Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Day Health - Finding 3

MassHealth Paid Providers $11,797 for 109 Claims for Services Allegedly Rendered to 31 Members Who Were Proven To Be Deceased.

Overview

We identified 109 claims, totaling $11,797, paid by MassHealth for Medicaid-covered services that were allegedly provided to 31 members whom we proved to be deceased before the date of service indicated on the claim. The graph below details the maximum number of days after death that each of the 31 members we identified allegedly received a medical service paid for by MassHealth.

Number of Days after Death That Services Were Allegedly Performed

By not always identifying deceased members, MassHealth risks paying fraudulent claims or overpaying its providers for services that were not rendered.

Authoritative Guidance

According to MassHealth’s administrative and billing regulations outlined in 130 CMR 450.235(A), “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 MMIS. This can result in the payment of claims after a member’s date of death. Additionally, 17 out of the 31 members identified by OSA as having claims paid after their date of death did not appear in the Department of Public Health’s Vital Statistics file and were therefore excluded from MassHealth’s post-death MMIS algorithms.

Recommendations

1. MassHealth should update its MMIS algorithms to cross-reference members’ dates of death with additional data sources and not rely solely on the Department of Public Health’s Vital Statistics file when verifying members’ dates of death.
2. MassHealth should establish a plan to recoup the $11,797 in overpayments it made on behalf of deceased members. 

Auditee’s Response

MassHealth agrees with these recommendations. MassHealth has robust program integrity controls in place to prevent payments after a member’s date of death. However, due to issues often beyond MassHealth’s control (e.g., inaccurate sources of death data and time lags in access to death data), it is possible for such payments to occur. As a result, MassHealth also has robust controls in place to identify and recover such claims post-payment.

Regarding recommendation 1, MassHealth has adjusted its program integrity processes to improve the identification and recovery of inappropriately paid claims for dates of service after a member’s date of death. Historically, it had been MassHealth’s process to use Department of Public Health (DPH) Vital Statistics data to identify claims that were incorrectly paid for dates [of] service after a member’s date of death; only members matching on the DPH Vital Statistics file would be included in any findings. MassHealth must balance the risk of missing potential overpayments with the risk of relying on less reliable sources of death data in pursuing recoupments of potential overpayments. In light of the OSA’s recommendation, as of January 2024, MassHealth has updated its program integrity efforts to no longer exclude members from post-death algorithms when members do not appear in the DPH Vital Statistics file.

Regarding recommendation 2, MassHealth agrees with this recommendation. MassHealth will review the claims identified by the OSA and carry out the recovery process as appropriate. MassHealth notes that 28 of the 109 claims have already been identified and included in initial notices of overpayment issued to the associated providers. MassHealth will ensure that all remaining overpayments identified are validated and recovered as appropriate.

Auditor’s Reply

We commend MassHealth for adjusting its program integrity process to include data sources outside of the Department of Public Health’s Vital Statistics file to identify potentially deceased MassHealth members. MassHealth also states that it will review the claims that we identified and recoup payments as appropriate. Based on its response, it appears that MassHealth is taking action to address our concerns regarding this finding. 

Date published:	October 1, 2024