Overview
The objectives of the performance audits conducted by the Office of the State Auditor (OSA) at MassHealth and its providers are not only to identify improper payments for Medicaid services, but also to identify and resolve any systemic problems such as deficiencies in internal controls that may exist in the MassHealth system. Consequently, while measures such as referrals to law enforcement for prosecution, restitution, and other remedial actions against individual Medicaid vendors are typical results of OSA audits and serve as a deterrent, the systemic changes made by MassHealth as a result of OSA audits, in many instances, have a more significant effect on the overall efficiency of the operation of Medicaid-funded programs.
In order to assess the impact of all our audits and the post-audit efforts made by auditees to address issues raised in our reports, OSA has implemented a post-audit review survey process that is conducted six months after the release of an audit. This process documents the status of the recommendations made by OSA, including any corrective measures taken by the auditee as well as any estimates of future cost savings resulting from changes made based on our recommendations.
During the report period, OSA issued, and agencies completed, 12 post-audit surveys regarding Medicaid audits. This number reflects audits with findings issued at least six months ago for which a follow-up survey has been completed. The self-reported surveys are issued six months after an audit is issued to allow management time to plan and implement its corrective action. Because the voluntary survey is sent to MassHealth six months after an audit ends, not all of the audits issued during the period covered by this report are included in this section of the report, as some surveys have not yet been completed.
According to the survey results, MassHealth reported that it has acted, or will act, on implementing 40 of 46 recommendations: 30 are fully implemented, 8 are in progress, and 2 are planned.
Two recommendations were reported as having no action taken. One provider did not take action because it had discontinued its participation in the Group Adult Foster Care Program, and the other did not take action because the action recommended was not in its capacity to perform.
Four recommendations were disputed by three different providers. One dental provider issued a letter to MassHealth (via the University of Massachusetts Medical School) disputing the conclusions of two OSA recommendations; one medical provider disputed the need to collaborate with MassHealth to review instances in which supervising physicians and registered nurses (RNs) worked in the same location; and one human-service provider essentially stated that MassHealth was responsible for responding to a recommendation about group adult foster care (GAFC).
From the survey results, MassHealth has successfully sought, or will seek, recovery of up to $2,125,318. This includes the recovery of $1,132,321 in overpayments to nursing facilities and $666,805 in improper payments for services covered by the Massachusetts Behavioral Health Partnership (MBHP). According to MassHealth, it also includes $227,189 in overpayments concerning durable medical equipment that the agency is in the process of recovering, $79,190 of improper payments for periapical radiographs that it has recovered, and $19,813 that one medical provider plans to reimburse MassHealth for evaluation and management (E/M) services performed by a nurse practitioner (NP) and for an improper payment. The tables and narratives below detail MassHealth’s and the auditees’ post-audit efforts during the reporting period.
Centro Las Americas, Inc.
Audit No. 2016-4591-3C
Issued September 6, 2016
Survey Response Received March 30, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
4 |
3 |
1 |
N/A |
Internal reporting has been amended to maintain unallowable costs in separate accounts to better identify and report them on its Uniform Financial Statements and Independent Auditor’s Reports (UFRs) |
In its survey response, Centro Las Americas, Inc. stated that it had fully implemented all three of the formal audit recommendations. The organization has resubmitted its UFRs for fiscal years 2014 and 2015, identifying the unallowable costs properly, and has applied available offsetting revenue to cover those costs accordingly. Internal reporting has also been amended to maintain unallowable costs in separate accounts to better identify and report such information on Centro’s UFRs. Centro’s procurement policy has also been amended to include a competitive bidding process for purchases of goods and services over $25,000.
As an “Other Matter”—an issue that is outside the scope of the audit but is substantial enough to be reported—OSA disclosed that MassHealth allowed Centro to bill $300,004 for unallowable adult foster care (AFC). OSA recommended that Centro collaborate with MassHealth to find out whether MassHealth would cease to pay for these services. On this recommendation, Centro has pursued and will continue to pursue clearer guidance from MassHealth on this matter. MassHealth stated that it was aware of the situation.
Additional Resources
Nonotuck Resource Associates, Inc.
Audit No. 2016-4592-3C
Issued December 6, 2016
Survey Response Received July 14, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
7 |
7 |
0 |
N/A |
|
Findings from the audit of the Northampton-based Nonotuck Resource Associates, Inc., a not-for-profit human-service agency that offered AFC that was billable to MassHealth, stated that the agency lacked written, signed, and/or current contracts for five consultants; did not maintain required documentation in its personnel files; and charged $4,304 of nonreimbursable costs to its state contracts.
