Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Services Provided by Norwood Adult Day Health Center
June 6, 2019 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published June 6, 2019 Audit covers January 1, 2016 – December 31, 2017 Under Suzanne M. Bump · 2011–2023
source
“NADHC did not obtain physician orders to support as much as $92,644 of ADH services provided to three MassHealth members.”
Read the plain-English breakdown
This is a state audit of MassHealth payments to Norwood Adult Day Health Center for adult day health services during 2016 and 2017.
“OSA has conducted an audit of MassHealth claims for adult day health (ADH) services paid to Norwood Adult Day Health Center (NADHC) for the period January 1, 2016 through December 31, 2017.”
The auditor checked whether the center had the required approvals before providing and billing MassHealth for services.
“The purpose of this audit was to determine whether NADHC obtained the required physician orders and clinical authorizations for ADH services for each MassHealth member.”
MassHealth is a major public healthcare program, so billing mistakes can affect taxpayer dollars and public trust.
“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”
If you use MassHealth, know someone who does, or pay state taxes, this audit is about making sure public healthcare money is spent properly.
“MassHealth provides access to healthcare services to approximately 1.9 million low- and moderate-income children, families, seniors, and people with disabilities annually.”
The center needs to work with MassHealth on possible repayment and strengthen its paperwork and billing checks.
“NADHC should collaborate with MassHealth to determine how much of the $92,644 discussed in this finding should be repaid.”
MassHealth agreed with the recommendations and said the audit means it needs to do its own audit of Norwood Adult Day Health.
“OSA’s audit findings have triggered a need for MassHealth to conduct its own audit of Norwood ADH.”
The audit found documentation and billing control problems, but it did not say the center intentionally billed incorrectly.
“Our report does not state or imply that NADHC intentionally billed MassHealth incorrectly for the services in question.”
ADH means adult day health: daytime services for eligible MassHealth members who need help with daily activities like eating, bathing, walking, toileting, or medication.
“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 NADHC properly bill for adult day health (ADH) medical services provided to MassHealth members?
What the Auditor found
Why it matters: There was a higher-than-acceptable risk that NADHC may not have provided appropriate types and levels of service to MassHealth members, and some payments may need to be repaid.
Standard: Section 404.406(F)(2) of Title 130 of the Code of Massachusetts Regulations required providers to obtain physician documentation, including physician orders, before a member's first attendance day. ( Section 404.406(F)(2) of Title 130 of the Code of Massachusetts Regulations )
2 recommendations
- NADHC should collaborate with MassHealth to determine how much of the $92,644 discussed in this finding should be repaid.agency: disagreed
- NADHC should develop policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.agency: disagreed
Agency response & Auditor reply
Agency: "As such, we do believe that there is sufficient evidence to support the requirement of a physician order to attend adult day health."
Auditor: "However, none of this documentation included physician orders for ADH services."
Why it matters: MassHealth could reject inaccurate claims, which could cause a loss of billing revenue for services that were provided.
Standard: 130 CMR 450.301(A) and 130 CMR 450.331 require claims to be submitted only by the provider that provided the service and make providers responsible for billing agents' acts. ( 130 CMR 450.301(A); 130 CMR 450.331 )
1 recommendation
- NADHC should enhance its policies and procedures to make sure that it properly monitors claims submitted to MassHealth by its billing agents to ensure that all the claims they submit indicate the locations where services were provided.agency: disagreed
Agency response & Auditor reply
Agency: "In summary, there was no act of intent to incorrectly bill MassHealth."
Auditor: "Our report does not state or imply that NADHC intentionally billed MassHealth incorrectly for the services in question."
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