Office of Medicaid (MassHealth) - Review of Paid Claims within MassHealth's Adult Foster Care and Group Adult Foster Care Programs
July 14, 2016 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published July 14, 2016 Audit covers January 1, 2010 – June 30, 2015 Under Suzanne M. Bump · 2011–2023
source
“Based on our audit, we have concluded that MassHealth improperly paid a total of $15,201,854 for AFC and GAFC services during the audit period.”
Read the plain-English breakdown
This is a state audit of MassHealth payments for adult foster care and group adult foster care services from January 1, 2010 through June 30, 2015.
“The Office of the State Auditor (OSA) has conducted an audit of paid claims for adult foster care (AFC) and group adult foster care (GAFC) services for the period January 1, 2010 through June 30, 2015.”
The audit began after the State Auditor’s fraud-investigation unit flagged possible improper payments in these programs.
“The audit was initiated as the result of a referral from OSA’s Bureau of Special Investigations (BSI).”
MassHealth is a major public program, so payment errors can involve large amounts of taxpayer money and affect public trust.
“Medicaid expenditures represent approximately 38% of the Commonwealth’s total annual budget.”
If you are a Massachusetts resident, this matters because the report says public healthcare dollars may have paid twice for similar care services.
“These payments were for services that were specifically identified in state licensing regulations as services already performed by LTC facilities.”
The auditor concluded that MassHealth should not have paid for these foster care services when members were already in rest homes or nursing homes receiving similar support.
“MassHealth improperly paid $15,201,854 for AFC and GAFC for members in LTC facilities, i.e., rest homes and nursing homes.”
The auditor recommended that MassHealth stop these payments, add computer checks to block them, and create specific regulations for the group adult foster care program.
“MassHealth should establish and implement system edits to detect and deny claims for AFC and GAFC services provided to members residing in LTC facilities.”
AFC means adult foster care, GAFC means group adult foster care, and ADLs are basic daily tasks like eating, bathing, dressing, and walking.
“ADLs include activities such as eating, toileting, dressing, bathing, transferring, and walking.”
4 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did MassHealth pay for AFC and GAFC services in accordance with applicable laws, rules, and regulations?
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