Overview
During this reporting period, the Office of the State Auditor (OSA) began or continued work on 12 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 the 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 counseling provided to MassHealth members receiving medication-assisted treatment for opioid use disorders for the period January 1, 2011 through December 31, 2015. We will perform data analysis on counseling provided to these members and conduct interviews of a statistical sample of members’ prescribers to understand whether prescribers are able to facilitate member participation in medically necessary counseling and, if not, what barriers both prescribers and members may be experiencing.
- A review of claims paid for members with both Medicaid and Medicare eligibility (referred to as “dual eligible” members) for the period July 1, 2014 through June 30, 2017. We will determine whether MassHealth inappropriately paid for healthcare expenses for members for whom it made “buy-in” payments that should have been covered by Medicare.
- 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 three 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 their 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 scenario; prescriptions are generally required to be 30-day supplies or more.)
- A review of a vision-care provider who primarily provided services at nursing facilities for the three-year period ended December 31, 2017. We will determine whether medical 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 three-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 (in Tewksbury, Chelsea, Springfield, and Taunton) for the two-year period ended December 31, 2017. We will determine whether the offices effectively evaluated new applicants in accordance with certain MassHealth eligibility requirements.
- Two 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 a physician who primarily provided services in nursing facilities and hospital settings for the three-year period ended December 31, 2018. We will determine whether medical services provided to MassHealth members were properly supported by documentation and allowable in accordance with certain MassHealth regulations.
| Date published: | March 15, 2019 |
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