The Bureau of Program Integrity:
1) Prevents and detects fraud, waste and abuse in the programs administered by the Executive Office of Health and Human Services
2) Makes recommendations to improve the business processes that support benefits programs
Created by the legislature in 2013, the Bureau of Program Integrity (“Bureau”) monitors the quality, efficiency and integrity of programs administered by the Executive Office of Health and Human Services (“EOHHS”). The Bureau contributes to the overall mission of the Office by conducting investigations and reviews in order to prevent and detect fraud, waste and abuse.
In addition, pursuant to its enabling statute, M.G.L. c. 6A, § 16V, the Bureau must assist EOHHS agencies in order to:
- Improve eligibility processes
- Coordinate program integrity efforts
- Enhance data sharing
After the Bureau was created, the legislature added a specific mandate in Section 36 of Chapter 18 of the Massachusetts General Laws for the Bureau to work in consultation with the Department of Transitional Assistance (“DTA”) to develop a fraud detection program.
To fulfill its mandates, the Bureau conducts ongoing assessments of fraud and business risks. The Bureau takes many factors into account to assess risks, including:
- The mission and scope of EOHHS programs
- The potential impact on public funds
- The potential impact on participants in the program
- Historical context regarding previously identified risks or corrective actions
With access to databases related to EOHHS agencies and programs, the Bureau relies extensively on data and analysis to conduct risk assessment. The Bureau follows up on its investigations, reviews and recommendations in order to ensure that EOHHS agencies continuously improve their administration of programs and address risks expeditiously.
While maintaining the Office’s independence, the Bureau works collaboratively with the senior management teams at EOHHS and its agencies. Since its creation in 2013, the Bureau has expanded the scope of its work beyond its initial engagement with DTA.
In 2019, in addition to DTA, the Bureau engaged with the Department of Developmental Services (“DDS”), the Department of Mental Health (“DMH”) and the Department of Children and Families (“DCF”). This year, as discussed below, the Bureau also evaluated the quality, efficiency and integrity of the services provided by EOHHS vendors and the oversight that EOHHS agencies exercised over these vendors.
The Bureau also works in conjunction with other divisions within the Office on investigations and reviews. For example, in 2019, the Bureau assisted the Audit, Oversight and Investigations Division with 16 complaints made through the Office’s hotline. In several instances, the Bureau opened a review or investigation in response to such complaints. These complaints also served as an important foundation for identifying emerging trends related to fraud and business risks in EOHHS agencies and programs.
2019 Highlights for the Bureau
- Assisted with the prosecution of a DDS employee for overtime fraud totaling $40,000
- Assisted with the prosecution of a DDS employee charged with misappropriating DDS funds to buy $15,000 worth of groceries for her personal use
- Hosted a statewide Summit for 40 managers from EOHHS and its agencies on the administration of Supplemental Nutrition Assistance Program (“SNAP”) benefits to residents of group homes
- Trained EOHHS investigators on the misuse of SNAP benefits at a training session hosted by the Disabled Persons Protection Commission
- Recommended the implementation of a Program Integrity Division within DMH
- Supported the development of DDS’s Bureau of Program Integrity and DDS’s internal controls and risk management program
- Consulted with the Program Integrity Division at DTA to enhance data matching
- Conducted reviews and investigations related to the quality, efficiency and integrity of vendors that administer EOHHS programs, as well as the oversight that EOHHS agencies exercise over such vendors, including:
- DDS vendors administering group homes
- DTA’s initial implementation of a new contract for a $64-million employment services program
- DCF’s implementation of its after-hours hotline contract
I. SNAP Administration and Group Homes
Starting in 2017, while investigating a whistleblower complaint about a DDS employee who allegedly diverted resources from a group home to buy food for her personal use (which, as mentioned, led to a criminal prosecution), the Bureau found vulnerabilities in DDS’s approach to administering SNAP benefits in the group homes that it operates (“state-operated group homes”).
