Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by Boston Senior Home Care (BSHC)
July 20, 2020 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published July 20, 2020 Audit covers January 1, 2016 – December 31, 2018 Under Suzanne M. Bump · 2011–2023
source
“As a result, MassHealth paid for AFC that it did not authorize.”
Read the plain-English breakdown
This is a state audit of MassHealth payments to Boston Senior Home Care for adult foster care services from January 1, 2016 through December 31, 2018.
“OSA has conducted an audit of MassHealth claims for adult foster care (AFC) paid to Boston Senior Home Care (BSHC) for the period January 1, 2016 through December 31, 2018.”
The audit checked whether Boston Senior Home Care billed MassHealth correctly for adult foster care services.
“The purpose of this audit was to determine whether BSHC properly billed for AFC provided to MassHealth members during our audit period.”
MassHealth is a major public program, and audits help protect taxpayer money and public trust.
“The audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program.”
If you are a Massachusetts taxpayer or MassHealth member, this report is about whether public healthcare dollars were spent with the proper checks in place.
“MassHealth provides access to healthcare for approximately 1.9 million low- and moderate-income children, families, seniors, and people with disabilities annually.”
The main problem was missing annual prior authorizations for adult foster care, and the auditor recommended that Boston Senior Home Care get them each year.
“BSHC should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.”
Boston Senior Home Care said it started submitting the required annual approvals after MassHealth’s online portal began operating, and MassHealth said it planned to audit compliance.
“EOHHS plans to conduct an audit of BSHC to determine compliance with the prior authorization requirement for MassHealth-covered AFC.”
The audit also flagged a possible cost-savings issue: some home care services may have overlapped with adult foster care services paid for the same people on the same dates.
“However, OSA believes that MassHealth should further examine this issue and determine whether there are opportunities for cost savings.”
What the Auditor checked
- Did not comply Did BSHC obtain prior authorizations from MassHealth for its members receiving AFC?
What the Auditor found
Why it matters: MassHealth paid for adult foster care that it had not authorized.
Standard: Section 408.417(B) of Title 130 of the Code of Massachusetts Regulations requires prior authorizations for adult foster care before the first date of service and annually thereafter. ( Section 408.417(B) of Title 130 of the Code of Massachusetts Regulations )
1 recommendation
- BSHC should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.agency: already implemented
Agency response & Auditor reply
Agency: "Since the [Long-Term Services and Supports] Provider Portal was implemented on April 16, 2019, BSHC has been submitting prior authorizations as required by AFC regulations."
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