Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services Provided by Liberty 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
“Liberty did not properly document physician orders in member records to support ADH services it billed, totaling $32,407.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of MassHealth payments to Liberty Adult Day Health for adult day health services from January 1, 2016 through December 31, 2017.
“OSA has conducted an audit of MassHealth claims for adult day health (ADH) services paid to Liberty Adult Day Health for the period January 1, 2016 through December 31, 2017.”
The auditor checked whether Liberty had the required doctor orders and MassHealth approvals before providing and billing for adult day health services.
“The purpose of this audit was to determine whether Liberty 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 paperwork and billing controls can reduce trust and lead to improper payments.
“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”
If you are a taxpayer or MassHealth member, this matters because the audit looked at whether public healthcare dollars were spent only when required medical approvals were in place.
“MassHealth provides access to healthcare services to approximately 1.9 million low- and moderate-income children, families, seniors, and people with disabilities annually.”
The auditor concluded Liberty did not properly bill in all cases reviewed because some required physician documentation was missing or incomplete.
“Did Liberty properly bill for medical services provided to MassHealth members?”
The report says Liberty should work with MassHealth to repay $32,407 and improve its procedures so doctor orders are complete before services are provided.
“Liberty should collaborate with MassHealth to repay the $32,407 discussed in this finding.”
Adult day health services are daytime healthcare and support services for people who need help with daily tasks like eating, toileting, bathing, walking, 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.”
2 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did Liberty properly bill for medical services provided to MassHealth members?
What the Auditor found
Why it matters: There was a higher-than-acceptable risk that Liberty may not have provided the appropriate types and levels of service.
Standard: Section 404.406 of Title 130 of the Code of Massachusetts Regulations required adult day health providers to obtain physician documentation, including physician orders, before the member's first attendance day. ( Section 404.406 of Title 130 of the Code of Massachusetts Regulations )
2 recommendations
- Liberty should collaborate with MassHealth to repay the $32,407 discussed in this finding.agency: disagreed
- Liberty should develop internal control policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.agency: agreed
Agency response & Auditor reply
Agency: "I feel Liberty provided services to this client and deserves to be paid for these services."
Auditor: "The Office of the State Auditor (OSA) did review the records of the preauthorization decisions from Fallon Navicare as well as the care plans Liberty mentions in its response; however, these records do not constitute a proper physician order, which, according to MassHealth regulations, is required before a member’s first attendance day."
Why it matters: Member care plans may have been inadequate because the physician orders did not include lists of required services.
Standard: 130 CMR 404.406(F)(3) required adult day health care plans to include a treatment plan based on the member's physician's orders. ( 130 CMR 404.406(F)(3) )
1 recommendation
- Liberty should develop policies and procedures for the review of physician orders to ensure that these orders contain the necessary information to develop adequate care plans for MassHealth members.agency: already implemented
Agency response & Auditor reply
Agency: "I absolutely agree with the recommendation of developing policy and procedure [to ensure] the physician’s documentation contains the necessary information."
Auditor: "OSA acknowledges that ADH providers are responsible for conducting clinical assessments to establish members’ specific care plans."
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