Office of Medicaid (MassHealth) - Review of Hospice Care Billing: Good Shepherd Community Care

This is a Massachusetts State Auditor performance audit of hospice claims that Good Shepherd Community Care billed to MassHealth from July 1, 2011 through June 30, 2016.

“OSA has conducted an audit of hospice claims paid to Good Shepherd Community Care for the period July 1, 2011 through June 30, 2016.”

The auditor checked whether Good Shepherd billed MassHealth properly for hospice care and kept the required paperwork in patient files.

“The purpose of this audit was to determine whether Good Shepherd Community Care billed MassHealth for appropriate hospice services and whether it documented them in member files in accordance with applicable state and federal regulations.”

MassHealth is a major public program serving many Massachusetts residents and spending billions of dollars, so accurate billing and records matter for public trust and taxpayer money.

“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”

If you are a Massachusetts taxpayer or MassHealth member, this audit is about whether public healthcare dollars were supported by the required records before hospice payments were made.

“During this period, MassHealth paid Good Shepherd Community Care approximately $5,992,563 to provide hospice services for 376 MassHealth members.”

The auditor found that Good Shepherd did not always keep properly completed required forms for the hospice services it billed to MassHealth.

“Good Shepherd Community Care did not always maintain properly completed required forms supporting hospice services provided to MassHealth members, based on our detailed review of each member’s Certification of Terminal Illness (CTI) Form and MassHealth Hospice Election Form.”

MassHealth agreed with the recommendation and said the provider should follow it; Good Shepherd also said it had changed its practice for filling in member addresses on the election form.

“Regarding the audit findings and recommendation in the audit . . . we agree with the Auditor’s recommendation, and recommend that the provider act in accordance with them.”

The finding matters because missing or incomplete paperwork can create a risk that MassHealth pays for hospice services that were not properly supported or may not have been necessary.

“Without ensuring that it obtains and maintains all of the required information, Good Shepherd Community Care risks providing and billing MassHealth for hospice services that may be unnecessary.”

A CTI Form is the doctor’s certification that a patient is terminally ill and expected to live six months or less. A Hospice Election Form is the form a member or representative signs to choose hospice care through MassHealth.

“The hospice provider also needs a qualified physician to complete a Certification of Terminal Illness Form certifying that the member is terminally ill and has a life expectancy of six months or less.”