Audit of the Office of Medicaid (MassHealth) - Payments for Hospice-Related Services for Dual-Eligible Members
July 20, 2021 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published July 20, 2021 Under Suzanne M. Bump · 2011–2023
source
“MassHealth did not ensure that it had accurate information in its Medicaid Management Information System (MMIS) about dual-eligible members who chose to receive hospice services.”
Read the plain-English breakdown
This is a state performance audit of MassHealth payments tied to hospice care for people who were enrolled in both Medicare and Medicaid.
“This report details the audit objectives, scope, methodology, findings, and recommendations for the audit period, January 1, 2015 through July 31, 2019.”
The audit checked whether MassHealth was following rules and making sure it only paid when no other payer, such as Medicare or a hospice provider, should have paid first.
“The purpose of this audit was to determine whether MassHealth effectively administered payments for hospice-related services in accordance with applicable state and federal requirements, including ensuring that Medicaid was the payer of last resort (i.e., that it only paid for covered services if no other payer existed) for hospice services.”
MassHealth is a very large public program, and mistakes in payment controls can put taxpayer money at risk.
“Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.”
If you are a Massachusetts taxpayer or MassHealth member, this matters because better payment controls can help preserve money for needed healthcare services.
“MassHealth could have used this money to provide additional services to other MassHealth members.”
The audit concluded that MassHealth did not fully comply with payment requirements for the hospice-related claims reviewed.
“Does MassHealth administer payments to non-hospice providers for hospice-related services in compliance with Section 450.316 of Title 130 of the Code of Massachusetts Regulations?”
MassHealth said it was taking steps to improve oversight, including processes to identify dual-eligible members in Medicare hospice and make sure MassHealth has the right hospice election forms.
“Based on its response, EOHHS is taking measures to address our concerns on this matter.”
The report points to a broad control problem: many claims for people in hospice were not matched with accurate hospice status in MassHealth’s system, raising the risk of improper payments.
“Based on our statistical sample of 400 reviewed claims, we estimate that during our audit period, approximately $56,640,242 in non-hospice-provider claims9 of the four types tested were for members who had chosen to participate in hospice.”
“Dual-eligible” means a person is enrolled in both Medicare and Medicaid; “DME” means durable medical equipment like wheelchairs or wound dressings; “MMIS” is MassHealth’s claims and member-information system.
“DME includes medical equipment such as wheelchairs, incontinence products, and wound dressings.”
1 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Does MassHealth administer payments to non-hospice providers for hospice-related services in compliance with Section 450.316 of Title 130 of the Code of Massachusetts Regulations?
What the Auditor found
Why it matters: This created a higher-than-acceptable risk that claims were not subjected to hospice-related system edits and payments may have been improper.
Standard: Section 437.412(C) of Title 130 of the Code of Massachusetts Regulations requires hospice providers to submit hospice election forms to MassHealth. ( Section 437.412(C) of Title 130 of the Code of Massachusetts Regulations )
3 recommendations
- MassHealth should establish an effective monitoring process to ensure that hospice providers send it a MassHealth Hospice Election Form for every dual-eligible member who chooses to receive hospice services.agency: agreed
- MassHealth should consider collaborating with the Centers for Medicare & Medicaid Services to obtain CMS’s hospice election information about dual-eligible members and determine whether all MassHealth’s hospice providers have submitted the required MassHealth Hospice Election Forms.agency: agreed
- MassHealth should review MMIS for all members who have elected the hospice benefit to ensure that their MassHealth Hospice Election Forms are accurately reflected in MMIS.agency: agreed
Agency response & Auditor reply
Auditor: "As noted above, for the majority of the claims, 223 (56%) of the 400 claims in our sample, for which the members had elected the hospice benefit, either MassHealth did not receive the member’s MassHealth Hospice Election Form and therefore could not update MMIS to reflect that the member had elected the benefit, or (in at least four instances) MassHealth received the member’s MassHealth Hospice Election Form but did not update MMIS to show that the member had elected the benefit."
Why it matters: The services may have duplicated services already provided by hospices and MassHealth could have used the money to provide other services.
