Office of Medicaid (MassHealth) Review of Controls over Mobility-Assistive Equipment
September 16, 2015 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published September 16, 2015 Audit covers July 1, 2011 – December 31, 2012 Under Suzanne M. Bump · 2011–2023
Read the plain-English breakdown
This is a State Auditor review of MassHealth payments for mobility-assistive equipment, mainly wheelchairs and wheelchair parts, covering July 1, 2011 through December 31, 2012.
“The Office of the State Auditor (OSA) has conducted an audit of claims for mobility-assistive equipment for the period July 1, 2011 through December 31, 2012.”
Auditors checked whether MassHealth paid correctly, had computer controls to stop improper claims, and watched for unusual or possibly fraudulent billing.
“The objective of our audit was to determine whether MassHealth paid for this equipment in accordance with state regulations, maintained effective system edits to control payments, and monitored payments to identify billing irregularities and potentially fraudulent claims.”
MassHealth is a major public program, so even narrow payment problems can affect large amounts of taxpayer money.
“Medicaid expenditures represent approximately 33% of the Commonwealth’s total budget.”
If you are a Massachusetts taxpayer or MassHealth member, this matters because the program serves many residents and depends on public money being spent properly.
“MassHealth provides access to healthcare services for approximately 1.4 million eligible low- and moderate-income individuals, couples, and families annually, including children, seniors, and people with disabilities.”
The auditor said MassHealth paid too much for some wheelchair purchases and also paid claims that should have been better authorized, denied, or recovered.
“MassHealth could have saved more than $1 million on wheelchair-related purchases for members.”
MassHealth said it would add computer checks and provider guidance, and the auditor recommended recovering improper payments and tightening authorization rules.
“MassHealth will implement new systems edits and will issue guidance for providers clarifying and reiterating its policies to ensure compliance.”
“Mobility-assistive equipment” means items that help people move around, such as canes, walkers, crutches, and wheelchairs.
“Mobility-assistive equipment includes walkers, canes, crutches, and manual or power wheelchairs.”
8 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did MassHealth pay for mobility-assistive equipment in accordance with 130 Code of Massachusetts Regulations (CMR) 409.401-430 and 114.3 CMR 22.00?
- Did not comply Did MassHealth maintain edits in its claim-processing system to detect and deny claims for mobility-assistive equipment that did not comply with the regulations?
- Complied Did MassHealth ensure that providers obtained and retained necessary service information for proof of delivery?
- Complied Did MassHealth ensure that providers obtained and retained necessary service information for medical necessity?
- Did not comply Did MassHealth ensure that providers obtained and retained necessary service information for prior authorization?
- Did not comply Did MassHealth monitor system outputs to identify billing irregularities and potentially fraudulent claims?
What the Auditor found
Why it matters: MassHealth may have missed opportunities to save more than $1 million, and possibly millions annually, on durable medical equipment.
Standard: 114.3 Code of Massachusetts Regulations 22.03 and 114.3 Code of Massachusetts Regulations 22.02 ( 114.3 Code of Massachusetts Regulations 22.03; 114.3 Code of Massachusetts Regulations 22.02 )
2 recommendations
- MassHealth should develop policies and procedures that would ensure that it is paying the lowest price for wheelchairs and wheelchair components in accordance with the requirements of 114.3 CMR 22.agency: agreed
- MassHealth should consider amending its regulations so that it has the flexibility to pay less than 100% of the Medicare rates for DME.agency: agreed
Agency response & Auditor reply
Agency: "MassHealth agrees that it is important to ensure that we pay the lowest price for wheelchairs and components, and [Recommendation 1] is in line with work that the Baker administration currently has underway to explore opportunities for cost savings in the DME program."
Auditor: "In its response, MassHealth states that it is exploring opportunities for cost savings for DME, such as bulk purchasing, and will develop and implement policies and procedures to ensure that the lowest cost is paid."
Why it matters: MassHealth made $540,801 in unallowable payments and lacked system controls to enforce payment limits and restrictions.
Standard: 130 Code of Massachusetts Regulations 409.418, 130 Code of Massachusetts Regulations 409.415, and 130 Code of Massachusetts Regulations 450.307 ( 130 CMR 409.418; 130 CMR 409.415(A)(1)(a); 130 CMR 409.415(A)(2)(b); 130 CMR 450.307 )
1 recommendation
- MassHealth should recover unallowable payments due to providers improperly billing MassHealth for repairs and replacement components for manual wheelchairs owned by nursing facilities, submitting claims for duplicate services, and submitting unbundled claims.agency: partially agreed
Agency response & Auditor reply
Agency: "MassHealth agrees with [OSA’s] findings regarding gaps in MassHealth's processes around authorization, provision and billing of wheelchair components."
Auditor: "We concur with MassHealth’s approach to addressing these systemic issues and seeking recoupment for the $340,000 identified as improper payments for services that exceeded stated limits, unbundled billings, and duplicate services."
Why it matters: MassHealth paid approximately $2.86 million in unauthorized wheelchair repair costs.
Standard: 130 Code of Massachusetts Regulations 409.418(E) and DME Transmittal Letter 26 ( 130 CMR 409.418(E); DME Transmittal Letter 26 )
1 recommendation
- MassHealth should ensure that prior authorization has been obtained for repairs when the billed amount exceeds $1,000.agency: agreed
Agency response & Auditor reply
Agency: "MassHealth agrees that our prior authorization system does not pick up instances where individual claims for a repair are each under $1,000 but the full cost of the repair is over $1,000."
Auditor: "Based on its response, it appears that MassHealth is taking steps to address the problems we identified in this area."
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.
Prior findings revisited
"Based on our current audit work, KPMG’s fiscal year 2013 testing of MMIS’s IT controls, and the corrective action planned by EOHHS to resolve our prior audit issues, we have determined that the claim data obtained were sufficiently reliable for the purposes of this report."
More audits of this entity
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- Audit of the Office of Medicaid (MassHealth) - Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy (UCP)MassHealth / Medicaid · September 19, 2019
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- Audit of the Office of Medicaid (MassHealth) - A Review of MassHealth Member Eligibility at the Tewksbury Enrollment CenterMassHealth / Medicaid · October 9, 2020
- Office of Medicaid (MassHealth) Claims for Wheelchair-Van Services SubmittedMassHealth / Medicaid · October 5, 2015
- Audit of the Office of Medicaid (MassHealth) - Review of Durable Medical Equipment Providers (October 30, 2025)MassHealth / Medicaid · October 30, 2025