Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by City Home Care, LLC
September 21, 2020 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published September 21, 2020 Audit covers January 1, 2016 – December 31, 2018 Under Suzanne M. Bump · 2011–2023
source
“City Home Care was paid as much as $268,494 for group adult foster care services that appear to be unallowable.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of MassHealth payments to City Home Care for group adult foster care services from January 1, 2016 through December 31, 2018.
“OSA has conducted an audit of MassHealth claims for group adult foster care (GAFC) paid to City Home Care, LLC for the period January 1, 2016 through December 31, 2018.”
The auditor checked whether City Home Care got required approvals and billed MassHealth properly for group adult foster care services.
“The purpose of this audit was to determine whether City Home Care obtained the required prior authorizations, and properly billed, for GAFC provided to MassHealth members during our audit period.”
This matters because MassHealth is a major public healthcare program, and the auditor says public trust is important for its support and success.
“As with any government program, public confidence is essential to this program’s success and continued support.”
For an ordinary Massachusetts resident, the issue is whether public Medicaid money is being spent only on services that are allowed and not on payments that should be recovered.
“City Home Care should work with MassHealth to determine the amount City Home Care was overpaid for GAFC, and MassHealth should recoup that amount.”
The auditor concluded that City Home Care did not bill group adult foster care in accordance with MassHealth’s guidelines, though it did get prior authorization for members receiving those services.
“Did City Home Care bill for group adult foster care (GAFC) in accordance with MassHealth’s sub-regulatory Group Adult Foster Care Guidelines?”
The report says City Home Care should stop billing for unallowable services, work with MassHealth to identify any overpayment, and MassHealth should recover that money.
“City Home Care should ensure that it does not bill MassHealth for unallowable GAFC services.”
The audit also points to a broader problem: MassHealth did not have clear, specific regulations for group adult foster care, which can confuse providers about the rules.
“MassHealth lacks specific regulations and clear guidelines for group adult foster care.”
Group adult foster care is help for elderly people or people with disabilities who need assistance with daily tasks so they can keep living outside a long-term-care facility.
“The Adult Foster Care and Group Adult Foster Care Programs provide MassHealth members who are elderly or have disabilities with assistance performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs).”
1 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did City Home Care bill for group adult foster care (GAFC) in accordance with MassHealth’s sub-regulatory Group Adult Foster Care Guidelines?
- Complied Did City Home Care obtain prior authorization from MassHealth for its members who received GAFC?
What the Auditor found
Why it matters: MassHealth may have overpaid City Home Care for duplicative or unallowable services.
Standard: MassHealth’s Adult Foster Care Manual, 130 CMR 408.437, and Section 13(H) of MassHealth’s sub-regulatory Group Adult Foster Care Guidelines. ( Section 408.437 of Title 130 of the Code of Massachusetts Regulations; Section 13(H) of MassHealth’s sub-regulatory Group Adult Foster Care Guidelines )
2 recommendations
- City Home Care should ensure that it does not bill MassHealth for unallowable GAFC services.
- City Home Care should work with MassHealth to determine the amount City Home Care was overpaid for GAFC, and MassHealth should recoup that amount.agency: disagreed
Agency response & Auditor reply
Agency: "We respectfully disagree that a repayment should be made on the basis that there are no clear guidelines in place and that as an agency providing said services, services have carefully [been] screened to assure that the GAFC services provided were not the same services that was or could have been provided by the other service program."
Auditor: "Based on the issues we identified with City Home Care’s billing practices during this audit, we urge it to implement our recommendations and work with MassHealth to resolve this matter."
More audits of this entity
Other Office of the State Auditor reports on Office of Medicaid (MassHealth) .
- Audit of the Office of Medicaid (MassHealth) - Review of Payment for Telehealth Adult Foster Care and Group Adult Foster Care (September 4, 2024)MassHealth / Medicaid · September 4, 2024
- Audit of the Office of Medicaid (MassHealth) - Review of Claims Submitted by Dr. Frederick Wagner Jr.MassHealth / Medicaid · September 24, 2019
- Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by Beyond Healthcare Agency, LLCMassHealth / Medicaid · September 21, 2020
- Office of Medicaid (MassHealth) - Review of Hospice Care Billing: HopeHealth Massachusetts, Inc.MassHealth / Medicaid · September 21, 2017
- Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy (UCP)MassHealth / Medicaid · September 19, 2019
- Office of Medicaid (MassHealth) Review of Controls over Mobility-Assistive EquipmentMassHealth / Medicaid · September 16, 2015
- Audit of the Office of Medicaid (MassHealth) - A Review of MassHealth Member Eligibility at the Chelsea Enrollment CenterMassHealth / Medicaid · October 9, 2020
- Audit of the Office of Medicaid (MassHealth) - A Review of MassHealth Member Eligibility at the Springfield Enrollment CenterMassHealth / Medicaid · October 9, 2020
- Audit of the Office of Medicaid (MassHealth) - A Review of MassHealth Member Eligibility at the Taunton Enrollment CenterMassHealth / Medicaid · October 9, 2020
- Audit of the Office of Medicaid (MassHealth) - A Review of MassHealth Member Eligibility at the Tewksbury Enrollment CenterMassHealth / Medicaid · October 9, 2020
- Office of Medicaid (MassHealth) Claims for Wheelchair-Van Services SubmittedMassHealth / Medicaid · October 5, 2015
- Audit of the Office of Medicaid (MassHealth) - Review of Durable Medical Equipment Providers (October 30, 2025)MassHealth / Medicaid · October 30, 2025