Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by Somerville-Cambridge Elder Services (SCES)
June 29, 2020 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published June 29, 2020 Audit covers January 1, 2016 – December 31, 2018 Under Suzanne M. Bump · 2011–2023
source
“SCES provided AFC to MassHealth members without submitting annual prior authorizations.”
Read the plain-English breakdown
The auditor wanted to know whether SCES billed MassHealth properly for adult foster care services.
“The purpose of this audit was to determine whether SCES properly billed for AFC provided to MassHealth members during our audit period.”
MassHealth is a major public program, so taxpayers and members need confidence that payments are properly reviewed and authorized.
“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 money is being checked carefully while helping older adults and people with disabilities stay out of more costly institutions.
“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.”
The main problem was paperwork and authorization: MassHealth paid for some adult foster care services even though the required annual approvals had not been submitted.
“As a result, MassHealth paid for AFC that it did not authorize.”
SCES said it began submitting annual prior authorizations after MassHealth’s provider portal went live, and MassHealth’s oversight agency said it planned another audit of SCES compliance.
“EOHHS plans to conduct an audit of SCES to determine compliance with the prior authorization requirement for MassHealth-covered AFC.”
The audit covered a meaningful amount of public money: over $13 million in MassHealth payments to SCES for 287 members during the audit period.
“During this period, MassHealth paid SCES $13,237,054 for 7,597 claims to provide AFC for 287 MassHealth members.”
Adult foster care means help for eligible people who need support with everyday tasks; ADLs are basic daily activities like eating, bathing, walking, and dressing.
“ADLs include activities such as eating, toileting, bathing, walking, and dressing.”
What the Auditor checked
- Did not comply Did SCES 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
- SCES should obtain annual prior authorizations from MassHealth for its members who are receiving AFC.agency: already implemented
Agency response & Auditor reply
Agency: "The Portal was implemented on April 16, 2019, and since that time SCES has been submitting prior authorizations as required in the regulations."
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