Medical Community Services, Inc.
April 6, 2017 · Read the full official report (PDF) ↗
Published April 6, 2017 Audit covers July 1, 2011 – June 30, 2016 Under Suzanne M. Bump · 2011–2023
source
“Our audit revealed no significant instances of noncompliance that must be reported under generally accepted government auditing standards.”
Read the plain-English breakdown
This is a state performance audit of Medical Community Services, Inc., a MassHealth group adult foster care provider, covering July 1, 2011 through June 30, 2016.
“The purpose of this audit was to determine whether MCS administered its GAFC program in accordance with applicable regulations and contractual requirements.”
The Auditor reviewed MCS because MassHealth spends heavily on adult foster care programs and MCS was among the biggest GAFC billers during the audit period.
“We selected MCS for audit because we determined that its billings (more than $11 million) were in the highest 10 billing totals of all GAFC providers during the audit period.”
The report says MassHealth paid MCS as much as $1.4 million for GAFC services that the Auditor considered unallowable because members also received skilled nursing at home on the same days.
“During the audit period, Medical Community Services, Inc. (MCS) billed, and received payments totaling as much as $1,434,256 from MassHealth, for group adult foster care (GAFC) services that were duplicative and therefore not allowable under MassHealth regulations.”
For taxpayers and MassHealth members, the issue is whether public money is paying for necessary care efficiently while still helping elderly or disabled people stay out of more expensive facilities.
“The Adult Foster Care and Group Adult Foster Care Programs are designed to provide sufficient assistance to allow members to continue to live independently and avoid the high cost of a long-term-care facility.”
The audit’s formal answer was that MCS properly administered its GAFC program, but the report separately flagged MassHealth payment and program-design issues.
“Did MCS properly administer its GAFC program?”
MassHealth said it planned to issue GAFC regulations and clarify when GAFC services overlap with other services; MCS said clearer guidance would help providers comply.
“Finally, MassHealth stated that in fall 2017, it will put forth regulations governing the GAFC program and “will clarify when GAFC services do not duplicate other services a member is receiving.””
The Auditor believed MassHealth could save substantial money if medication help for GAFC members were delivered differently, including possible savings at MCS alone.
“If MassHealth had assigned medication management to CNAs, it would have decreased this cost to $6.4 million, resulting in savings of as much as $1.5 million at MCS alone.”
GAFC means group adult foster care. ADLs are basic daily tasks like eating, bathing, dressing, toileting, and walking; IADLs are household and independent-living tasks like laundry, shopping, transportation, meals, and medication management.
“ADLs include activities such as eating, toileting, dressing, bathing, and walking.”
3 figure(s) pending source verification - not shown
What the Auditor checked
- Complied Did MCS properly administer its GAFC program?
What the Auditor found
Why it matters: MassHealth paid as much as $1,434,256 for GAFC services provided on the same days members received skilled nursing in their homes, creating unallowable duplicate payments.
Standard: MassHealth Adult Foster Care regulations at 130 CMR 408.437 prohibit payment when the member is receiving other personal care services, including home care services under 651 CMR 3.03(5). ( Section 408.437 of Title 130 of the Code of Massachusetts Regulations; 651 CMR 3.01(2); 130 CMR 408.402; 130 CMR 408.415(B) )
1 recommendation
- MCS should collaborate with MassHealth to determine whether MassHealth intends to stop paying for duplicative services.
Agency response & Auditor reply
Agency: "It is difficult to follow guidelines that are not in place or explicitly explained."
Auditor: "We do not dispute that all the claims in question may have had referrals for VNA services."
Why it matters: MassHealth could reduce costs if certified nursing assistants certified in medication management provided medication management instead of registered nurses from visiting nurse associations.
Standard: 105 CMR 700.003(F)(2) allows trained unlicensed personnel to administer prescription medication. ( 105 CMR 700.003(F)(2) )
1 recommendation
- MassHealth should investigate whether changing how medication management services are delivered could produce substantial savings.
Agency response & Auditor reply
Agency: "MassHealth appreciates the purpose and intent of the [OSA] recommendation for possible cost savings that might be achieved through a change in the design of the GAFC program."
Auditor: "However, our analysis involved using CNAs who are, by virtue of their training, already certified in medication management to provide both home health and medication management services."