MassHealth Payments for Hospice-Related Services for Dual-Eligible Members
Learn how the AI-generated research projects were createdOverall Conclusion
MassHealth did not administer payments to non-hospice providers for hospice-related services in compliance with applicable state and federal regulations, including ensuring that Medicaid is payer of last resort and that hospice election data and service coordination were properly enforced (Findings 1–4).
Source Document
Audit Scope
Performance audit of MassHealth’s administration of claims for hospice-related services provided to dual-eligible members (Medicare and MassHealth) for January 1, 2015 through July 31, 2019. The audit tested payments to non-hospice providers for hospice-related services; examined MassHealth’s MMIS data reflecting hospice elections; evaluated coordination of professional services and billing among hospice and non-hospice providers; reviewed DME-related billing and whether DME was included in or should have been included in members’ plans of care; assessed ambulance and inpatient service payments; included site visits to 59 of 81 hospice providers; used a sample of 400 claims across four claim types (professional, inpatient, DME, transportation); and evaluated relevant regulatory and program integrity controls, including CMS and CFR/CMR requirements. The audit also analyzed massHealth’s handling of HCBS waivers and related programs in the context of hospice care.
Key Findings Summary
Finding 2: MassHealth paid for professional services that were not coordinated by hospice providers, totaling an estimated $45,110,697 in claims during the audit period, with $5,952,842 potentially duplicative of services already in members’ plans of care.
Finding 1: MassHealth did not ensure that it had accurate information in its Medicaid Management Information System (MMIS) about dual-eligible members who chose to receive hospice services, with 223 of the 400 sampled claims (56%) lacking or not reflecting the hospice election in MMIS.
Finding 3a: MassHealth paid for durable medical equipment (DME) that was included in members’ plans of care.
View the Findings tab to see all 5 findings
AI-Assisted
AI Scope Summary
Assess MassHealth's administration of hospice-related payments to non-hospice providers for dual-eligible members during Jan 1, 2015–Jul 31, 2019, focusing on MMIS data accuracy, provider coordination, payer-of-last-resort compliance, and the adequacy of system edits to prevent improper payments.
AI-Generated Insight
This MassHealth audit highlights critical gaps in data integrity and inter-provider coordination that can drive improper payments in hospice-related services for dual-eligible members. The findings show MassHealth’s MMIS often did not reflect members’ hospice elections, undermining system edits and payer-of-last-resort protections. The large projected at-risk amounts ($56.6 million) and the substantial professional services paid without hospice coordination stress the need for stronger governance, data validation, and CMS collaboration. The audit underscores the importance of robust plan-of-care coordination, clearer delineation of which services are payer-of-last-resort, and tighter controls in MMIS to prevent duplicative or inappropriate payments, with potential policy updates and provider sanctions if compliance fails.
Audit Objectives
Does MassHealth administer payments to non-hospice providers for hospice-related services in compliance with Section 450.316 of Title 130 of the Code of Massachusetts Regulations?
Audit Findings (5)
Finding 2: MassHealth paid for professional services that were not coordinated by hospice providers, totaling an estimated $45,110,697 in claims during the audit period, with $5,952,842 potentially duplicative of services already in members’ plans of care.
Finding 1: MassHealth did not ensure that it had accurate information in its Medicaid Management Information System (MMIS) about dual-eligible members who chose to receive hospice services, with 223 of the 400 sampled claims (56%) lacking or not reflecting the hospice election in MMIS.
Finding 3a: MassHealth paid for durable medical equipment (DME) that was included in members’ plans of care.
Finding 3b: MassHealth paid for DME that should have been included in members’ plans of care.
Finding 4: MassHealth unnecessarily paid for ambulance and inpatient services for dual-eligible members.
Recommendations (9)
Finding 2 – Recommendation 2: MassHealth should update its system edits in MMIS to detect and deny claims for dual-eligible members in hospice care that might be duplicative of services that should be paid for by hospice providers.
Finding 3 – Recommendation 1: MassHealth should ensure that its hospice providers coordinate professional services with non-hospice providers for dual-eligible members to ensure proper service coordination and billing.
Finding 4 – Recommendation 2: MassHealth should ensure that the system edits in MMIS for claims for hospice services for dual-eligible members are effective in detecting and denying improper claims.
Finding 3 – Recommendation 2: MassHealth should update its system edits in MMIS to detect and deny claims for dual-eligible members in hospice care that might be duplicative of services that should be paid for by hospice providers.
Finding 4 – Recommendation 1: MassHealth should ensure that its hospice providers explain to members and their families that the members and families are required to inform any non-hospice providers that the members have elected the hospice benefit to ensure service coordination and billing.
Finding 1 – Recommendation 1: MassHealth should establish an effective monitoring process to ensure that hospice providers send it a MassHealth Hospice Election Form for every dual-eligible member who chooses to receive hospice services.
Finding 1 – Recommendation 2: MassHealth should consider collaborating with CMS to obtain CMS’s hospice election information about dual-eligible members and determine whether all MassHealth’s hospice providers have submitted the required MassHealth Hospice Election Forms.
Finding 1 – Recommendation 3: MassHealth should review MMIS for all members who have elected the hospice benefit to ensure that their MassHealth Hospice Election Forms are accurately reflected in MMIS.
Finding 2 – Recommendation 1: MassHealth should ensure that its hospice providers coordinate professional services with non-hospice providers for dual-eligible members to ensure proper service coordination and billing.