Nonotuck responded that it had fully implemented all six of the formal audit recommendations. Nonotuck has established written policies and procedures for consultant contracts, which ensure that the agency pays a set cost for the contracts’ established time periods. It has developed a consultant contract database to carefully track the execution of such documents. Nonotuck has strengthened its procedures to ensure that all AFC and Department of Developmental Services care provider files contain the required documents and has centralized these files in its headquarters. Finally, to address the $4,304 of nonreimbursable costs, Nonotuck refiled its 2014 UFR and has established procedures to ensure that such costs are identifiable and properly classified on the annual UFR.
OSA disclosed as an “Other Matter” that MassHealth allowed Nonotuck to bill $164,649 for unallowable AFC and recommended that Nonotuck collaborate with MassHealth to find out whether MassHealth will cease to pay for these services. On this recommendation, Nonotuck reported that MassHealth had started to share the information that prevents disallowed duplication of AFC. As a result, before it begins any AFC, Nonotuck now consults with MassHealth before performing services in order to prevent disallowed duplication of care.
Additional Resources
Review of Dental Periapical Radiograph Claims Submitted by Dr. Najmeh Rashidfarokhi
Audit No. 2016-1374-3M11
Issued February 10, 2017
Survey Response Received September 19, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
2* |
0 |
0 |
N/A |
Dr. Rashidfarokhi says that she will explicitly document in her patient charts the reasons for taking a periapical radiograph and will only bill allowable radiographs under the MassHealth regulation |
* Both findings/recommendations were disputed by Dr. Rashidfarokhi.
The audit of MassHealth dental-service provider Dr. Najmeh Rashidfarokhi found that Dr. Rashidfarokhi submitted claims, and was paid approximately $267,251, for unallowable dental periapical radiographs. Specifically, she billed for dental periapical radiographs performed as part of routine dental examinations. A periapical radiograph shows the whole tooth from the top to the jaw. When taken independently (not as one of a periodic full set of radiographs), it is used to locate problems with a tooth and the surrounding areas. MassHealth regulations allow periapical radiographs to be taken by a dental-service provider either as part of a full-mouth series of radiographs (allowed once every three years) or to evaluate a specific dental problem independently. They are not to be part of routine examinations.
Dr. Rashidfarokhi disputed both of OSA’s recommendations. Dr. Rashidfarokhi has sent a letter to MassHealth (via the University of Massachusetts Medical School, which contracts with MassHealth to perform reviews, audits, and recoveries for the agency) disputing OSA’s figures and conclusions. However, she says that she will explicitly document in her patient charts the reasons for taking periapical radiographs and will only bill allowable radiographs under the MassHealth regulation.
Additional Resources
Review of Dental Periapical Radiograph Claims Submitted by Sawan & Sawan, DMD
Audit No. 2016-1374-3M11B
Issued February 10, 2017
Survey Response Received September 12, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
3 |
3 |
0 |
$79,190 |
The practice has repaid to MassHealth the $79,190 identified as improper payments received for periapical radiographs |
Audit findings from the review of MassHealth dental-service provider Sawan & Sawan, DMD revealed that Sawan & Sawan submitted claims, and was paid approximately $79,190, for unallowable dental periapical radiographs. Specifically, it billed for dental periapical radiographs as part of routine dental examinations. Also, in some cases the dental records were incomplete, so OSA could not determine the reasons periapical radiographs were taken.
In its survey response, Sawan & Sawan, DMD stated that it had fully implemented all three recommendations. It has repaid to MassHealth the $79,190 identified as improper payments received for periapical radiographs, has ensured that it will follow regulations concerning billing for periapical radiographs, and has improved its recordkeeping process, which will help it make sure that its records reflect the need for periapical radiographs for MassHealth members.
Additional Resources
Review of Fee-for-Service Payments for Services Covered by MBHP
Audit No. 2015-1374-3M11
Issued April 3, 2017
Survey Response Received November 20, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
4 |
1 |
3 |
$666,805 |
|
The audit of MassHealth’s contract with MBHP found that MassHealth paid providers $192,600,577 for improper or questionable claims for services that should have been paid for by MBHP.
The approximately $100 million of questionable payments were for services that should have been included in MBHP’s contract. MassHealth made approximately $93 million of improper payments to providers on a fee-for-service basis after it had paid MBHP a fixed monthly payment to cover the same services.
