Office of Medicaid (MassHealth) Review of Providers Excluded from Participating in the Medicaid Program

This is a state audit of whether MassHealth kept banned providers out of the Medicaid program during 2013 and 2014.

“The Office of the State Auditor has conducted an audit of the Office of Medicaid’s (MassHealth’s) activities to ensure that excluded providers do not participate in the state’s Medicaid program for the period January 1, 2013 through December 31, 2014.”

Auditors wanted to know whether MassHealth had working safeguards to stop excluded providers from billing and being paid.

“The purpose of this audit was to determine whether MassHealth has sufficient controls in place to ensure that such providers are not billing and receiving payments from MassHealth, in accordance with federal law and regulations.”

If barred providers are still involved, patients may get lower-quality care and public money may be spent improperly.

“If excluded providers are allowed to abuse the Medicaid system, MassHealth members could receive substandard services.”

MassHealth serves many Massachusetts residents and uses a large share of the state budget, so weak controls can affect patients and taxpayers.

“Medicaid expenditures represent approximately 38% of the Commonwealth’s total annual budget.”

The audit found MassHealth did not have enough controls to keep excluded providers from participating or getting paid.

“Based on our audit, we have concluded that MassHealth did not have sufficient controls to ensure that excluded providers neither participate in the Medicaid program nor receive payments from MassHealth.”

The auditor recommended better controls and recovery of the improper payments.

“MassHealth should take appropriate action to recoup the $476,787 in unallowable payments associated with excluded providers.”

The issue included prescriptions for controlled substances, not just routine billing mistakes.

“330 of these prescriptions, for 251 members, were for controlled substances such as opiates and amphetamines.”

An excluded provider is a healthcare provider barred from federally funded programs such as Medicaid, often because of serious legal or regulatory violations.

“Healthcare providers who are found to have violated federal law and/or regulations may be excluded by the federal government from further participation in federally funded programs, including Medicaid.”