Report  Bureau of Special Investigations Annual Report Fiscal Year 2023

Public assistance programs administered by the Department of Transitional Assistance, EEC, and MassHealth provide vital social services for the Commonwealth’s most vulnerable residents—children, persons with disabilities, low-income individuals and families, and seniors.

Following the end of the public health emergency related to the COVID-19 pandemic, this fiscal year saw a return to some government operational norms. BSI staff members increased their physical presence within regional offices under an updated hybrid workplace model and resumed conducting investigatory tasks in person. While the last few years have had their share of unprecedented challenges, BSI continues to leverage a variety of technology solutions to bridge the distance between offices, to increase accessibility, and to effectively complete public benefits fraud investigations. The fiscal year 2023 (FY23) Bureau of Special Investigations Annual Report summarizes BSI’s work and initiatives to execute its mission to make government work better by investigating, under its statutory charge, fraud, abuse, and illegal acts involving public assistance benefits throughout the Commonwealth. During FY23, BSI continued to investigate and identify fraud to maintain program integrity and uphold the Commonwealth’s residents’ faith in public assistance programs. BSI’s efforts ensure that public assistance programs operate with transparency, accountability, and equity.

During FY23, the COVID-19-related operational challenges the bureau experienced decreased significantly —both internally and externally, along with our partners and stakeholders—. Key improvements included: (1) external stakeholders implemented procedural changes based on guidance and best practices from the federal government, (2) referrals increased and remained steady, (3) backlogs decreased, and (4) fraud calculations experienced fewer delays.²

In FY23, BSI opened 8,643 new investigations and completed 5,100³ total investigations. This report includes a comprehensive breakdown of the fraud identified within each program BSI investigates. It is notable that of the 782⁴ completed cases with identified fraud, the average amount of fraud per completed case was $15,757.91.⁵

2.    During FY23, BSI completed numerous fraud investigations related to EEC and MassHealth benefits. Notably, identified fraud amounts for both of these programs have decreased throughout this fiscal year. Administration changes and staffing transitions affected EEC’s ability to complete BSI calculation requests. In addition, MassHealth ceased calculating member-benefit overpayments in December 2022 because of uncertainty related to guidance from the Centers for Medicare and Medicaid Services (CMS). Specifically, CMS issued guidance to states declaring that “states cannot recover or recoup the cost of services from a beneficiary, even if they have been found after an administrative or criminal proceeding to have committed Medicaid beneficiary fraud or abuse.” See https://www.medicaid.gov/federal-policy-guidance/downloads/covid-19-unwinding-fags-oct-2022.pdf at FAQ 31. To ensure compliance with this CMS guidance, MassHealth paused overpayment calculations from December 2022 through April 2023. EEC and MassHealth have since resumed completing BSI overpayment calculations, but not civil recoveries. BSI anticipates that future reports will include calculated overpayments and, when permitted by CMS, recoveries.

3.     This figure includes investigations that may have been opened during previous fiscal years and is not only tied to investigations opened during FY23.

4.     This number reflects all the cases with a calculated overpayment (financial type) of a specific public benefit.

5.     Comparatively, during FY21, BSI completed 479 cases with identified fraud and the average amount of fraud was $12,817.79 and during FY22, BSI completed 668 cases with identified fraud and the average amount of fraud was $20,238.55. See https://www.mass.gov/lists/reports-on-public-benefit-fraud.