Additionally, auditors disclosed $10,623,476 in behavioral-health services that were included in payment amount per episode (PAPE) claims. MassHealth had used PAPE payments for individual episodes of care that involved both general medical care and behavioral-health services. MassHealth should have identified the behavioral-health services and directed them to MBHP for payment. However, MassHealth did not have a system edit to identify behavioral-health care within PAPEs.
MassHealth replied that it had fully implemented one recommendation. MassHealth no longer uses PAPE for acute outpatient hospital payments. According to the agency, before the audit, it had recognized that the acute outpatient payment process needed updating and had proceeded to do so. As a result of this action, proper payments of PAPE claims will commence, resulting in a cost savings of $92,070.
Three recommendations were listed as in progress. Concerning recoupment of the $93 million in payments identified as improper, MassHealth stated after several reviews that more than 99% of the claims were paid correctly. However, it also stated that new system edits had been put in to place to improve behavioral-health billing in August 2017. MassHealth noted that it was pursuing $503,028 in recoupment as part of the contract reconciliation process with MBHP.
With regard to the $100 million of questionable claims, after review, MassHealth stated that more than 98% of the claims related to that finding were in fact proper. The agency implemented additional system edits and noted that it planned to recoup $53,396. MassHealth was also developing a list of comprehensive behavioral-health services outlining provider types and procedure codes for claims that MBHP would cover and process. MassHealth further stated that 270 claims for services, totaling $18,311, were improperly paid and cost savings in that amount would be realized as a result of the edits to the behavioral-health procedure and revenue codes.
Additional Resources
Medical Community Services, Inc.
Audit No. 2016-4596-3C
Issued April 6, 2017
Survey Response Received November 9, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
1 |
1 |
0 |
N/A |
Provider is collaborating with MassHealth on finding out whether MassHealth intends to cease paying for duplicative GAFC |
Responding to the post-audit survey, Medical Community Services, Inc. (MCS), a Framingham-based GAFC business, stated that it was collaborating with MassHealth on finding out whether MassHealth intended to cease paying for duplicative GAFC. MCS stated that the company had updated its risk-management policies and procedures to address duplication of services and cost control for GAFC. The audit had found that MassHealth allowed MCS to bill for $1,434,256 in unallowable GAFC, and in the survey, MCS stated that MassHealth wanted to continue paying for these services, if they are crucial for patients’ wellbeing.
Additional Resources
Office of Medicaid (MassHealth)—Review of Claims for Durable Medical Equipment
Audit No. 2016-1374-3M12
Issued April 13, 2017
Survey Response Received November 20, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
5 |
3 |
2 |
$227,189 |
|
Audit findings from a review of MassHealth’s paid claims for durable medical equipment (DME) indicated that MassHealth did not pay DME providers in accordance with the Center for Healthcare Information and Analysis’s rate schedule. This resulted in overpayments totaling $57,067. In addition, MassHealth made $148,978 of duplicate payments to DME providers.
MassHealth responded that it had fully implemented three recommendations. MassHealth’s DME program staff regularly reviews all DME rate changes to ensure their timely entry in the Medicaid Management Information System (MMIS). The agency also instituted a system edit that triggers a prepay review of certain claims that may have also been paid as crossover claims. Additionally, MassHealth issued DME provider bulletins in September 2016 clarifying and emphasizing providers’ responsibilities in submitting crossover claims for DME.
Two recommendations were in progress. MassHealth had entered into a contract with a third-party administrator to recover $227,189.48 of overpayments and duplicate payments.
Additional Resources
Nizhoni Community Care LLC
Audit No. 2016-4595-3C
Issued April 18, 2017
Survey Response Received November 7, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
1* |
0 |
0 |
N/A |
Nizhoni discontinued participation in the Group Adult Foster Care Program |
* No action was taken on the sole recommendation.
In replying to the survey, Nizhoni Community Care LLC stated that it had not taken any action on OSA’s one recommendation (to collaborate with MassHealth to find out whether MassHealth intends to cease paying for GAFC that was duplicative and unallowable when a member was receiving skilled nursing care). The agency stated that it had discontinued its participation in the Group Adult Foster Care Program.
Additional Resources
Review of Evaluation and Management Claims Paid to Resil Medical Associates, P.C.
Audit No. 2016-1374-3M14
Issued April 24, 2017
Survey Response Received November 23, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
11* |
8 |
0 |
$19,813 |
Provider plans to reimburse MassHealth $19,813 in improper payments |
* Two recommendations were planned, and one was disputed.
