- Office of State Auditor Suzanne M. Bump
Media Contact for Annual Report Shows Auditor’s Office Identified More Than $211 Million in Inappropriate MassHealth Payments
Mike Wessler, Communications Director
Boston — State Auditor Suzanne M. Bump today released the annual report for her office’s Medicaid Audit Unit, which examines certain activities of the MassHealth program. The report shows that over the past year (March 15, 2017 – March 14, 2018), the Unit identified more than $211 million in unallowable, questionable, duplicative, unauthorized, or potentially fraudulent billing in the program.
“MassHealth is a critically important program,” Bump said, “and accounts for nearly 40 percent of state spending. Our goal in auditing the program and its providers is to ensure quality, efficiency and integrity. The audits released by my office over the past year provide valuable recommendations that can result in significant savings and improve program performance.”
The annual report notes that during the previous year, Bump’s office released nine audit reports examining MassHealth’s administration of the Medicaid program and Medicaid service providers’ compliance with applicable laws and other regulations. These audits include:
- A review of fee-for-service payments for services covered by the Massachusetts Behavioral Health Partnership (MBHP), which identified nearly $193 million in improper or questionable payments by MassHealth for services that should have been paid for by MBHP;
- A review of claims submitted by a Newton physician, which found that he improperly billed MassHealth for over $200,000 in services, including services he claims were administered while he was out of the country.
- A review of payments for nursing-facility claims that found that MassHealth did not recover approximately $966,000 in overpayment for these services.
Additionally, the report highlights four audits of human services providers certified by MassHealth to provide group adult foster care (GAFC) services. In these audits, Bump’s office recommended a change to MassHealth regulations to allow certified nursing assistants (CNAs) to manage medication for GAFC members, noting that this change would provide significant financial savings without resulting in a reduction in quality of care.
Bump’s office uses data-mining and analytics software in audits conducted by the Medicaid Audit Unit to identify areas of high risk, providers whose billing patterns are anomalous, and trends that indicate fraud or other irregularities.
Today’s report also previews upcoming work from Bump’s office including reviews of:
- Claims paid for members of both Medicaid and Medicare, commonly referred to as “dual eligibles”;
- MassHealth members’ access to counseling services when they were being treated with suboxone, a drug used in the treatment of substance abuse and addiction; and
- MassHealth’s recoupment processes for overpayments during a five-year period.
In fiscal year 2017, MassHealth paid healthcare providers $15.3 billion for healthcare services for approximately 1.9 million low-and-moderate income individuals. MassHealth is the state’s largest program and accounts for approximately thirty-nine percent of the state budget.
The Medicaid Audit Unit was established by the legislature in fiscal year 2007 to detect fraud, waste and abuse in the MassHealth program. The Unit has a budget of approximately $1.16 million in fiscal year 2018.
The Medicaid Audit Unit’s Annual Report is available here.
Bump’s audits of the MassHealth program and providers are available here.
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