Office of Medicaid (MassHealth) - Review of Payments for Nursing-Facility Claims
April 28, 2017 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published April 28, 2017 Audit covers January 1, 2010 – June 30, 2015 Under Suzanne M. Bump · 2011–2023
source
“Based on our audit, we have concluded that MassHealth overpaid approximately $1 million to nursing facilities for room and board.”
Read the plain-English breakdown
This is a state audit of MassHealth payments to nursing facilities for room and board from January 1, 2010 through June 30, 2015.
“I am pleased to provide this performance audit of the Office of Medicaid’s (MassHealth’s) payments for nursing-facility claims.”
Auditors wanted to know whether MassHealth paid nursing facilities the right amount under the rules.
“The purpose of this audit was to determine whether MassHealth properly paid nursing facilities for room and board provided to members, in accordance with applicable laws, regulations, and other authoritative guidance.”
Overpaid money is public money that could have supported other Medicaid services instead.
“This money could have been used to provide other program services.”
MassHealth is a major public healthcare program serving many Massachusetts residents, so payment errors affect taxpayer dollars and program resources.
“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 auditors found MassHealth did not always recover overpayments, update care-level records quickly, record recoupments clearly, or properly document some system access.
“MassHealth did not recover $639,445 of overpayments to nursing facilities.”
MassHealth said it would improve the process, use a third-party administrator, and expand recoupment work to collect identified overpayments.
“To ensure that overpayments identified by OSA are collected, MassHealth is extending its 2017 recoupment efforts to include nursing-facility payments from 2010.”
Medicaid is a large part of the state budget, so even process problems in one payment area can involve substantial public funds.
“Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.”
1 figure(s) pending source verification - not shown
What the Auditor found
Why it matters: Money that could have been used to provide other program services was not recovered promptly.
Standard: Section 456.420(E) of Title 130 of the Code of Massachusetts Regulations ( Section 456.420(E) of Title 130 of the Code of Massachusetts Regulations )
2 recommendations
- MassHealth should develop system edits that adjust all affected nursing-facility claims after MMQ audits, rather than relying on nursing facilities to resubmit adjusted claims.agency: agreed
- MassHealth should recover the $639,445 that we identified in overpayments to nursing facilities.
Agency response & Auditor reply
Agency: "MassHealth does agree, however, that adjustments should be made more quickly and recoupments more frequently."
Auditor: "We disagree with MassHealth and contend that our audit finding properly characterizes the problems we found with the process MassHealth uses to identify and collect overpayments made to nursing facilities."
Why it matters: MassHealth overpaid nursing facilities because member care levels were overstated.
Standard: 130 CMR 456.420 ( 130 CMR 456.420 )
2 recommendations
- MassHealth should develop policies and procedures to validate that it promptly updates members’ levels of care in MMIS.
- MassHealth should recover the $326,201 that we identified in overpayments to nursing facilities.
Agency response & Auditor reply
Agency: "MassHealth will be reviewing its existing policies and procedures to ensure that all action items are performed in a timely fashion."
Auditor: "Our concern is that MassHealth’s current process does not ensure that all adjustments to members’ levels of care are made promptly by its contractor Maximus."
Why it matters: Specific claim payment fields were overstated and accurate claim-level accounting of recoveries was not available.
Standard: MassHealth’s Claims Operations Department’s internal control plan ( MassHealth’s Claims Operations Department’s internal control plan )
1 recommendation
- MassHealth should ensure that all recoupments are reflected in MMIS’s specific claim information.agency: agreed
Agency response & Auditor reply
Agency: "[Regarding the recommendation], while MassHealth does record and report recoupments done on the MMQ audit, we agree with [OSA] that the optimal practice would include updating member claim level detail with recoupments."
Why it matters: There was a higher-than-acceptable risk of unauthorized personnel gaining access to sensitive data that they could alter or misuse.
Standard: EOHHS MMIS system security plan ( EOHHS MMIS system security plan )
1 recommendation
- MassHealth should formally document all manager access-privilege requests on properly approved EOHHS Security Request Forms.agency: agreed
Agency response & Auditor reply
Agency: "[Regarding the recommendation], MassHealth agrees with [OSA] and has identified opportunities in its general off-boarding process for user accounts in MMIS that are presently being implemented."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
Identified dollar findings that do not fall in a named band.
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