recommendation 2]. See also EOHHS response to Recommendation 2 to Audits Findings 3a and 3b, above.

Auditor’s Reply

Federal regulations require hospices to pay for ambulance transportation that is related to members’ terminal illnesses regardless of whether it is emergency transportation. Hospice providers told us that they were unaware that these services had been provided because the non-hospice providers who provided them billed MassHealth directly. Had MassHealth denied these claims, the non-hospice providers would have been required to submit their claims directly to the hospice providers for reimbursement. The hospice providers could then have determined whether the transportation was related to the members’ terminal illnesses. EOHHS’s analysis indicated that none of the claims was improper, but they did not provide OSA with evidence of how they determined this. As noted above, management at some of the hospices we visited indicated that they would have paid the claims had they been aware that the services had been performed.

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

22.     The dollar amount represents the sum from two of our sample types: inpatient and transportation. The inpatient sample totaled $28,497, and the transportation sample totaled $174,638. We are 90% confident that the lower limit for inpatient services is $15,123 and the upper limit is $41,871, and we are 90% confident that the lower limit for transportation services is $152,258 and the upper limit is $197,019.

23.     In some instances, Medicare directly pays for ambulance transportation that is not paid for by the hospice provider if the transportation was not arranged by the hospice (e.g., if it was requested by a family member).

Date published:	July 20, 2021