Overview
During our audit period, Old Colony Elder Services (OCES) did not submit required annual prior authorizations (determinations of MassHealth members’ clinical eligibility to receive adult foster care, or AFC) for AFC it provided to MassHealth members. Specifically, for 40 of 208 MassHealth members who received AFC, OCES did not submit 55 (58%) of 95 required annual prior authorizations. As a result, MassHealth paid for AFC that it did not authorize.
Authoritative Guidance
According to Section 408.417(B) of Title 130 of the Code of Massachusetts Regulations, prior authorizations are required for AFC before the first date of service and annually thereafter.
Reasons for Issue
OCES officials told us MassHealth did not have a process for providers to submit annual prior authorizations, although MassHealth authorizations were required as of May 5, 2017. MassHealth officials told us the agency could not process annual prior authorizations online until April 16, 2019. They stated that this was because of a two-year delay with the new vendor that was responsible for implementing MassHealth’s Long-Term Services and Supports Provider Portal, an online tool for submitting prior authorizations to MassHealth for AFC.
Recommendation
OCES should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.
Auditee’s Response
As noted in the Audit Report, during the period of May 5, 2017 through December 31, 2018, we were unable to submit Prior Authorizations (PA) on the LTSS Provider Portal (Portal). The Portal was implemented on April 16, 2019 and we immediately started submitting PA as required in the regulations. We have continued this practice and will do so going forward to maintain compliance with the Adult Family Care Regulations.
MassHealth Response
The Executive Office of Health and Human Services (EOHHS, MassHealth’s oversight agency) and MassHealth responded,
EOHHS agrees with the [Office of the State Auditor] that OCES should submit annual prior authorizations. EOHHS plans to conduct an audit of OCES to determine compliance with the prior authorization requirement for MassHealth-covered AFC.
Date published: | June 29, 2020 |
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