- Office of the State Auditor
Media Contact for Audits Show Elder Service Organizations Provided Potentially Unallowable Services to MassHealth Members
Boston — Today, State Auditor Suzanne M. Bump released the last two in a series of six audits of elder service providers that questioned certain billings for services provided to MassHealth members. The audits found two primary issues. First, some of the providers reviewed received payments for services that were not properly authorized. Second, it appears some providers received payment for duplicative services. The audits, which examined the period of January 1, 2016 through December 31, 2018, reviewed Old Colony Elder Services (OCES), Somerville-Cambridge Elder Services (SCES), Boston Senior Home Care (BSHC), WestMass ElderCare, Inc. (WMEC), Beyond Healthcare Agency, and City Home Care.
“These audits are the latest demonstrations of technological and regulatory shortcomings at MassHealth that confuse and stymie providers, and likely waste significant amounts of taxpayer money,” Bump said. “While the burden of ensuring claims are appropriate and properly documented falls on providers, MassHealth must do more to ensure these providers have a clear understanding of what services are allowed and an effective way to submit information to support their claims.”
Four of the audits found Adult Foster Care (AFC) providers were paid for care without submitting to MassHealth required annual prior authorizations, resulting in MassHealth paying for services that were not properly approved. Bump’s audits revealed the following:
- OCES did not submit 58 percent of required annual prior authorizations;
- WMEC did not submit 57 percent required annual prior authorizations
- SCES did not submit 53 percent of required annual prior authorizations; and
- BSHC did not submit 53 percent required annual prior authorizations.
These providers stated they were unable to submit prior authorization requests due to inadequate guidance from the agency and technical issues with the MassHealth IT portal. In its responses to the audits, MassHealth indicates it agrees with the findings and will conduct its own reviews of the AFC providers.
The two audits released today, which examined Beyond Healthcare Agency and City Home Care, found the providers billed MassHealth for Group Adult Foster Care (GAFC) services given on the same day members also received Home Health Program services, which is unallowable under agency guidelines. Both programs provide participants with assistance with activities such as laundry, meal preparation, and shopping, and as a result, the Commonwealth could be paying for these services twice for individuals enrolled in both programs. The audits note Beyond Healthcare Agency was paid as much as $887,225 and City Home Care was paid as much as $268,494 for group adult foster care services that appear to be unallowable. These audits only represent the claims of these providers and do not represent all potentially duplicative payments for AFC or GAFC services.
These two audits also call on MassHealth to update its guidelines and regulations for GAFC services, a step Bump initially called on the agency to take in a 2016 audit. In its responses to these audits, MassHealth indicates it agrees with the findings and will conduct its own reviews of the GAFC providers. It also indicated that it is in the process of developing and promulgating provider regulations for the GAFC program.
These six providers offer services to MassHealth members, including AFC, GAFC, and home health care, for older adults, and people with disabilities. MassHealth covers claims for AFC services for members who are elderly or have disabilities and need assistance performing activities of daily living, such as eating, bathing, walking, and dressing. During the audit period, MassHealth paid approximately $1.03 billion for AFC and GAFC for 28,287 members.