Group homes are small, community-based residences that provide 24-hour, seven-day-a-week care to residents. Group homes in Massachusetts are operated directly by an EOHHS agency or a vendor. In light of the vulnerabilities found and the significant amount of public funds involved, the Bureau identified the administration of SNAP benefits in group homes as a priority area, and it has developed partnerships with the senior leadership teams at EOHHS and its agencies to address identified risks.
During an investigation of a DDS employee, the Bureau found that DDS was not exercising appropriate stewardship of the SNAP benefits and recommended stronger controls for the administration of SNAP benefits on behalf of group home residents. To restructure DDS’s administration of SNAP benefits, throughout 2018 and 2019, the Bureau facilitated a working group that included managers from DTA and DDS who shared data, reviewed cases and engaged in problem-solving.
Starting in August 2018, the Bureau helped facilitate a second working group with DTA and DMH. This working group focused on group homes operated directly by DMH, which DMH calls Group Living Environments (“GLEs”). Throughout 2019, the Bureau supported both of these working groups with data analysis and other technical assistance aimed at assessing and addressing business risks and building an internal controls infrastructure for administering SNAP benefits to residents of group homes.
The senior leadership team at EOHHS provided valuable support for these working groups and agreed to work collaboratively with the Bureau on a Secretariat-wide effort to improve the administration of SNAP benefits in a variety of EOHHS group-living programs.
A. Statewide Summit for EOHHS Managers and Its Agencies
In May 2019, in partnership with EOHHS, the Bureau convened an innovative, one-day Summit for representatives from DTA, DDS, DMH and the Department of Public Health (“DPH”).
The Summit focused on the stewardship of SNAP benefits and public funds, and included training on SNAP program rules and on how to conduct risk assessments. The Bureau presented on the fraud risks in the group home setting; the Bureau emphasized that the best approach to serving residents of group homes involves collaborative case management and SNAP utilization monitoring efforts. At the Summit, the Bureau and EOHHS outlined the following next steps for EOHHS agencies:
- Secretariat-wide risk assessment, with the assistance of the Bureau, to identify vulnerabilities and improve controls related to the misuse and misappropriation of SNAP benefits in state- and vendor-operated group homes
- Data-sharing to identify SNAP recipients who reside in group homes
- Budget planning around food purchasing, facilitated by EOHHS, to maximize the value and minimize the waste of SNAP benefits.
Following the Summit, the Bureau analyzed SNAP enrollment data to learn more about utilization of SNAP benefits in group homes operated by vendors.
The Bureau found that there was significant variation among vendors in their SNAP enrollment rates. This data raised questions about whether vendors were fulfilling their obligations to maintain SNAP benefits for group home residents, to utilize those benefits on behalf of the residents, and to offset the cost of food for group homes. The Bureau presented these findings at a post-Summit meeting in October 2019, hosted by EOHHS, to a group of managers representing EOHHS agencies.
To expedite risk assessment, the Bureau continued using the working group model; the Bureau facilitated working group meetings and led discussions about how DTA and DDS could share and analyze data related to vendor billing and SNAP benefit utilization. DDS worked directly with the Bureau to review enrollment issues and assess the extent to which vendors may have failed to maintain SNAP benefits and offset the cost of food in group homes.
To complement the Bureau’s risk assessment work, EOHHS and DDS initiated outreach to the vendor community to discuss problem-solving and training opportunities related to SNAP administration.
II. Department of Developmental Services
In addition to improving the administration of SNAP benefits in DDS group homes, the Bureau continued its broader efforts to improve DDS’s internal controls infrastructure and to address fraud and business risks in its administration of group home programs.
In 2019, the annual budget appropriation for state-operated group homes was $217 million. The appropriation for vendor-operated group homes falls under a broader appropriation of $1.2 billion for “residential and day programs” operated by vendors, which also includes several other types of community-based services.
