Office of Medicaid (MassHealth)—Review of Payment for Telehealth Adult Foster Care and Group Adult Foster Care - Finding 3

MassHealth Paid for Adult Foster Care and Group Adult Foster Care Caregiver / Direct Care Aide Services That Were Incorrectly Coded As Telehealth.

Overview

MassHealth paid for AFC and GAFC services with the service code for telehealth when caregiver / direct care aide services are not allowable telehealth services. During the audit period, 5 out of the 258 AFC and GAFC providers incorrectly included the telehealth code in their bills, totaling $22,979,654¹⁴ in AFC and GAFC services.

If MassHealth pays for services billed incorrectly without verifying how the services are provided, it may pay for unallowable services. By paying for unallowable services, MassHealth will have less money available to pay for allowable services for other MassHealth members.

Authoritative Guidance

MassHealth Adult Foster Care Bulletin 21, dated September 2021 states,

Adult foster care and group adult foster care providers may not use telehealth for

• Caregiver or direct care aide assistance with activities of daily living or instrumental activities of daily living, inclusive of cueing and supervision of such activities.

Reasons for Issue

MassHealth does not have sufficient system controls to prevent the payment of unauthorized services in the Medicaid Management Information System (MMIS). These controls should automatically deny payment for caregiver / direct care aide telehealth services from AFC and GAFC providers.

Recommendation

MassHealth should add a system control in MMIS to deny AFC and GAFC caregiver / direct care aide services in a telehealth setting.

Auditee’s Response

MassHealth agrees with this recommendation. MassHealth will implement a system edit to prevent AFC and GAFC providers from submitting claims for AFC / GAFC services when coded as telehealth.

As noted above, because personal care is a type of care that cannot be delivered via telehealth, AFC and GAFC providers were not—and are not—permitted to use telehealth for the delivery of personal care. MassHealth appreciates that the [Office of the State Auditor] draft report acknowledges that the identified claims were billed as telehealth in error and that AFC / GAFC services were in fact rendered in person and based on the auditor’s review of provider documentation. MassHealth further notes this error appears to be concentrated to a small percentage of providers within the network with only 5 out of 268 providers having billed claims coded as telehealth. As noted above, MassHealth agrees with the recommendation and will implement an edit to prevent the ability for AFC / GAFC claims to be submitted when coded as telehealth.

Auditor’s Reply

Based on its response, MassHealth agrees with our recommendation and plans to implement the system control to prevent providers the ability to submit claims for AFC and GAFC as telehealth. We will be conducting a post-audit review in approximately six months to follow up.

14.    It should be noted that we determined through testing that this was a coding error and that the services were actually provided in person. Given the coding of these services, these bills should have been rejected because they were submitted as telehealth expenses and therefore were ineligible for payment.

Date published:	September 4, 2024