Audit of the Office of Medicaid (MassHealth) - Review of Payment for Telehealth Adult Foster Care and Group Adult Foster Care (September 4, 2024)

This is a State Auditor review of MassHealth payments for adult foster care and group adult foster care services delivered or billed as telehealth during the COVID-19 period.

“OSA has conducted a performance audit of MassHealth’s payments for telehealth adult foster care (AFC) and group adult foster care (GAFC) services for the period January 1, 2020 through December 31, 2021.”

The Auditor’s office reviews Medicaid spending to look for fraud, waste, abuse, and weak controls in MassHealth.

“The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to help identify fraud, waste, and abuse in the Commonwealth’s Medicaid program.”

These programs serve older adults and adults with disabilities, so missing oversight and missing records can raise questions about whether people got the care they needed.

“The MassHealth adult foster care (AFC) and group adult foster care (GAFC) programs provide adult members over 65 and adult members with disabilities with assistance performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs).”

If you are a taxpayer, MassHealth member, caregiver, or family member, the audit is about whether public healthcare money was spent properly and whether care was documented and monitored.

“Our audit is designed to identify issues that will help improve the Medicaid program, so taxpayers know that their dollars are spent prudently and that there is a system of continuous improvement to support improved efficiency and service over time.”

The audit found three main problems: missing required oversight visits, missing or incomplete caregiver logs, and claims incorrectly coded as telehealth.

“Below is a summary of our findings, the effects of those findings, and our recommendations, with links to each page listed.”

MassHealth agreed with the recommendations, said it will strengthen monitoring, and said it will add a system edit to stop these telehealth-coded AFC and GAFC claims.

“We will be conducting a post-audit review in approximately six months to follow up.”

The dollars were large: MassHealth paid more than $771 million for AFC and GAFC claims in the audit period, including nearly $23 million for claims coded as telehealth.

“During this period, MassHealth paid $771,112,638 for 7,099,054 AFC and GAFC claims, of which, $22,979,654 was paid for 310,831 telehealth AFC and GAFC claims.”

AFC means adult foster care, GAFC means group adult foster care, and ADLs are basic daily needs like eating, dressing, bathing, toileting, and walking.

“ADLs include activities such as eating, toileting, dressing, bathing, and walking.”