Standard: 42 CFR 418.56(e), 130 CMR 437.421(C)(2), and 130 CMR 437.412(B)(3)(a) require hospice providers to coordinate services and prohibit payment for duplicative hospice services. ( Section 418.56(e) of Title 42 of the Code of Federal Regulations; 130 CMR 437.421(C)(2); 130 CMR 437.412(B)(3)(a) )
2 recommendations
- MassHealth should ensure that its hospice providers coordinate professional services with non-hospice providers for dual-eligible members to ensure proper service coordination and billing.
- MassHealth should update its system edits in MMIS to detect and deny claims for dual-eligible members in hospice care that might be duplicative of services that should be paid for by hospice providers.
Agency response & Auditor reply
Agency: "EOHHS disagrees with Finding 2."
Auditor: "Rather, our report concludes that members who have elected the hospice benefit should receive all of their required services."
Why it matters: The DME should have been paid for by hospice providers, so MassHealth could have used the money for additional services to members.
Standard: 42 CFR 418.202(f), 42 USC 1395x(1861)(dd)(1), 130 CMR 437.423(G), and 130 CMR 450.316 require hospices to provide DME needed under the plan of care and MassHealth to be payer of last resort. ( 42 CFR 418.202(f); 42 USC 1395x(1861)(dd)(1); 130 CMR 437.423(G); 130 CMR 450.316 )
2 recommendations
- MassHealth should ensure that information in MMIS about hospice election by dual-eligible members is accurate.agency: agreed
- MassHealth should ensure that the system edits in MMIS for claims for hospice services for dual-eligible members are effective in detecting and rejecting improper claims.agency: agreed
Agency response & Auditor reply
Agency: "EOHHS disagrees with Finding 3a."
Auditor: "Regarding Finding 3a, as noted above, we found that MassHealth paid an estimated $65,727 in claims for DME that were unnecessary because DME was included in the members’ plans of care and therefore should have been paid for by their hospice providers."
Why it matters: MassHealth paid for DME that should have been paid by hospice providers and could have used the money for additional services to members.
Standard: Federal Register 83, No. 89 (2018), Federal Register 84, No. 151 (2019), 42 CFR 418.202(f), 42 USC 1395x(1861)(dd)(1), 130 CMR 437.423(G), and 130 CMR 450.316. ( Federal Register 83, No. 89 (2018); Federal Register 84, No. 151 (2019); 42 CFR 418.202(f); 42 USC 1395x(1861)(dd)(1); 130 CMR 437.423(G); 130 CMR 450.316 )
2 recommendations
- MassHealth should ensure that information in MMIS about hospice election by dual-eligible members is accurate.agency: agreed
- MassHealth should ensure that the system edits in MMIS for claims for hospice services for dual-eligible members are effective in detecting and rejecting improper claims.agency: agreed
Agency response & Auditor reply
Agency: "EOHHS disagrees with Finding 3b."
Auditor: "Regarding Finding 3b, MassHealth also paid an estimated $723,640 for DME21 that should have been, but was not, included in the members’ plans of care."
Why it matters: Hospice providers could not review the claims and determine who was responsible for paying them, so MassHealth may have paid unnecessarily.
Standard: 42 CFR 418.56(e), 130 CMR 437.421(D)(3), Section 40.1.9 of CMS’s Medicare Benefit Policy Manual, and CMS Medicare Learning Network guidance. ( 42 CFR 418.56(e); 130 CMR 437.421(D)(3); Section 40.1.9 of CMS’s Medicare Benefit Policy Manual )
2 recommendations
- MassHealth should ensure that its hospice providers explain to its members and their families that the members and families are required to inform any non-hospice providers that the members have elected the hospice benefit to ensure service coordination and billing.agency: agreed
- MassHealth should ensure that the system edits in MMIS for claims for hospice services for dual-eligible members are effective in detecting and denying improper claims.agency: agreed
Agency response & Auditor reply
Agency: "EOHHS disagrees with Finding 4."
Auditor: "Federal regulations require hospices to pay for ambulance transportation that is related to members’ terminal illnesses regardless of whether it is emergency transportation."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
Identified dollar findings that do not fall in a named band.
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