Press Release  Audit Finds $3.5 Million in Questionable MassHealth Personal Care Attendant Services

Boston — State Auditor Suzanne Bump today issued an audit of MassHealth, which found the healthcare agency paid more than $3.5 million in questionable, unallowable, and potentially fraudulent medical claims for Personal Care Attendant (PCA) services for its members. Since 2011, Auditor Bump has identified more than $95 million in unallowable, questionable, or potentially fraudulent spending and savings opportunities in the MassHealth program.

MassHealth, the state’s Medicaid agency, with annual payments to healthcare providers of more than $10.8 billion, provides access to healthcare services for approximately 1.4 million eligible low- and moderate-income individuals. MassHealth is the state’s largest program and accounts for approximately one third of the state’s annual budget. Today’s audit report examined MassHealth’s Personal Care Attendant (PCA) program, a service that provides in-home personal care for the elderly and people with disabilities. These services include hands-on assistance in certain daily activities, including taking medications, bathing, dressing, eating, and preparing meals, shopping, doing housework, and traveling to medical providers.

“The PCA program allows tens of thousands of people the comfort and dignity of living at home in their communities. I hope this audit will strengthen the integrity of this important program and the public’s trust in it,” said Auditor Bump.

Auditors found that MassHealth improperly paid more than $3,354,838 for PCA services to individuals participating in individual or group adult foster care. Such expenses are duplicative and contrary to state regulations because adult foster care programs provide 24-hour care. In addition, auditors identified $214,605 in PCA services which exceed set limits and other duplicative costs.

MassHealth officials said services should be provided in a relatively consistent manner and in accordance with the authorized level of care, but auditors noticed large fluctuations in the daily hours of care. While third party oversight entities are required to report to MassHealth when PCA services are over utilized, the report notes that there is no requirement to report underutilization, creating a risk that a MassHealth member is not getting the care they need. 

The report also revealed inadequacies in the program’s tracking and inputting of date of death information, which opens the door to fraud. It identifies more than $600,000 paid for services billed after the members’ recorded date of death. MassHealth contends that only $92,000 - $123,000 was erroneously paid, and the rest of the amount was attributable to data entry mistakes.

In response to audit findings, MassHealth stated that it is improving its IT systems and data analysis process to prevent unallowable payments. In addition, while the audit was ongoing, the PCA Workforce Council, and the 1199 Service Employees International Union signed an agreement requiring all Massachusetts PCAs hired after January 1, 2014 to attend a training session within the first six months of their employment. The training aims to familiarize PCAs with MassHealth requirements and the penalties of inappropriate behavior.

The Office of the State Auditor conducts performance audits of state government’s programs, departments, agencies, authorities, contracts, and vendors. With its reports, the OSA issues recommendations to improve accountability, efficiency, and transparency.

The audit of MassHealth's claims for Personal Care Attendant (PCA) services is available here.

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