Medicaid Audit Unit Completed Audits, March 2, 2022 - March 1, 2023

An overview of the audits conducted by the Medicaid Audit Unit over the past year, and their findings.

Overview

During this reporting period, the Office of the State Auditor (OSA) released five audit reports on MassHealth’s compliance with state and federal laws, regulations, and other applicable authoritative guidance. These reports identified $96,444,509 in improper payments for telehealth providers and two dental services providers. The reports also made a number of recommendations to strengthen internal controls and oversight in MassHealth’s program administration. The following is a summary of our Medicaid audit work.

Office of Medicaid (MassHealth)—Review of Telehealth

The purpose of this audit was to determine whether MassHealth monitored telehealth practices for behavioral health services to ensure compliance with its All Provider Bulletins 281, 289, 291, 298, 303, and 314.

 

OSA reported one finding in this audit:

1. MassHealth made payments totaling at least $91,852,881 to its providers for telehealth behavioral health services that were not properly documented.

OSA’s recommendation to MassHealth was as follows:

1. MassHealth should train its providers, and establish monitoring controls, to ensure that telehealth services are documented in accordance with its All Provider Bulletins.

Additional Resources

https://www.mass.gov/audit/audit-of-the-office-of-medicaid-masshealth-review-of-telehealth

Office of Medicaid (MassHealth)—Review of Continuity of Operations Plan

The purpose of this audit was to determine whether MassHealth: (1) annually updated its continuity of operations plan (COOP) for its mission-critical information technology system, the Medicaid Management Information System (MMIS), and (2) updated its disaster recovery plan (DRP) and tested the DRP annually.

 

OSA reported two findings in this audit:

1. MassHealth did not annually update its COOP or conduct staff training or exercises related to the plan.
2. MassHealth did not annually update or test its DRP.

OSA’s recommendations to MassHealth to address these issues were as follows:

1. MassHealth should establish monitoring controls to ensure that it properly adheres to the policies and procedures it has established for updating and testing its COOP.
2. MassHealth should work with the Executive Office of Health and Human Services to annually update its COOP and conduct staff training and exercises.
3. MassHealth should establish written policies and procedures for assigning, managing, and monitoring its DRP.
4. MassHealth should identify an offsite disaster recovery location to use for MMIS. Once the site has been selected, MassHealth should test the updated DRP and incorporate the results into it.

 

Additional Resources

https://www.mass.gov/audit/audit-of-the-office-of-medicaid-masshealth-review-of-continuity-of-operations-plan

Office of Medicaid (MassHealth)—Massachusetts Delivery System Reform Incentive Payment Program

The purpose of this audit was to determine whether MassHealth administered Delivery System Reform Incentive Payment (DSRIP) Program payments in accordance with the DSRIP Protocol.

OSA reported one finding in this audit:

1. MassHealth did not ensure that accountable care organizations (ACOs) submitted their budget proposals before the beginning of the budget period.

OSA’s recommendation to MassHealth was as follows:

1. MassHealth should establish monitoring activities to ensure that every ACO submits its budget proposal before the beginning of each budget period.

Additional Resources

https://www.mass.gov/audit/audit-of-the-office-of-medicaid-masshealth-massachusetts-delivery-system-reform-incentive-payment-program

Review of Claims Submitted by Dr. Melissa Hamilton

The audit was initiated as the result of a referral from OSA’s Bureau of Special Investigations (BSI).[1] BSI conducted data analytics of Dr. Hamilton’s claims that identified potential improper payments.

[1].     BSI is charged with investigating potential fraudulent claims or wrongful receipt of payment or for services from public assistance programs.

 

OSA reported one finding in this audit:

1. Dr. Hamilton had inadequate documentation to support at least $2,063,481 in dental claims.

OSA’s recommendations to Dr. Hamilton to address this issue were as follows:

1. Dr. Hamilton should collaborate with MassHealth to determine how much of the $2,063,481 in unallowable dental claims should be repaid.
2. Dr. Hamilton should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations.

Additional Resources

https://www.mass.gov/audit/audit-of-the-office-of-medicaid-masshealth-review-of-claims-submitted-by-dr-melissa-hamilton

The audit was initiated as the result of a referral from OSA’s BSI. BSI conducted data analytics of Dr. Franco’s claims that identified potential improper payments.

 

OSA reported one finding in this audit:

1. Dr. Nicholas Franco did not have adequate documentation to support at least $2,528,147 in dental claims.

OSA’s recommendations to Dr. Franco to address this issue were as follows:

1. Dr. Franco should collaborate with MassHealth to determine how much of the $2,528,147 in unallowable dental claims should be repaid.
2. Dr. Franco should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations and American Dental Association (ADA) guidelines.

Additional Resources

https://www.mass.gov/audit/audit-of-the-office-of-medicaid-masshealth-review-of-claims-submitted-by-dr-nicholas-franco

Date published:	March 2, 2023