Overview
During the audit period, MassHealth paid ADH providers for transportation claims that it did not authorize and/or did not have any supporting documentation. Specifically, we found that ADH providers did not obtain prior authorization from MassHealth for 17 out of 53 MassHealth members in the population of members who may have received telehealth ADH and transportation on the same day. This accounted for 632 ADH and transportation claims, totaling $47,572. We also found that telehealth ADH and transportation claims for 45 out of 53 members who may have received telehealth ADH and transportation on the same day did not have supporting documentation, such as service notes, attendance logs, or transportation logs. This accounted for $58,658 paid by MassHealth for 1,315 telehealth ADH and transportation claims. Additionally, 8 out of 53 MassHealth members who may have received telehealth ADH and transportation on the same day did not have a plan of care on file with an ADH provider to document how members’ qualifying needs for ADH were to be met in a telehealth format. This accounted for 112 telehealth ADH claims, totaling $9,827.
When providers submit claims for ADH without maintaining documentation to support how the service was performed, MassHealth risks paying for services that are not appropriate for a member’s needs, or that may not have been provided at all.
Further, because none of the claims for the 45 members identified in our testing had supporting documentation, we were unable to determine whether transportation services were provided on the same day that members received telehealth ADH. By not ensuring that telehealth claims are adequately documented by providers, MassHealth limits its capabilities to detect potential fraud.
Authoritative Guidance
According to 130 CMR 404.406(B)(1),
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(C)(3), “The MassHealth agency pays ADH providers for ADH only if the . . . ADH provider has obtained prior authorization for MassHealth payment for ADH in accordance with the requirements.”
According to 130 CMR 404.414 (D)(1)(b),
The ADH provider must document how a qualifying need or 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, as applicable: daily ADL service delivery, daily behavior support or evaluation, daily activity participation, and/or evidence of skilled services care.
According to 130 CMR 450.205(A),
The MassHealth agency will not pay a provider for services if the provider does not have adequate documentation to substantiate the provision of services payable under MassHealth. All providers must keep such records, including medical records, as are necessary to disclose fully the extent and medical necessity of services provided to, or prescribed for, members and must provide to the MassHealth agency and the Attorney General’s Medicaid Fraud Division, the State Auditor and the United States Department of Health and Human Services on request such information and any other information about payments claimed by the provider for providing services. . . .
MassHealth’s ADH Bulletin 18, effective August 2020 through December 2020, states the following:
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, further 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.
Reasons for Issue
MassHealth officials told us that MassHealth did not implement system edits in MMIS to deny ADH claims that did not have prior authorization until September 1, 2021. MassHealth officials told us that this was based on a decision by MassHealth leadership to help maintain services provided to members during the COVID-19 pandemic. Additionally, MassHealth does not have sufficient procedures in place to regularly review its ADH providers’ documentation of the services they provide to their 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 OSA and take corrective action as it deems appropriate. MassHealth should also investigate ADH claims from providers outside the five OSA reviewed for improper documentation.
- MassHealth should establish monitoring controls to ensure that ADH claims are documented.
Auditee’s Response
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 investigations and recoveries. Of note, MassHealth is currently finalizing a claim-based algorithm recovery for ADH nonemergency transportation services provided without a PA for ADH services, 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.
Regarding recommendation 3, MassHealth agrees with this recommendation and is committed to ensuring ADH providers’ compliance with documentation requirements. MassHealth works to ensure ADH provider compliance via training conducted during provider meetings, as well as robust program integrity controls. Such program integrity controls include a comprehensive set of pre-pay edits, a prior authorization process that ensures services rendered are clinically appropriate, post-payment claims recoveries, and regularly scheduled audits of providers. Specifically, MassHealth regularly initiates 1 to 2 ADH provider audits per month which may result in the issuance of corrective actions and overpayments for improper documentation. Since January 1st, 2022, MassHealth has initiated 36 audits of ADH providers and has issued 20 initial notices of overpayment which detail the agency’s overpayment and sanction findings.
Auditor’s Reply
MassHealth agrees with our recommendations and states that it will investigate the claims that we identified and recover overpayments as necessary. Further, MassHealth states that it has implemented program integrity controls to deny ADH claims as appropriate and regularly audits ADH providers for compliance with MassHealth billing regulations. Based on its response, it appears that MassHealth is taking action to address our concerns. We will follow up on this during our post audit review process, which will occur approximately six months from now.
| Date published: | October 1, 2024 |
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