A. DDS Bureau of Program Integrity
The Bureau continued to meet with DDS management on a regular basis throughout 2019, monitoring DDS’s responses to the Bureau’s recommendations and assisting DDS with developing its internal controls infrastructure. In 2018, in response to the Bureau’s recommendations, DDS created its own Bureau of Program Integrity (“DDS BPI”) and an internal fraud hotline. In 2019, DDS BPI expanded its capacity by hiring additional staff and placing internal controls coordinators in each regional office.
In addition, the Bureau regularly collaborated with managers in the DDS BPI who operate an internal fraud hotline. The number of complaints to DDS’s hotline tripled between fiscal year 2018 (12 hotline complaints) and fiscal year 2019 (36 hotline complaints).
Hotline complaints, which can be anonymous and from any source inside or outside of DDS, covered a range of fraud and theft issues involving DDS field offices, state-operated group homes and programs administered by vendors. The Bureau checked to ensure that DDS was:
- Conducting internal reviews
- Implementing risk management protocols
- Referring appropriate cases to law enforcement or other appropriate authorities
B. State-Operated Group Homes
During 2018 and 2019, the Bureau outlined an extensive series of recommendations to strengthen the management of group homes, which were informed by complaints to the Office’s hotline, the DDS hotline, data analysis, document review and employee interviews.
For example, the Bureau recommended and assisted DDS with identifying, pilot testing and implementing new procedures for food purchasing and payroll monitoring. In particular, the Bureau’s investigators and analysts worked directly with DDS BPI to review payroll data and identify “red flags” for fraud and waste. The Bureau also provided technical assistance while DDS BPI developed reports, based on these “red flags,” to monitor payroll data.
These reports will help DDS supervisors and managers look for patterns and trends, such as excessive overtime hours and deviations from procedures regarding supervisory approval of electronic timecards. The Bureau’s efforts were aimed at preventing the abuse of overtime, minimizing other vulnerabilities and building better, sustainable business practices for state-operated group homes.
To further strengthen the management of group homes, the Bureau focused a series of recommendations specifically on the role of the residential supervisor. Residential supervisors, also known as house managers, are the on-site managers of state-operated group homes. Through its investigative work, the Bureau found that DDS lacked controls and procedures for residential supervisors to follow. Where procedures were in place, residential supervisors often violated them or made ad hoc changes. There was also evidence that many of them had insufficient business skills to support their responsibilities for recordkeeping and data entry.
The Bureau recommended that DDS take significant steps to:
- Manage and monitor residential supervisors more closely
- Develop the business skill sets of residential supervisors
- Create procedures to ensure consistency of practice among group homes
- Enforce and monitor compliance with existing policies and procedures
C. Vendor-Operated Group Homes
Vendors provide the vast majority of DDS’s group home services; these vendors are non-profit organizations that vary in size and business structure. In 2019, 338 vendors provided residential and day program services to developmentally disabled individuals; within that group of 338 vendors, 112 vendors run group homes and serve approximately 8,400 individuals.
As discussed above, the Bureau reviewed vendors’ administration of SNAP benefits to group home residents and grew concerned about vendors’ fiscal management and potential waste of public funds. Informed by additional budget data and hotline complaints about other potential waste and fraud, the Bureau initiated investigations and reviews and found significant concerns about selected vendors’ fiscal management and stewardship of public funds.
The Bureau also identified significant concerns about gaps in DDS’s infrastructure for contract administration. As a result, the Bureau brought these concerns to the senior leadership at EOHHS and DDS in order to develop further context for them and to set priorities for problem-solving.
The Bureau recommended that DDS:
- Utilize data analytics for program monitoring and risk assessment
- Leverage the resources of DDS BPI to create systems for detecting fraud and waste in vendors’ fiscal management and operations
- Break down internal silos and integrate resources within DDS to improve contract administration
III. Department of Transitional Assistance
In 2019, the Bureau continued its support for DTA’s Budget and Policy Analytics group, the internal group of data analysts at DTA who support data-informed and evidence-based management at DTA. The Bureau provided technical assistance and identified opportunities for DTA to study its own data in order to:
- Conduct risk assessment
- Evaluate program implementation
- Identify strategies for continuous improvement and program development
In addition, the Bureau conducted reviews to improve employment support programs, program integrity, and intake and eligibility processes.
