Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services by WestMass ElderCare, Inc.
July 21, 2020 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published July 21, 2020 Audit covers January 1, 2016 – December 31, 2018 Under Suzanne M. Bump · 2011–2023
source
“WMEC provided AFC to MassHealth members without submitting annual prior authorizations.”
Read the plain-English breakdown
This is a state audit of MassHealth payments to WestMass ElderCare for adult foster care services from 2016 through 2018.
“OSA has conducted an audit of MassHealth claims for adult foster care (AFC) paid to WestMass ElderCare, Inc. (WMEC) for the period January 1, 2016 through December 31, 2018.”
The auditor checked whether WestMass ElderCare billed MassHealth properly for adult foster care services.
“The purpose of this audit was to determine whether WMEC properly billed for AFC provided to MassHealth members during our audit period.”
This matters because public Medicaid money should only pay for services that were properly approved and billed.
“As with any government program, public confidence is essential to this program’s success and continued support.”
For an ordinary resident, the issue is whether taxpayer-supported MassHealth dollars are being watched carefully and whether services for older adults and people with disabilities are being properly approved.
“MassHealth provides access to healthcare for approximately 1.9 million low- and moderate-income children, families, seniors, and people with disabilities annually.”
The audit found a paperwork and approval problem: MassHealth paid for adult foster care that had not received required annual authorization.
“As a result, MassHealth paid for AFC that it did not authorize.”
WestMass ElderCare said it started submitting annual prior authorizations once the MassHealth online portal became available, and MassHealth said it planned to audit WestMass ElderCare’s compliance.
“EOHHS plans to conduct an audit of WMEC to determine compliance with the prior authorization requirement for MassHealth-covered AFC.”
The audit covered more than $20 million in MassHealth payments to WestMass ElderCare for adult foster care services for 404 members.
“During this period, MassHealth paid WMEC $20,296,251 for 11,709 claims to provide AFC for 404 MassHealth members.”
Adult foster care means help for older adults or people with disabilities with everyday tasks like eating, bathing, walking, dressing, laundry, shopping, and meals.
“The AFC and GAFC 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).”
What the Auditor checked
- Did not comply Did WMEC obtain prior authorizations from MassHealth for its members receiving AFC?
What the Auditor found
Why it matters: MassHealth paid for adult foster care services that it did not authorize.
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
- WestMass ElderCare should obtain annual prior authorizations from MassHealth for its members who are receiving adult foster care.agency: already implemented
Agency response & Auditor reply
Agency: "Since April 16, 2019, WMEC has been and will continue to submit Prior Authorizations as required per all MassHealth regulations and applicable guidance."
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