Overview
During our audit period, WestMass ElderCare, Inc. (WMEC) 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 45 of 392 MassHealth members who received AFC, WMEC did not submit 63 (57%) of 110 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
WMEC 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
WMEC should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.
Auditee’s Response
WestMass ElderCare’s (WMEC) Management and Adult Foster Care program staff strive to follow all program guidance in accordance with MassHealth and other directives at all times. During the period of May 5, 2017 and April 16, 2019, WMEC’s Adult Foster Care program was not able to submit Prior Authorizations via the [Long-Term Services and Supports] Provider Portal, as the Portal was not operational for accepting the Prior Authorizations electronically. All Prior Authorizations were available to the Office of the State Auditor’s team upon request. Since April 16, 2019, WMEC has been and will continue to submit Prior Authorizations as required per all MassHealth regulations and applicable guidance. As is our practice, WMEC will continue to monitor compliance and quality in relation to Prior Authorizations and all aspects of the Adult Foster Care program.
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 WMEC should submit annual prior authorizations. EOHHS plans to conduct an audit of WMEC to determine compliance with the prior authorization requirement for MassHealth-covered AFC.
| Date published: | July 21, 2020 |
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