Office of Medicaid (MassHealth) - Review of Hospice Care Billing: HopeHealth Massachusetts, Inc.

This is a state audit of hospice claims that HopeHealth submitted to MassHealth for services from July 1, 2011 through June 30, 2016.

“OSA has conducted an audit of hospice claims paid to HopeHealth Massachusetts, Inc. for the period July 1, 2011 through June 30, 2016.”

The auditor checked whether HopeHealth billed MassHealth only for proper hospice services and kept the required records to back up those bills.

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

Incomplete or inaccurate records make it harder to know whether public healthcare dollars are paying for the right services.

“Without ensuring that it obtains and maintains all required documentation in members’ files, HopeHealth has a higher-than-acceptable risk of providing and billing MassHealth for levels and types of hospice services that may not be medically necessary.”

If you are a taxpayer or MassHealth member, this matters because MassHealth is a major public program serving many Massachusetts residents and using a large share of the state budget.

“Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.”

HopeHealth was told to fix its paperwork process and add checks to make sure member files are complete and accurate.

“HopeHealth should put controls in place to monitor the completion and filing of hospice documentation to ensure that all member files contain complete and accurate information.”

The report is significant because MassHealth paid HopeHealth about $17.5 million for hospice services during the audit period, and the auditor found weaknesses in the records supporting some of those payments.

“During this period, MassHealth paid HopeHealth approximately $17,483,302 to provide hospice services for 611 MassHealth members.”

A Certification of Terminal Illness form is the required doctor paperwork saying the patient is expected to live six months or less if the illness follows its normal course.

“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.”