Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by Beyond Healthcare Agency, LLC

This is a State Auditor performance audit of MassHealth payments to Beyond Healthcare Agency for group adult foster care from January 1, 2016 through December 31, 2018.

“OSA has conducted an audit of MassHealth claims for group adult foster care (GAFC) paid to Beyond Healthcare Agency, LLC for the period January 1, 2016 through December 31, 2018.”

Auditors checked whether Beyond Healthcare had required approvals and billed MassHealth properly for group adult foster care.

“The purpose of this audit was to determine whether Beyond Healthcare Agency obtained the required prior authorizations, and properly billed, for GAFC provided to MassHealth members during our audit period.”

MassHealth is a major public healthcare program, so improper payments affect public trust and taxpayer-funded services.

“As with any government program, public confidence is essential to this program’s success and continued support.”

For ordinary residents, this audit is about whether public healthcare dollars are being spent correctly on services for low- and moderate-income people, seniors, and people with disabilities.

“MassHealth provides access to healthcare for approximately 1.9 million low- and moderate-income children, families, seniors, and people with disabilities annually.”

The auditor says Beyond Healthcare should not bill for services that are not allowed and should work with MassHealth to figure out and repay any overpayment.

“Beyond Healthcare Agency should work with MassHealth to determine the amount Beyond Healthcare Agency was overpaid for GAFC, and MassHealth should recoup that amount.”

The issue is bigger than one provider because the report says MassHealth still lacked clear, specific group adult foster care regulations, which can confuse providers.

“In OSA’s opinion, the lack of specific regulations and clear guidelines can cause confusion among GAFC providers regarding Group Adult Foster Care Program requirements.”

Group adult foster care means help with everyday activities like bathing, dressing, meals, transportation, and medication support so eligible people can keep living outside a long-term-care facility.

“Both programs are designed to provide sufficient assistance to allow members to continue to live independently and avoid the high cost of a long-term-care facility.”