Auditors discovered in the review of E/M claims paid by MassHealth to Resil Medical Associates, P.C. (RMA) that RMA did not always use properly licensed staff members to perform high-complexity E/M services; it used RNs instead of NPs. Additionally, RMA improperly billed MassHealth for $17,346 of E/M services performed by NPs. Further, required physician supervision was not always given to non-independent NPs, and RMA lacked collaborative arrangements and prescriptive-practice guidelines for independent NPs.
RMA stated that it had fully implemented eight recommendations. According to RMA, two NPs now provide services under appropriate supervision by a physician and the practice has updated its website to accurately reflect personnel licensure. RMA also stated that it had modified its eClinical system to record service-provider information and to use such information in billing MassHealth for E/M services. Further, RMA said that it had implemented internal controls to ensure accuracy of claims submitted, begun periodically reviewing MassHealth billing requirements, ensured that the supervising physician was on site when non-independent NPs were attending to patients, developed a collaborative arrangement detailing medical services and prescriptive practices for independent NPs, and established policies ensuring that independent NPs functioned within the scope of their licensure.
Two recommendations had action planned. RMA planned to reimburse MassHealth for a total of $19,813 in improper payments: $2,467 for an unspecified improper payment and $17,346 for E/M services performed by NPs.
RMA disputed one finding and recommendation. Concerning collaborating with MassHealth to determine any additional funds due the Commonwealth in instances where the supervising physician and RNs worked in the same location, RMA stated that all decisions were made by the supervising physician and that the RNs only helped in that process.
Additional Resources
Office of Medicaid (MassHealth)—Review of Payments for Nursing-Facility Claims
Audit No. 2016-1374-3M8
Issued April 28, 2017
Survey Response Received November 20, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
6 |
4 |
2 |
$1,132,321 |
|
An audit of MassHealth’s payment of claims submitted by nursing facilities revealed that MassHealth had not recovered $639,445 of overpayments to nursing facilities. Additionally, MassHealth had not ensured that records of members’ care levels were promptly updated; this had resulted in a further $326,201 of overpayments. The agency also did not update specific claim information in MMIS for approximately $3 million of recoupments from nursing facilities, and it had granted MMIS access privileges to staff members without proper documentation.
MassHealth stated that it had fully implemented four recommendations. It has implemented a change to MMIS to adjust affected nursing-facility claims after MMQ audits, eliminating the need for nursing facilities to resubmit adjusted claims. It has also contracted with a third-party administrator to perform MMQ reviews and update level-of-care changes in MMIS. Additionally, deficiencies in the Executive Office of Health and Human Services’ off-boarding process for user accounts in MMIS have been identified and are in the process of being remediated.
Two recommendations were reported as in progress. MassHealth has recovered $1,132,321 in overpayments to nursing facilities, with $124,521 in overpayments still outstanding as of November 2017.
Additional Resources
Community Connection Healthcare LLC
Audit No. 2016-4597-3C
Issued May 23, 2017
Survey Response Received December 18, 2017
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
1* |
0 |
0 |
N/A |
No action was undertaken because the action recommended was not within Community Connection Healthcare LLC’s (CCHC’s) capacity to change |
* CCHC did not take any action on the recommendation.
The audit disclosed an “Other Matter”: MassHealth allowed CCHC to bill $1,814,810 for unallowable GAFC. OSA recommended that CCHC collaborate with MassHealth to find out whether it intended to stop paying for these duplicative services.
In response to the survey, CCHC stated that it had not taken any action on OSA’s recommendation. CCHC said the recommendation was not within its capacity to change, but rather would need to be executed by MassHealth.
Additional Resources
SafetyNet Solutions Inc.
Audit No. 2016-4598-3C
Issued July 11, 2017
Survey Response Received February 6, 2018
|
Number of Recommendations |
Fully Implemented |
In Progress |
Fiscal Benefit |
Selected Actions and Results |
|---|---|---|---|---|
|
1* |
0 |
0 |
N/A |
MassHealth intended to put forth GAFC regulations in fall 2017, clarifying when GAFC services do not duplicate other member services |
* This provider disputed the finding.
The audit disclosed an “Other Matter”: MassHealth had allowed SafetyNet Solutions Inc. (SNS) to bill as much as $1,848,082 for unallowable GAFC. OSA recommended that SNS collaborate with MassHealth to find out whether it intended to cease paying for these duplicative services.
SNS responded to the post-audit survey by disputing the finding and recommendation; it referred OSA to the response given by MassHealth to characterize its own response. MassHealth stated that its regulations did allow for individuals in GAFC to receive skilled nursing services as well.
Additional Resources
| Date published: | March 15, 2018 |
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