Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services Provided by Cozy Corner Adult Day Health
March 15, 2019 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published March 15, 2019 Audit covers January 1, 2016 – December 31, 2017 Under Suzanne M. Bump · 2011–2023
source
“Cozy Corner did not properly document physician orders and clinical authorizations in member records to support ADH services it billed.”
Read the plain-English breakdown
This is a state audit of MassHealth payments to Cozy Corner Adult Day Health for services provided from January 1, 2016 through December 31, 2017.
“OSA has conducted an audit of MassHealth claims for adult day health (ADH) services paid to Cozy Corner Adult Day Health for the period January 1, 2016 through December 31, 2017.”
The audit checked whether Cozy Corner had the required doctor orders and clinical approvals before billing MassHealth for adult day health services.
“The purpose of this audit was to determine whether Cozy Corner obtained the required physician orders and clinical authorizations for ADH services for each MassHealth member.”
MassHealth is a major public program funded with taxpayer money, so weak documentation can put public funds at risk and reduce confidence in the program.
“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”
The auditor recommended that MassHealth decide how much of the $955,587 should be recovered from Cozy Corner.
“MassHealth should determine how much of the $955,587 discussed in this finding should be repaid and seek reimbursement.”
MassHealth said it agreed with the recommendations and planned to use the state auditor’s work as the basis for its own audit of Cozy Corner.
“MassHealth will use [the Office of the State Auditor’s (OSA’s)] audit as the basis for its own audit of Cozy Corner.”
The finding covered all 47 MassHealth members Cozy Corner served during the audit period, so this was not described as an isolated paperwork issue.
“During our audit period, Cozy Corner Adult Day Health provided adult day health (ADH) services totaling $955,587 to 47 MassHealth members; however, for all 47 members, it lacked the physician orders and/or clinical authorizations necessary to substantiate the types of services each member was authorized to receive.”
Adult day health means daytime healthcare and supervision for eligible MassHealth members who need help with basic daily activities like eating, bathing, walking, toileting, or taking medicine.
“MassHealth covers ADH services for eligible MassHealth members who need assistance with activities of daily living (ADLs) such as eating, toileting, bathing, walking, and taking medication.”
1 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did Cozy Corner properly bill for medical services provided to MassHealth members?
What the Auditor found
Why it matters: There was a higher-than-acceptable risk that Cozy Corner may not have provided the appropriate types of services to members, and MassHealth may need to recover improper payments.
Standard: MassHealth transmittal letter ADH-25, amending 130 CMR 404, required clinical authorization before service commencement and physician documentation before the member's first attendance day. ( Section 12 of Chapter 11 of the Massachusetts General Laws; MassHealth transmittal letter ADH-25, Section 404 of Title 130 of the Code of Massachusetts Regulations )
3 recommendations
- MassHealth should determine how much of the $955,587 should be repaid and seek reimbursement.agency: agreed
- Cozy Corner should contact MassHealth for guidance if regulatory requirements are unclear.agency: disagreed
- Cozy Corner should ensure completed and authorized physician orders and clinical authorizations are in place before providing ADH services.agency: disagreed
Agency response & Auditor reply
Agency: "Cozy Corner adamantly denies the Report’s allegations that it violated any MassHealth regulations or received an overpayment."
Auditor: "Despite what it asserts in its response, Cozy Corner did not always have adequate documentation on file at the time it began providing services to MassHealth members."
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