In these areas, the Bureau made the following recommendations to DTA’s management team:
- Expand the size and capacity of the Budget and Policy Analytics group
- Continue to expand resources and opportunities for workforce development and economic stability through strategic partnerships with the Department of Career Services as well as other public and private agencies engaged in workforce development
- Establish a culture of collaboration with DTA’s Program Integrity Division and promote agency-wide commitment to program integrity
A. Intake and Eligibility Processes
In accordance with the Bureau’s mandate, the Bureau continued to monitor DTA’s intake and eligibility processes and assist with improving them. In 2018, the Bureau identified issues with the quality of data collection during the intake process for the Transitional Aid to Families with Dependent Children (“TAFDC”) program, as well as flaws in DTA’s intake and electronic document management systems.
The Bureau recommended that DTA leverage TAFDC supervisors to engage in quality control of data collection and design system changes to improve electronic document management.
In 2019, in response to the Bureau’s recommendations, DTA invited the Bureau to oversee a working group to improve TAFDC eligibility processing and electronic document management. DTA outlined plans for implementing changes to its policies and systems, but did not implement them, citing limited resources from the information technology division of EOHHS.
The Bureau recommended that DTA focus on the following steps, which did not require system enhancements and would have significantly improved DTA’s eligibility processes and functions:
- Leverage field supervisors as resources for quality control of case managers’ data entry during the intake process
- Revisit, clarify and monitor compliance with procedures for verifying recipients’ identity, particularly for recipients who have received TAFDC or SNAP benefits in the past
- Assess existing electronic case management features in the eligibility database – and case managers’ utilization of them – in order to inform requirements for future enhancements
The Bureau found that DTA remained focused on system enhancement as the primary way to improve eligibility processing and prioritized other initiatives for its program managers. The Bureau continued to address concerns about DTA’s IT resources and eligibility processes during regularly scheduled meetings with DTA’s senior management team.
B. Employment Support Programs
Since its establishment, the Bureau has dedicated significant resources to oversee welfare reform initiatives and improve DTA’s employment support programs, publishing reports in 2014 and 2016 and following up on key recommendations to improve program development.
For example, in 2018, the Bureau recommended specific ways for DTA to use data sharing to evaluate its ongoing implementation of the Work Innovation and Opportunity Act (“WIOA”). WIOA is a federal law that requires DTA to coordinate employment services for benefits recipients with the Department of Career Services (“DCS”), which oversees one-stop career centers.
In 2019, in response to the Bureau’s recommendations, DTA implemented methods for self-assessment and created and distributed data reports to DTA and DCS staff, who reviewed metrics regarding their joint work and adjusted strategies accordingly. For example, DTA tracked the number of recipients who were referred to career centers, who enrolled in career center programs, and who exited career centers with and without employment. DTA also studied the demographic characteristics of these recipients and the amount of time that they spent receiving career center services.
As a result, DTA and DCS had valuable insight into their joint case management processes as well as their outcomes, and the Bureau found that DTA had laid a sound foundation for data-informed program development and management.
Starting in May 2019, the Bureau conducted oversight of DTA’s implementation of a new 8-year, $64-million contract for the Competitive Integrated Employment Services (“CIES”) program. The CIES program is part of DTA’s Employment Services Program; under this program, approximately 81 vendors provide training, education and job search services to 1,800 TAFDC recipients per year.
Through this new contract, DTA indicated that it would focus on outcomes, rather than service components. Through a tiered payment structure, DTA intended to set requirements for vendors to deliver outcomes of family stability and a career pathway. DTA described the CIES program as a critical component of its “ecosystem for change,” through which DTA intended to become a “workforce agency.” In addition to the CIES program, DTA included its WIOA initiatives and initiatives for young parents in its plan for this coordinated system of workforce development resources.
