Medicaid Audit Impact and Post-Audit Efforts, March 2, 2022 - March 1, 2023

During this time period auditees implemented recommendations from the Office of State Auditor that will save taxpayer dollars and make the MassHealth program work better.

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 within the MassHealth system. Consequently, while measures such as referring cases to law enforcement for prosecution, recommending restitution, and taking 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 and integrity of the operation of Medicaid-funded programs.

To assess the impact of our audits and the post-audit efforts made by auditees to address issues raised in our reports, OSA has implemented a post-audit review (PAR) 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 reporting period, OSA issued, and agencies completed, three PAR surveys for Medicaid audits. This number reflects audits with findings issued at least six months ago for which follow-up surveys have 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(s). Because the voluntary surveys were sent to MassHealth six months after the audit ends, not all of the audits conducted from March 2, 2022 through March 1, 2023 are included in this section of the report, as those surveys have not yet been completed.

According to the survey results received, MassHealth and its providers reported that it has acted, or will act, on implementing the 13 recommendations. Summaries of the PAR surveys follow.

Audit of the Office of Medicaid (MassHealth)—Payments for Hospice-Related Services for Dual-Eligi

Audit Number: 2020-1374-3M1
Issued: July 20, 2021
Survey Response Received: January 31, 2022

Total Recommendations	9
Fully Implemented Recommendations	2
Recommendations in Progress	7
Fiscal Benefit	N/A

 

In its response to the PAR survey, MassHealth indicated that the following two of OSA’s nine recommendations were fully implemented:

1. 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.
2. MassHealth should ensure that information in MMIS about hospice election by dual-eligible members is accurate.

In addition, MassHealth had the following responses to the 7 recommendations still in progress:

1. MassHealth should establish an effective monitoring process to ensure that hospice providers send MassHealth the 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.

Additional Resources

https://www.mass.gov/audit/audit-of-the-office-of-medicaid-masshealth-payments-for-hospice-related-services-for-dual-eligible-members

Audit of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Nicholas Franco

Audit Number: 2022-1374-3M2
Issue Date: May 26, 2022
Survey Response Received: November 30, 2022

Total Recommendations	2
Fully Implemented Recommendations	2
Recommendations in Progress	N/A
Fiscal Benefit	N/A

 

MassHealth partially agreed with our recommendations in the audit report, while Dr. Franco fully agreed. In the PAR survey, Dr. Franco stated that he had fully implemented both recommendations.

Audit of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Melissa Hamilton

Audit Number: 2022-1374-3M1
Issue Date: May 26, 2022
Survey Response Received: November 30, 2022

Total Recommendations	2
Fully Implemented Recommendations	1
Recommendations in Progress	1
Fiscal Benefit	N/A

 

In the PAR survey, Dr. Hamilton indicated that she disagrees with the finding. However, it appears Dr. Hamilton fully implemented our recommendation that she should collaborate with MassHealth to determine how much of the $2,063,481 in unallowable dental claims should be repaid.

Based on Dr. Hamilton’s response below she fully implemented OSA’s recommendation and worked with MassHealth to determine how much she should repay, “MassHealth recouped a lesser amount in September, 2022.”

In addition, Dr. Hamilton indicated in the PAR survey that she is making progress implementing OSA’s second recommendation: Dr. Hamilton should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations.

Date published:	March 2, 2023