Overview
During the audit period, MassHealth made $337,829 in overpayments to adult day health (ADH) providers for services that MassHealth did not authorize and/or that did not have supporting documentation, such as service notes, attendance logs, or Remote Services Logs. Specifically, we found that MassHealth paid providers for 11 out of 71 members in our sample to receive ADH without prior authorization, accounting for 1,432 claims, totaling $75,144. Additionally, we found that MassHealth paid providers for 67 out of the 71 members in our sample to receive ADH that was not documented with attendance logs, Remote Services Logs, or service notes. This accounted for 6,965 claims, totaling $262,685. It should be noted that $123,773 out of the $262,685 (47%) in undocumented ADH claims were for retainer payments to ADH providers.
When ADH providers do not fully document the services provided to MassHealth members, MassHealth cannot ensure that its members receive services that are consistent with their plans of care. Additionally, by not authorizing ADH before making payments to providers, MassHealth risks paying providers for unnecessary services.
Authoritative Guidance
MassHealth’s ADH Bulletin 18, effective August 2020 through December 2020, states,
All remote/telehealth/in-person service delivery must be clearly documented in the member’s record, noting how the service provided promoted the prevention of decompensation of member’s baseline and/or care management services that were provided to maintain safety in the home. Documentation of telehealth must indicate that the visit was completed via telehealth due to COVID-19, note any limitations of the visit, and include a plan to follow up on any medically necessary components deferred due to those limitations.
Providers must complete the Remote Services Log for each month remote services are provided, delineating the services that were provided to each member.
MassHealth’s ADH Bulletin 20, effective January 2021 through December 2021, states,
All remote service delivery must be clearly documented in the member’s record, noting how the provided service promoted the prevention of decompensation of member’s baseline and/or aligned with the member’s plan of care. Documentation must indicate that the visit was completed remotely or in-home due to COVID-19 and include a plan to follow up on any medically necessary components. . . .
Providers must maintain accurate attendance records for each date of service on which services were provided to members in the congregate setting. Members’ scheduled remote services must be documented and maintained onsite. The ADH provider must document scheduled remote services for each date for which services are billed and make this information available to the MassHealth agency or its designee upon request.
Section 404.406(B)(1) of Title 130 of the Code of Massachusetts Regulations (CMR) states, “As a prerequisite for payment of ADH, the ADH provider must obtain prior authorization from the MassHealth agency or its designee before the first date of service delivery and annually thereafter, or upon significant change.”
According to 130 CMR 404.414(D)(1)(b) and (D)(2)(c),
The ADH provider must document how a qualifying . . . needs were met for each member in a manner consistent with the member’s plan of care on each date for which services are billed and make this information available to the MassHealth agency or its designee upon request. Such documentation must include evidence of the following having been provided pursuant to the member’s plan of care: daily ADL service delivery, daily behavior support or evaluation, daily activity participation, and/or evidence of skilled services care.
Reasons for Issue
MassHealth officials informed us that between April 1, 2020 and July 31, 2020, ADH providers were allowed to submit claims for each day that members would have been scheduled to attend the ADH provider’s program. MassHealth implemented retainer payments to financially support ADH providers and ensure the continued delivery of services. MassHealth officials told us that system edits, which are designed to prevent the payment of unauthorized services, in the Medicaid Management Information System (MMIS) were not implemented until September 1, 2021.
Additionally, MassHealth did not have sufficient procedures in place to regularly review its ADH providers’ documentation of the services they provided to members.
Recommendations
- MassHealth should ensure that system edits to prevent payments for ADH without prior authorization are properly implemented.
- MassHealth should investigate the paid claims identified by the Office of the State Auditor (OSA) and take corrective action as it deems appropriate. MassHealth should also investigate for improper documentation of ADH claims from providers that OSA did not review.
Auditee’s Response
Regarding recommendation 1. . . MassHealth delayed the planned activation of a system edit related to prior authorization that—prior to the pandemic—had been set to be activated on April 15, 2020. MassHealth made the decision to delay activation of the edit to avoid further disruption to the ADH program at a time when ADH providers had been forced to close and MassHealth was intently focused on finding ways to retain the existence of ADH providers and ensure the continued availability of ADH services. This decision was also premised on the understanding that any claims for ADH services that were paid absent a [prior authorization (PA)] could be recovered via post payment review, a process which has since occurred, and as noted in further detail below. Ultimately MassHealth activated the PA edit on September 1, 2021, after the height of the pandemic had receded. . . .
Regarding recommendation 2, MassHealth agrees with this recommendation. MassHealth will review the OSA’s findings and recover any identified overpayments that are not already subject to ongoing MassHealth provider audits and recoveries. Specifically, and as noted above, MassHealth is finalizing a claim-based algorithm recovery for ADH services provided without a PA, which encompass the OSA’s audit period and was previously in development as part of MassHealth’s standard program integrity controls. Further, MassHealth will ensure that any findings from the OSA not captured in the existing recovery project will be validated and pursued through overpayment recoveries as appropriate.
MassHealth further requests, however, that in . . . the draft audit report, where it states “$123,733 out of the $262,685 (47%) in undocumented ADH claims were for retainer payments to ADH providers” that the auditor identify whether the identified retainer payment claims with no documentation were for dates that occurred in a week with no other documentation of a member contact, as it was permissible for ADH providers to claim multiple retainer payments in a given month so long as they had at least one contact with the member during each week in that month.
Auditor’s Reply
In its response, MassHealth states that it delayed activating the system edit to prevent payment for ADH without a prior authorization from April 15, 2020 until September 1, 2021 to avoid further disruption to the ADH program during the COVID-19 pandemic. We recognize the need for MassHealth to avoid disruptions in the ADH program during that difficult time. We also believe it is critical to ensure that ADH is authorized, especially during a public health emergency, to ensure that these resources are being directed to those who need them. Further, we note that the MassHealth regulation requiring prior authorization for ADH was effective as of July 27, 2018, approximately 19 months before the start of the COVID-19 pandemic. This system edit could have been implemented at that time.
Additionally, in its response, MassHealth requests that we identify whether the retainer payment claims with no documentation were for dates that occurred in a week with no other documentation of a member contact, as multiple retainer payments were allowed in a given month if ADH providers contacted MassHealth members at least once per week. During our audit, we requested documentation for ADH provided to MassHealth members that covers the entire months in question. We found no evidence of any service provided to the members associated with the retainer payments that we identified in our finding and, therefore, consider these retainer payments to be unallowed.
| Date published: | October 1, 2024 |
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