Review of Durable Medical Equipment Providers
Learn how the AI-generated research projects were createdOverall Conclusion
MassHealth did not fully ensure that DME was not ordered by excluded providers or for deceased members, as evidenced by three identified findings and associated overpayments; ongoing post-payment and data-lag issues necessitate strengthened controls and more comprehensive death data sources.
Source Document
Audit Scope
The audit evaluated MassHealth durable medical equipment (DME) providers for the period January 1, 2021 through December 31, 2023, including verification of ordering providers, exclusions, and member death status within MMIS and related data sources.
Key Findings Summary
MassHealth paid an estimated $521,526 for durable medical equipment that could not be verified as having been ordered by an eligible provider.
MassHealth paid $31,724 for durable medical equipment that was ordered by providers who were excluded from participating in Medicaid.
MassHealth paid providers $27,400 for durable medical equipment that was ordered for members who were deceased.
AI-Assisted
AI Scope Summary
This performance audit evaluated MassHealth’s durable medical equipment (DME) controls for the period 2021–2023, focusing on ensuring DME is ordered by eligible providers and not paid for deceased or excluded providers, and found three overpayment issues with recommendations to tighten pre-pay edits and death-data verification.
AI-Generated Insight
This audit identifies gaps in DME ordering verification, provider exclusions, and death-verification processes, highlighting ongoing need for strengthened pre-pay checks and expanded death-data sources to prevent improper payments.
Audit Objectives
Did MassHealth ensure that it did not pay for DME for deceased members?
Did MassHealth ensure that durable medical equipment (DME) was not ordered for its members by providers who are excluded from participating in the Medicaid program?
Audit Findings (3)
MassHealth paid an estimated $521,526 for durable medical equipment that could not be verified as having been ordered by an eligible provider.
MassHealth paid $31,724 for durable medical equipment that was ordered by providers who were excluded from participating in Medicaid.
MassHealth paid providers $27,400 for durable medical equipment that was ordered for members who were deceased.
Recommendations (6)
MassHealth should investigate the identified claims and recoup any overpayments determined to be appropriate.
MassHealth should not pay claims for DME that do not have a licensed provider’s name and NPI on the DME order form.
MassHealth should develop procedures to deny any DME claims that are ordered, referred, or prescribed by providers who are excluded from Medicaid or whose licenses are suspended or terminated.
MassHealth should evaluate and recover overpayments tied to excluded providers or suspended/terminated licenses as appropriate.
MassHealth should investigate the deceased-member claims and recoup overpayments that are deemed appropriate.
MassHealth should reduce the lag between a member’s death and MMIS entry and employ additional data sources to verify death status.