MassHealth Audit Finds $22.9 Million in Improper Billing by Home Health and Adult Foster Care Programs

Boston, MA –  As part of its ongoing efforts to improve internal controls to ensure proper billing and to reduce fraud, waste and abuse of Medicaid benefits, MassHealth has uncovered  $22.9 million in improper billing after conducting its own audit of nine home health agencies and nine adult foster care agencies.

“The integrity of the MassHealth program is a top priority for the Baker-Polito Administration,” said the Secretary of the Executive Office of Health and Human Services (EOHHS), Marylou Sudders, who oversees the state’s Medicaid program. “We are engaged in a thorough review of each of MassHealth’s long-term services and support programs to improve both the quality and cost effectiveness of the programs MassHealth members rely on.”

MassHealth spent more than $755 million on home health services in the fiscal year ending June 30, 2016– an 82 percent or $340 million increase from just two years earlier.  More than 80 percent of the spending growth since 2013 has been driven by 62 companies that started doing business with the state during that time. MassHealth works with 195 home health providers overall.  Earlier this year, MassHealth froze enrollments of new home health providers and strengthened prior authorization requirements for home health services. MassHealth remains committed to ensuring member access to appropriate services and not reducing member benefits. 

“The spending growth in the home health program and concerns identified by our clinical and program staff for member health and safety prompted us to take a closer look at quality control, claims activity, strengthen oversight and improve our systems,” said Dan Tsai, EOHHS Assistant Secretary and head of MassHealth. “We know our members rely on these important programs to remain living independently in their homes, and we will continue to ensure they are receiving the appropriate support.”

MassHealth determined that the home health agencies overbilled by nearly $22.5 million and the Adult Foster Care programs by $500,000. In addition to inappropriate billing activities, MassHealth also found instances of health and safety violations and evidence of non-compliance with state regulations. MassHealth is requiring repayment and corrective action plans from all the agencies to ensure they come into compliance with all state regulations.

MassHealth nurse auditors reviewed medical records and conducted home visits to evaluate members receiving services. The audits found many instances of non-compliance with MassHealth regulations, including:

    • Not having records of members’ medical histories
    • Failing to document medication administration
    • Insufficient or total lack of records documenting services
    • Providing services not appropriately authorized by a physician
    • Members whose needs did not match the documentation

In addition to conducting its own audits, MassHealth asked Attorney General Maura Healey’s Medicaid Fraud Division to investigate several home health providers suspected of submitting fraudulent bills. 

MassHealth is the state Medicaid program that provides health insurance to over 1.8 million residents. 

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