Office of Medicaid—Review of Capitation Payments With Multiple Identification Numbers

Performance audit conducted by the Office of the State Auditor (Massachusetts) of MassHealth, the Commonwealth’s Medicaid program, for the period January 1, 2019 through December 31, 2022. The audit evaluated capitation payments made by MassHealth to its two contracted managed care organizations (MCOs), Tufts Health Together and WellSense Essential MCO, to determine whether payments were made on behalf of members assigned more than one MassHealth identification number (ID). Data came from MassHealth’s MMIS and the Transformed Medicaid Statistical Information System (T-MSIS) data provided by the US Department of Health and Human Services Office of Inspector General (HHS OIG); analyses included automated match criteria (eight MMIS matching rules), master data management (MDM) processes, and automated and manual recovery procedures for duplicate payments. The audit examined data reliability, scope, and methodology, and discussed privacy considerations related to linking IDs. The objective was to determine whether capitation payments were not made on behalf of enrollees with multiple IDs; the audit covered approximately 3,678 enrollee matches totaling about $20.47 million in potential duplicates within the audit period, with a sample of 115 members tested and a projection to the full population.