Overview
During this reporting period, the Office of the State Auditor (OSA) began or continued work on 17 audits on MassHealth’s administration of the Medicaid program and on Medicaid service providers’ compliance with state and federal laws, regulations, and other authoritative guidance. These audits were selected based on our research and applied data analysis to identify areas of risk in the state’s Medicaid program. We anticipate that these audits will identify millions of dollars in questionable, unallowable, unauthorized, and potentially fraudulent payments. As part of our current initiatives, we will make recommendations to strengthen internal controls and oversight in MassHealth’s program administration. The following is a summary of our Medicaid audit work in process.
- A review of claims paid for members with both Medicaid and Medicare eligibility (referred to as “dual eligible” members) for the period July 1, 2010 through June 30, 2015. We will determine whether MassHealth inappropriately paid healthcare expenses for members already covered by Medicare.
- A review of MassHealth members’ access to counseling services when they were being treated with buprenorphine/naloxone (also known as suboxone) for substance use disorders (SUDs) for the period January 1, 2011 through March 31, 2017. We will determine whether members who had SUDs and were being treated with buprenorphine/naloxone had access to appropriate counseling services to aid in their recovery.
- A review of pharmacy claims paid by MassHealth for refilled prescriptions for the two-and-a-half-year period ended June 30, 2017. We will determine whether MassHealth improperly paid for prescription refills that the pharmacy program had specifically eliminated or disallowed, including whether (1) prescription refills exceeded the maximum number allowed per year, (2) emergency refills exceeded the allowed period (72 hours or 3 days), (3) refills were dispensed one year or more after the prescription dates, (4) refills exceeded the number allowed on a prescription, (5) refills were provided when there was no indication of whether the prescription could be refilled, (6) refills were provided when there was no specific request from the member or his/her caregiver to refill the prescription (e.g., when the prescription was an auto-refill), or (7) “splitting” of prescriptions occurred with refills. (Splitting is a potentially fraudulent billing scheme; prescriptions generally are required to be 30-day supplies or more.)
- A review of a vision-care provider for the five-and-a-half-year period ended December 31, 2016. This audit will determine whether the optometrist properly billed and maintained appropriate documentation for services he provided on a statistical sample of patients, including patients residing in state facilities (such as those operated by the state Department of Youth Services) and in homes run by the Department of Children and Families.
- A review of services provided by an SUD treatment provider for the three-year period ended December 31, 2016. We will determine whether the provider properly documented SUD treatment and drug tests provided to MassHealth members and used the drug tests to treat and diagnose the members.
- A review of an orthodontic-service provider for the five-year period ended June 30, 2017. We will determine whether orthodontic services provided to MassHealth members were properly supported by documentation and allowable in accordance with certain MassHealth regulations.
- A review of MassHealth’s recoupment processes for the five-year period ended December 31, 2017. We will determine whether MassHealth’s recoupment processes effectively identified, recorded, and collected all overpayments and recoupments.
- Four separate audits of MassHealth’s enrollment offices (Tewksbury, Chelsea, Springfield, and Taunton) for the two-year period ended December 31, 2017. We will determine whether the enrollment offices effectively evaluated new applicants in accordance with certain MassHealth eligibility requirements.
- Four separate audits of certain adult day health (ADH) centers for the two-year period ended December 31, 2017. We will determine whether the ADH centers maintained proper documentation and provided services to MassHealth members in accordance with certain MassHealth regulations.
- A review of claims for drug tests and drug screens for the period March 1, 2013 through June 30, 2017. We will determine whether MassHealth properly identified and denied payment for both duplicate and unbundled drug tests. This audit will follow up on our prior audit on this subject (No. 2013-1374-3C), in which OSA identified significant weaknesses in these areas resulting in millions of dollars of improper claim payments.
- A review of drug tests that MassHealth paid for during the audit period to determine whether the nature and frequency of member drug testing complied with MassHealth regulations, which allow authorized prescribers treating MassHealth members to order and use drug tests for diagnosis, treatment, or otherwise medically necessary purposes. The audit period is July 1, 2012 through June 30, 2016. In a previously issued audit report (No. 2012-1374-3C), OSA disclosed significant weaknesses in MassHealth’s claim-processing system for drug tests, which resulted in millions of dollars in potentially improper payments.
| Date published: | March 15, 2018 |
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