Office of Medicaid (MassHealth) Review of Non-Emergency Ambulance Transportation
June 5, 2015 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published June 5, 2015 Audit covers January 1, 2012 – December 31, 2013 Under Suzanne M. Bump · 2011–2023
Read the plain-English breakdown
This is a state audit of how MassHealth handled non-emergency ambulance transportation during 2012 and 2013.
“The Office of the State Auditor has conducted an audit of MassHealth’s non-emergency ambulance transportation for the period January 1, 2012 through December 31, 2013.”
Auditors wanted to see whether MassHealth was following the rules when paying for these ambulance rides.
“The purpose of this audit was to determine whether MassHealth was properly administering non-emergency ambulance transportation in accordance with applicable federal and state requirements.”
MassHealth is a very large public program, so weak payment controls can affect taxpayer money and program accountability.
“Medicaid expenditures represent approximately 33% of the Commonwealth’s total annual budget.”
If you use or pay taxes toward MassHealth, this report is about whether ride payments were properly documented, whether ambulance staff had required checks, and whether duplicate payments were caught.
“MassHealth, the state’s Medicaid program, provides access to healthcare services to approximately 1.4 million eligible low- and moderate-income individuals, couples, and families annually.”
The rides reviewed appeared connected to medical care, but MassHealth needed stronger controls over paperwork, background checks, and duplicate payments.
“For each non-emergency ambulance claim reviewed, we found a corresponding medical claim on the same date of service.”
MassHealth said it would clarify rules, update forms, remind providers about CORI checks, and begin reviews and site visits.
“After the Program Integrity Unit sampling is complete, MassHealth will initiate periodic site visits of non-emergency transportation providers to verify compliance with MNF requirements.”
The paperwork issue was potentially large: auditors estimated up to $3.7 million in questionable payments among the providers they tested.
“The Office of the State Auditor (OSA) estimates that for the service providers included in our testing, MassHealth processed an estimated $3,680,796 in questionable payments for non-emergency ambulance transportation during the audit period.”
A Medical Necessity Form is the paperwork meant to show that a patient really needed an ambulance instead of a cheaper kind of transportation.
“It must be authorized by a Medical Necessity Form, filled out by the member’s caregiver.”
2 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did MassHealth determine that non-emergency ambulance transportation was properly authorized?
- Did not comply Did MassHealth establish policies and procedures to ensure that Criminal Offender Record Information (CORI) checks were consistently performed and documented for all ambulance drivers and attendants?
- Did not comply Did MassHealth establish system edits to ensure that non-emergency ambulance transportation claims paid as fees for service by MassHealth were not also paid by a managed-care organization (MCO)?
What the Auditor found
Why it matters: MassHealth processed an estimated $3,680,796 in questionable payments for non-emergency ambulance transportation during the audit period.
Standard: Section 407.421(D) of MassHealth’s Transportation Manual ( Section 407.421(D) of MassHealth’s Transportation Manual )
2 recommendations
- MassHealth should ensure that providers maintain properly completed MNFs to support their non-emergency transportation claims.agency: agreed
- MassHealth should consider performing periodic site visits at provider locations to verify compliance with MNF requirements.agency: agreed
Agency response & Auditor reply
Agency: "MassHealth recognizes that [OSA’s] finding raises important provider recordkeeping and compliance issues and will therefore implement the following actions:"
Auditor: "OSA did use the additional criteria stated in All Provider Bulletin 229, and we would have deemed an MNF compliant if the “physician’s designee” title had been used."
Why it matters: MassHealth could not be certain that employees with disqualifying criminal records lacked access to vulnerable MassHealth members.
Standard: 130 CMR 407.405(B) ( 130 CMR 407.405(B) )
2 recommendations
- MassHealth should immediately notify all ambulance providers of the requirements for CORI checks and periodically give subsequent reminders to these providers.agency: agreed
- MassHealth should establish an effective monitoring process to ensure that its transportation providers perform required CORI checks for all drivers and attendants.agency: agreed
Agency response & Auditor reply
Agency: "MassHealth recognizes that this finding raises an important provider education issue regarding MassHealth's requirement that providers complete annual CORI checks on drivers and attendants."
Why it matters: Duplicate payments totaling $8,594 were made for non-emergency transportation for members enrolled in managed-care organizations.
Standard: Section 1902(a)(37)(B) of the Social Security Act, Section 1902(a)(30)(A) of the Social Security Act, and 31 US Code 3321(2)(d)(2)(A) and (B) ( Section 1902(a)(37)(B) of the Social Security Act (42 US Code 1396a[a][37][B]); 31 US Code 3321(2)(d)(2)(A) and (B) )
3 recommendations
- MassHealth should update member enrollment data promptly to ensure that claims are paid properly.
- MassHealth should develop policies and procedures to detect and deny duplicate payments for non-emergency medical transportation.
- MassHealth should work with MCOs to recover the $8,594 in duplicate payments that we identified in relation to this issue.agency: agreed
Agency response & Auditor reply
Agency: "MassHealth agrees that these claims were duplicative."
Auditor: "However, MassHealth’s response did not address the primary cause of this problem, i.e., the untimely updating of member enrollment status."
Verified dollar findings
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 the MMIS information-technology 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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