Office of Medicaid (MassHealth) Claims for Wheelchair-Van Services Submitted
October 5, 2015 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published October 5, 2015 Audit covers January 1, 2013 – December 31, 2014 Under Suzanne M. Bump · 2011–2023
source
“As a result, we question all $17,258,633 of the payments made to Rite Way for wheelchair-van transportation during our audit period.”
Read the plain-English breakdown
This is a state audit of wheelchair-van transportation claims Rite Way submitted to MassHealth for 2013 and 2014.
“The Office of the State Auditor has conducted an audit of claims for wheelchair-van services provided to MassHealth members by Rite Way LLC (Rite Way) for the period January 1, 2013 through December 31, 2014.”
Auditors wanted to see whether Rite Way followed MassHealth rules when billing for transportation.
“The purpose of this audit was to determine whether Rite Way submitted transportation claims to MassHealth in compliance with state regulations and MassHealth policies.”
MassHealth is a major public healthcare program, and improper payments use money that could support valid medical care.
“The funds used to make these improper payments could have been used to provide medically necessary services for eligible MassHealth members.”
If you are a Massachusetts taxpayer or MassHealth member, this matters because public healthcare dollars are supposed to pay only for necessary, eligible services.
“MassHealth, the state’s Medicaid program, provides access to healthcare services to approximately 1.5 million eligible low- and moderate-income individuals, couples, and families annually.”
The auditor found that Rite Way lacked required paperwork and billed for rides involving ambulatory people, hospitalized people, or trips where no medical service was received.
“During our audit, Rite Way was unable to substantiate the medical necessity of any of the wheelchair-van transportation it provided to members.”
The report recommended repayment, better paperwork, no wheelchair billing for ambulatory members, and stronger billing controls.
“Rite Way should repay MassHealth the $16,416,705 it received in improper payments for wheelchair-van transportation for ambulatory members.”
MassHealth later suspended payments to Rite Way, and the auditor said that was appropriate given the findings.
“We believe that MassHealth’s decision to suspend payments to Rite Way as of August 27, 2015 was appropriate under the circumstances.”
What the Auditor checked
- Did not comply Did Rite Way bill MassHealth only for wheelchair-van services that were medically necessary, properly authorized, and paid in accordance with state regulations and MassHealth policies?
- Complied Did Rite Way establish policies and procedures to ensure that Criminal Offender Record Information (CORI) checks were consistently performed and documented for all wheelchair-van drivers?
What the Auditor found
Why it matters: Without completed authorization forms, Rite Way risked providing transportation to ineligible members.
Standard: Sections 407.421(C), 407.421(D), and 407.411(E) of MassHealth’s Transportation Manual ( Section 407.421(C) of MassHealth’s Transportation Manual; Section 407.421(D) of MassHealth’s Transportation Manual; Section 407.411(E) of MassHealth’s Transportation Manual )
1 recommendation
- Rite Way should maintain required PT-1 forms or MNFs for all members who need wheelchair-van transportation.
Agency response & Auditor reply
Agency: "All of Rite Way’s services were provided at the direction of MassHealth, which confirmed that Rite Way is not required to collect PT-1 forms for its transportation services."
Auditor: "At no time during our audit was Rite Way able to provide us with documentation supporting its assertion that MassHealth was aware that most of Rite Way’s riders were ambulatory and had instructed it to bill these services as if the members required wheelchair-van transportation."
Why it matters: MassHealth paid for a higher-cost transportation service for members who did not meet the wheelchair-van criteria.
Standard: Sections 407.471(A) and 407.411(E) of MassHealth’s Transportation Manual ( Section 407.411(E) of MassHealth’s Transportation Manual )
2 recommendations
- Rite Way should repay MassHealth the $16,416,705 it received in improper payments for wheelchair-van transportation for ambulatory members.
- Rite Way should not bill for any wheelchair transportation for ambulatory members.
Agency response & Auditor reply
Agency: "The Commonwealth’s decision to direct Rite Way to submit payment information under A0130, even with knowledge that most of Rite Way’s riders were ambulatory and attending methadone clinics, does not diminish the fact that Rite Way provides services, and does so promptly pursuant to its contractual arrangement with the Commonwealth."
Auditor: "MassHealth’s response also refutes Rite Way’s assertion that MassHealth had full knowledge of, and consented to, Rite Way’s improper billings."
Why it matters: MassHealth paid for transportation services that did not occur.
Standard: Section 450.235(A) of MassHealth’s Transportation Manual ( Section 450.235(A) of MassHealth’s Transportation Manual )
1 recommendation
- Rite Way should develop internal controls to ensure that claims are not submitted for hospitalized members or those who have not received medical services.
Agency response & Auditor reply
Agency: "In fact, Rite Way upgraded its reporting system and driver protocols in April 2014, long before the release of the Auditor’s Draft Report."
Auditor: "However, of the 393 instances in which Rite Way billed for wheelchair-van transportation for hospitalized members, 174 (44%) occurred after April 2014."
Why it matters: MassHealth paid for transportation not connected to covered medical services.
Standard: Section 407.431(A) of MassHealth’s Transportation Manual and 130 Code of Massachusetts Regulations 407.431(B) ( Section 407.431(A) of MassHealth’s Transportation Manual; 130 Code of Massachusetts Regulations 407.431(B) )
1 recommendation
- Rite Way should develop internal controls to ensure that claims are not submitted for hospitalized members or those who have not received medical services.
Agency response & Auditor reply
Agency: "Whether patients transported by Rite Way actually received methadone treatment is not dispositive of Rite Way’s entitlement to compensation."
Auditor: "Had Rite Way maintained completed forms for all members, as required by state regulations and by its contract, it would have been able to ascertain the exact dates for which these members were authorized to receive wheelchair-van transportation for medical services."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
Identified dollar findings that do not fall in a named band.
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