Office of Medicaid—Review of Capitation Payments With Multiple Identification Numbers
Learn how the AI-generated research projects were createdOverall Conclusion
MassHealth did not ensure that capitation payments were not made on behalf of Medicaid beneficiaries who were assigned multiple IDs.
Source Document
Audit Scope
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.
Key Findings Summary
MassHealth made capitation payments on behalf of members with multiple identification numbers.
AI-Assisted
AI Scope Summary
Assess whether MassHealth has adequate controls to prevent capitation payments to MCOs for enrollees with multiple MassHealth IDs, including the effectiveness of ID matching, data governance, and recoupment processes.
AI-Generated Insight
This audit highlights a material risk to MassHealth integrity by duplicate member identifiers driving duplicate capitation payments. While MassHealth has implemented master data management and recoupment processes, the identified overpayments and the projected population-wide impact indicate gaps in timely linkage and recovery, compounded by privacy concerns that complicate full ID matching. The recommendations emphasize documentation, SSN-focused matching, and stronger data governance across MMIS/MDM and data sharing with HHS OIG. If implemented, these steps could reduce duplicate payments, improve program efficiency, and yield substantial public-funds savings, while balancing privacy safeguards.
Audit Objectives
Did MassHealth ensure that capitation payments were not made on behalf of Medicaid beneficiaries who were assigned multiple identification numbers (IDs) in accordance with Sections 450.235(A), 450.237, 450.259(A), and 450.307(B) of Title 130 of the Code of Massachusetts Regulations, and Sections 433.312 and 438.2 of Title 42 of the Code of Federal Regulations?
Audit Findings (1)
MassHealth made capitation payments on behalf of members with multiple identification numbers.
Recommendations (3)
MassHealth should require that all members flagged by data matches submit documentation to confirm their identity. If the member does not provide documentation, then MassHealth should either pause the member’s coverage or move the member to its fee-for-service model until it can determine whether the member’s coverage should be terminated.
MassHealth should investigate and resolve all instances where its data matches indicate that a member has been assigned more than one member ID.
MassHealth should implement a match criterion that focuses solely on Social Security Numbers (SSNs). Because an SSN should be unique to each individual, a targeted match criterion that only includes an SSN would reduce the prevalence of multiple IDs by 19%, based on our sample testing.