The launch for the new contractual period began on July 1, 2019, and the Bureau conducted a close review, with DTA’s cooperation, during the first few months of DTA’s implementation of the contract. The Bureau found that DTA was in the process of restructuring its contract management, with the assistance of a consultant. The Bureau also found that DTA had requested enhancements to EOHHS’s invoice management system and wanted to expand the scope of data collection in the system, but it had encountered technical barriers when it pursued enhancements to an aging EOHHS invoicing system. The Bureau raised concerns that DTA had not planned adequately around these business risks.
The Bureau offered these recommendations – which did not require any system enhancements – in order to build sound, evidence-based contract administration practices from the outset of the new contractual period:
- Analyze and improve the quality of the referrals that DTA case managers make to the CIES program
- The Bureau pointed out that DTA needed to understand the existing trends and practices in referrals to CIES vendors, through data analysis and case review, in order to improve referrals during the new contractual period.
- Evaluate vendor processes
- The Bureau encouraged DTA to visit vendors frequently, observe their operations and conduct joint case reviews in order to assess how vendors are implementing the new service model.
C. Program Integrity
In accordance with its statutory mandate, the Bureau continued to consult with DTA’s Program Integrity Division on fraud detection and data sharing with other agencies. The Bureau met with DTA’s Program Integrity managers on a regular basis as DTA proceeded with phased implementation of a new approach to utilizing employment and wage data collected by the Department of Unemployment Assistance (“DUA”).
The Bureau followed up on its 2018 recommendations and assisted the Program Integrity Division with streamlining its processes and focusing on cases in which the potential overpayment presented a high risk of fraud. The Bureau supported the Program Integrity Division as it pilot tested new approaches and evaluated them incrementally. The Bureau found that the Program Integrity Division engaged in a careful implementation of the Bureau’s recommendations and demonstrated the value of using data and self-assessment to improve its business processes. In addition, the Bureau found that DTA used these new processes effectively to detect fraud and initiate investigations into program violations.
In 2018, the Bureau recommended that DTA develop methods for utilizing the wage data to track outcomes for its employment programs. The Bureau proposed options for tracking individual recipients or cohorts of recipients and evaluating the potential impact of DTA’s employment strategies and supports. Following up on this recommendation, the Bureau met with representatives from the Program Integrity Division, the TAFDC and SNAP program development teams, and the Budget and Policy Analytics group.
The Bureau found a lack of integration within DTA across divisions and organizational units; across the agency, many still regarded the wage data as a resource solely focused on fraud detection. In December 2019, the Bureau met with managers from all of these divisions and organizational units, along with DTA’s senior team, to focus on building an understanding of the wage data and the Program Integrity Division’s updated approach to using it. The Bureau further encouraged DTA’s senior management team to break down silos within the agency in order to utilize the wage data not only for fraud detection, but also to inform employment services and strategies for engagement with recipients.
Working with the Program Integrity Division, the Bureau conducted an analysis of benefits recipients who earned income as Personal Care Attendants (“PCAs”). PCAs assist MassHealth members with personal care needs, and Medicaid members can obtain approval to hire PCAs to provide personal care in their homes. PCAs are employed by the member and are paid through third-party vendors who manage the Medicaid billing. DTA investigators pointed to examples of PCAs who failed to report their income and raised concerns about fraud risks. To assess potential vulnerabilities related to PCAs, the Bureau collaborated with the Policy and Government Division, which engaged in a broad review of the PCA program.
The Bureau used a 2018 data sample of PCAs and matched it with wage data from DUA and recipients’ data from DTA. The Bureau found that 17% of those who were earning wages as PCAs were also receiving either TAFDC or SNAP benefits or both. The Bureau also found that 20% of the recipients who were employed as PCAs had never reported any income to DTA.
