Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Foster Care and Group Adult Foster Care - Finding 1

MassHealth Did Not Ensure That Adult Foster Care and Group Adult Foster Care Registered Nurses / Licensed Practical Nurses and Care Managers Conducted Required Oversight Visits.

Overview

MassHealth did not ensure that adult foster care (AFC) and group adult foster care (GAFC) registered nurses / licensed practical nurses and care managers conducted required oversight visits. Specifically, 67¹¹ out of the 119 members in our telehealth member sample were missing at least one required oversight visit by either a registered nurse / licensed practical nurse or a care manager during the audit period. Out of these 67 members, 54 were missing two or more required oversight visits by either a registered nurse / licensed practical nurse or care manager. Moreover, 34¹² out of the 128 members in our non-telehealth member sample were missing at least one required oversight visit by either a registered nurse / licensed practical nurse or a care manager. Out of these 34 members, 29 were missing two or more required oversight visits by either a registered nurse / licensed practical nurse or care manager.

The absence of required oversight visits, whether on-site or through telehealth, calls into question whether the proper quality of care was given to each member who received AFC or GAFC. Because these oversight visits also assist caregivers and direct care aides in the work they do to care for AFC and GAFC members, this also calls into question whether each caregiver / direct care aide was adequately supported in the work they provided.

Authoritative Guidance

According to Section 408.415 of Title 130 of the Code of Massachusetts Regulations (CMR),

(B)  Nursing Oversight. . . .

      (a)  For AFC level I service payment, the nurse must conduct on-site visits every other month,             or more often as the member’s condition warrant where such visits alternate with the                 required visits by the care manager to ensure the member receives one visit by the nurse             or care manager every month. . . .

      (b)  For AFC level II service payment, the nurse must conduct on-site visits every month, or                 more often as the member’s condition warrants, to ensure the member receives one visit             by the nurse and one visit by the care manager every month. . . .

(C)  Care Management. . . .

1. For AFC level I service payment, the care manager must conduct on-site visits every other month, or more often as the member’s condition warrants, where such visits alternate with the required visits by the nurse to ensure the member receives one visit by the nurse or care manager every month. . . .
2. For AFC level II service payment, the care manager must conduct on-site visits every month, or more often as the member’s condition warrants, to ensure the member receives one visit by the nurse and one visit by the care manager every month.

According to 130 CMR 408.505(B)(6),

(B)  Nursing Oversight. . . .

      (6)  [Responsibilities include] conducting on-site visits with each member at the member’s                 home every other month or more often as the member’s condition warrants, where such             visits alternate with the required visits by the care manager to ensure the member                       receives one visit by the nurse or care manager every month. . . .

(C)  Care Management. . . .

     (5)  [Responsibilities include] conducting on-site visits with each member at the member’s                  home every other month, or more often as the member’s condition warrants, where such            visits alternate with the required visits by the nurse or care manager to ensure the                       member receives one visit by the care manager or nurse every month.

Reasons for Issue

MassHealth does not have sufficient monitoring controls over care management and nursing oversight visits. AFC and GAFC providers do not bill required oversight visits separately to MassHealth; rather, these visits are included in a daily rate for AFC or GAFC services. The only way MassHealth could target the issue is by performing individual provider audits. While there were 258 providers during the audit period, MassHealth completed 3 audits of AFC and GAFC providers during the audit period and has 29 audits of AFC and GAFC providers still in progress.

Recommendation

MassHealth should establish effective monitoring controls to ensure that AFC and GAFC providers conduct the required oversight visits for MassHealth members and caregivers / direct care aides. To establish effective monitoring controls, we believe MassHealth should establish a goal for the number of AFC / GAFC providers it will audit each year.

Auditee’s Response

MassHealth agrees with this recommendation. MassHealth is committed to ensuring AFC and GAFC providers’ compliance with federal and state requirements through clear and frequent outreach to the provider network via periodic trainings and 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.

Program integrity initiatives developed and implemented since the period covered under this audit include instituting a temporary moratorium on new AFC providers from March 10, 2023, through September 10, 2023. The purpose of the temporary moratorium was to allow MassHealth to focus on enhanced training and education of existing AFC providers and the development of a more robust onboarding process for new AFC providers. Following the end of the moratorium, and in addition to instituting a more robust onboarding process, MassHealth schedules audits of every new AFC and GAFC provider within six months of their enrollment.

Additionally, to monitor compliance, and as part of MassHealth’s overall program integrity strategy, MassHealth initiates audits of 2 to 3 AFC and GAFC providers each month (approximately 24-36 audits per year). As part of these audits, MassHealth auditors review documentation submitted by providers to ensure [registered nurse / licensed practical nurse] and care manager visits are documented and occur within the timeframes required by the provider regulations. Where MassHealth identifies instances of non-compliance, MassHealth issues overpayments and sanctions as appropriate.

From 2022 to present, MassHealth has initiated 92 audits of AFC and GAFC providers (approximately 3 audits per month) and has issued 49 initial notices of overpayment and sanction, which outline MassHealth’s audit findings and initiates the recovery process for identified overpayments and sanctions.

Auditor’s Reply

We commend MassHealth for implementing stronger monitoring controls over AFC and GAFC providers.

11.    Out of these 67 members from our telehealth member sample, 1 was a GAFC member. In addition, the same GAFC member was missing two or more required oversight visits by either a registered nurse / licensed practical nurse or care manager.

12.    Out of these 34 members from our non-telehealth member sample, 2 were GAFC members. In addition, both GAFC members were missing two or more required oversight visits by either a registered nurse / licensed practical nurse or a care manager.

Date published:	September 4, 2024