Overview
We identified 865 claims, totaling $27,400 paid by MassHealth, for DME that was allegedly provided to 131 members who we proved to be deceased before the date of service indicated on the claim. We found that MassHealth paid for DME for these 131 deceased members for an average of 516 days after their dates of death and up to 2,779 days after their dates of death.
By not always identifying deceased members quickly enough, MassHealth risks paying fraudulent claims or overpaying its providers for services that were not rendered.
Authoritative Guidance
According to Section 450.235(A) of Title 130 of the Code of Massachusetts Regulations, “Overpayments include, but are not limited to, payments to a provider . . . for services that were not actually provided or that were provided to a person who was not a member on the date of service.”
Reasons for Issue
MassHealth officials told us that, although they have program integrity controls in place to prevent some inappropriate payments for deceased members, there may still be a delay between the actual date of death for a MassHealth member and when that date is entered into the Medicaid Management Information System (MMIS). This can result in the payment of claims after a member’s date of death.
Recommendations
- MassHealth should investigate the claims identified in this finding and recoup overpayments that it deems appropriate.
- MassHealth should find a way to address the lag that occurs between a member’s death and when that death is entered into MMIS. MassHealth should also use additional data sources to confirm whether a member is deceased.
Auditee’s Response
MassHealth agrees with [Recommendation 1]. MassHealth will review the claims identified by the [Office of the State Auditor (OSA)] and carry out the recovery process as appropriate. MassHealth notes that 381 of the 895 claims in the OSA’s finding have already been identified in MassHealth’s ongoing post-pay recovery process. Upon review of the OSA’s findings, MassHealth was unable to verify the date of death for one member and had verified a more recent date of death for another member, accounting for an additional 47 of the 895 claims identified by the OSA and the claims with the most days between the claim’s date of service and the member’s date of death. The remaining claims reflect cases where the member’s date of death was not present in our available death data sources at the time of our most recent analysis or MassHealth received a different date of death via an existing death data source. MassHealth will ensure that all remaining overpayments identified are validated and recovered as appropriate. . . .
MassHealth has robust program integrity controls to identify members’ dates of death and prevent or recoup payment for services made after a member’s date of death. MassHealth obtains information about deceased members in multiple ways, including but not limited to, the Department of Public Heath Vital Statistics Date of Death File, the Social Security Administration’s Death Master File (DMF) and State Verifications and Exchanges System (SVES), as well as referrals from members’ head of households, providers, managed care entities and other state and federal agencies.
Because MassHealth’s death data sources may report a member’s date of death months or years after the member’s death, MassHealth is reliant on routine post-pay recoveries to capture any services that were paid after a member’s date of death but prior to notification to MassHealth’s. MassHealth has recently increased the frequency of these reviews to occur annually, and because these reviews assess claims up to six years old, the vast majority of claims paid after a member’s date of death are ultimately recouped even when a death data source identifies a date of death years after the member’s death. In addition, MassHealth will continue to collaborate with state and federal agencies to access new sources of death data to improve the identification members’ dates of death.
Auditor’s Reply
MassHealth stated that it has increased the frequency of post-payment reviews and continues to collaborate with state and federal agencies to improve the quality of its death data. As part of our post-audit review process, we will follow up on this matter in approximately six months.
| Date published: | October 30, 2025 |
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