Office of Medicaid (MassHealth) - Review of Fee-for-Service Payments for Services Covered by the Massachusetts Behavioral Health Partnership
April 3, 2017 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published April 3, 2017 Under Suzanne M. Bump · 2011–2023
source
“Based on our audit, we have concluded that MassHealth paid approximately $193 million in improper or questionable FFS claims for members enrolled in MBHP during our audit period.”
Read the plain-English breakdown
This is a state audit of MassHealth payments for behavioral health services from July 1, 2010 through June 30, 2015.
“The Office of the State Auditor (OSA) has conducted an audit of fee-for-service (FFS) payments for services covered under the Massachusetts Behavioral Health Partnership (MBHP) contract for the audit period, July 1, 2010 through June 30, 2015.”
Auditors checked whether MassHealth was rejecting bills that should have been handled under its behavioral health contractor instead.
“The purpose of this audit was to determine whether MassHealth disallowed FFS claims for services that should have been covered by MBHP in accordance with its contract with EOHHS as well as applicable regulations and other requirements.”
The concern is that the state could pay once through its monthly MBHP payment and then pay again when a provider bills separately.
“Otherwise, MassHealth may pay twice for the same service (by paying a monthly fee to MBHP to provide a type of service and then paying a provider on an FFS basis when the service is actually performed).”
If you live in Massachusetts, this matters because MassHealth is a major public program serving many residents and using a large share of state spending.
“MassHealth provides access to healthcare services to approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities annually.”
The audit’s main finding was that MassHealth paid roughly $193 million in improper or questionable claims connected to MBHP members.
“MassHealth paid approximately $193 million in improper or questionable FFS claims for members enrolled in MBHP.”
The auditor recommended that MassHealth try to recover about $93 million identified as improper.
“MassHealth should take appropriate action to recoup the approximately $93 million of payments we identified as improper.”
The report frames the issue as important for public trust in Medicaid, not just accounting.
“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”
5 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did MassHealth disallow FFS claims for MBHP enrollees for services that should have been covered by MBHP?
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
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