Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy (UCP)
September 19, 2019 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published September 19, 2019 Audit covers April 1, 2015 – July 31, 2018 Under Suzanne M. Bump · 2011–2023
source
“UCP did not obtain physician or primary care clinician authorizations to support payment for DH services provided to six MassHealth members.”
Read the plain-English breakdown
This is a state audit of MassHealth payments to United Cerebral Palsy for day habilitation services from April 1, 2015 through July 31, 2018.
“OSA has conducted an audit of MassHealth claims for day habilitation (DH) services paid to United Cerebral Palsy (UCP) for the period April 1, 2015 through July 31, 2018.”
The auditor checked whether United Cerebral Palsy had the required medical approval before billing MassHealth for these services.
“The purpose of this audit was to determine whether UCP obtained the required authorization from a physician or primary care clinician for DH services for each MassHealth member.”
This matters to residents because MassHealth is a major public program paid for with state and federal money, and audits help protect that money from waste and improper payments.
“The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to help prevent and identify fraud, waste, and abuse in the Commonwealth’s Medicaid program.”
Auditors questioned $122,357 in MassHealth payments tied to the six members without proper authorization documentation.
“During our audit period, UCP received a total of $122,357 from MassHealth for DH services provided to these six members.”
The report says United Cerebral Palsy should work with MassHealth to decide how much money should be paid back, and MassHealth said it would do its own audit.
“MassHealth will conduct its own audit of UCP.”
The audit is significant because MassHealth paid United Cerebral Palsy more than $4.5 million for these services during the period reviewed, and the auditor found a documentation problem affecting payment support.
“During this period, MassHealth paid UCP $4,505,326 to provide DH services for 111 MassHealth members.”
1 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did UCP properly bill MassHealth for day habilitation (DH) services provided to MassHealth members?
What the Auditor found
Why it matters: There was a higher-than-acceptable risk that UCP may not provide appropriate types and levels of service, and $122,357 in MassHealth payments may need to be repaid.
Standard: Section 419.407(D)(3) of Title 130 of the Code of Massachusetts Regulations required physician or primary care clinician authorizations for day habilitation services. ( Section 419.407(D)(3) of Title 130 of the Code of Massachusetts Regulations )
2 recommendations
- UCP should collaborate with MassHealth to determine how much of the $122,357 discussed in this finding should be repaid.
- UCP should update its policies and procedures to require its staff to ensure the completion of physician or primary care clinician authorizations before it provides DH services for MassHealth members.
Agency response & Auditor reply
Agency: "These periodic authorizations clearly suffice to satisfy the regulation that governed [DH] providers during the Audit Period, which did not require a [DH] provider to indefinitely rely on the PCP authorization obtained upon initial enrollment."
Auditor: "However, none of this documentation included physician or primary care clinician authorizations for DH services."
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