In December 2019, the Bureau shared these results with DTA’s senior team and encouraged them to lead an agency-wide study of benefits recipients and PCA employment. The Bureau identified opportunities for addressing recipients’ failure to report PCA wages, as well as for supporting recipients who are engaging in PCA work and reporting their employment and income appropriately. The Bureau recommended collaborative work across the divisions within DTA to complete the following:
- Additional data analysis and case review to identify what obstacles to reporting employment and income that PCAs might encounter
- Program support for addressing any such barriers as well as promoting PCA employment as a potential pathway to economic stability
- Investigations into potential intentional program violations for PCAs who presented a high risk of fraud and whose income was high enough to disqualify them from benefits
IV. Department of Mental Health
The Bureau’s involvement with DMH has been focused on the administration of SNAP benefits in state-operated group homes, which DMH calls Group Living Environments (“GLEs”). There are approximately 20 GLEs statewide.
As discussed above, in 2018, the Bureau joined with DTA and DMH in a workgroup to identify and address vulnerabilities in the administration of SNAP benefits to residents of DMH-operated group homes. Throughout 2019, the Bureau worked directly with DMH to assess business and fraud risks, conducted through data analysis and a review of the utilization of SNAP benefits at the GLEs.
While collaborating with DMH, the Bureau found that the agency did not have important tools for business risk assessment. The Bureau recommended that DMH bring in additional resources to complete the risk assessment with respect to SNAP administration, identify high-priority risks and outline plans to address them. The Bureau also recommended data sharing between DTA and DMH regarding GLE residents who receive SNAP.
The Bureau also found that DMH had delegated business management functions of GLEs and stewardship responsibilities for SNAP benefits to its regional management without any structured oversight. The Bureau recommended that DMH build a stronger infrastructure for internal controls.
EOHHS assisted DMH in responding to these recommendations and brought in an individual consultant to assist with risk assessment. In addition, DTA and DMH agreed to share data, and the Bureau helped facilitate the exchange and analysis of the data.
To address the Bureau’s concerns about infrastructure, EOHHS and DMH outlined plans to create new management roles related to internal controls and program integrity. To assist EOHHS and DMH, the Bureau provided input on the ideal qualifications for these roles, as well as how to integrate them into the management infrastructure at DMH.
V. Department of Children and Families
In 2019, the Bureau continued working with DCF to improve its contract administration. In 2017 and 2018, the Bureau received complaints about the administration of DCF’s vendor contract for after-hours hotline services and the performance of the vendor, Judge Baker Children’s Center (“JBCC”). JBCC has operated the after-hours hotline for 37 years.
The Bureau brought these complaints to EOHHS and DCF, and the Bureau found that they were already working with JBCC on a corrective action plan. The Bureau also found that DCF lacked the appropriate infrastructure for contract administration, and in September 2018, the Bureau provided an introductory training for DCF contract managers, focused on the fundamentals of contract administration and quality management.
DCF redesigned its after-hours hotline services and, in the spring and summer of 2019, engaged in a procurement process for a new service provider. Following the procurement, DCF selected Judge Baker Children’s Center for a new, 10-year, 45-million-dollar contract for after-hours services.
In October 2019, as DCF was finalizing details around the new contract, the Bureau engaged with EOHHS and DCF to review the contract and monitor DCF’s approach to implementing it. EOHHS and DCF collaborated with the Bureau during the review, providing materials related to the contract and DCF’s initial implementation plan.
The Bureau identified several areas in which DCF could improve its implementation plan and its ongoing review of the quality of the after-hours hotline services. The Bureau offered to provide technical assistance and training to the after-hours hotline contract administration team, as well as to JBCC, in order to institute best practices from the outset of the contract period. DCF and JBCC agreed to work closely together and to consult with the Bureau as they began to implement the contract.
The Bureau recommended that DCF work with JBCC to:
- Develop and implement monitoring functions, such as data sampling, case review, surveys, staff and stakeholder interviews, and random audits
- Create regular quality-management reports focused on current business risks
- Implement other appropriate quality-management resources and functions
- Use data analysts and data reporting to support and monitor the quality, integrity and efficiency of the after-hours hotline services