Press Release  Audit Finds Nearly $1 Million in Improper Payments by MassHealth for Prescription Drugs

Boston — Today State Auditor Suzanne M. Bump released an audit of MassHealth’s handling of claims for prescription drugs.  It found that the program improperly paid for 25,144 prescription claims, totaling $982,535, during the two-and-a-half-year audit period (January 1, 2015 through June 30, 2017).  The total number of prescriptions filled during this period was 43,579,259.

The audit found improper payments by MassHealth in three areas:

• It paid $300,863 for prescription drug refills that were in excess of what was prescribed to patients. In one instance, a MassHealth member was prescribed a 30-day supply of the drug amphetamine, with no refills. However, the member received two unauthorized 30-day-supply refills that were paid for by MassHealth, which gave them a total 90-day supply of the drug.
• The program paid $526,229 for refills of emergency (non-refillable) medications. MassHealth allows pharmacies to dispense an appropriate supply of drugs to ensure members have an uninterrupted drug supply in emergency situations, such as when a patient loses their existing supply. However, Bump’s office found the program sometimes paid for back-to-back emergency drug fills, contrary to its regulations.
• It also paid $155,443 to pharmacies for over-the-counter drugs supplied to members living in nursing or skilled nursing facilities. MassHealth regulations prohibit it from paying for these prescriptions for members residing in these facilities.

In each of these instances, Bump points to failures in MassHealth’s prescription processing system, known as the Pharmacy Online Processing System (POPS), as the cause of the problem. The audit notes POPS does not have systems in place to identify and deny these claims that are against MassHealth regulations. Bump calls on the agency to address this deficiency.

MassHealth is administered through the Executive Office of Health and Human Services, through the Division of Medical Assistance. The state’s Medicaid program annually provides access to health care for approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities. In FY17, MassHealth paid providers more than $15 billion, of which 50 percent was funded by the Commonwealth. Medicaid expenditures represent approximately 39 percent of the state’s total annual budget.

The full audit report is available here.

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