Evidence record
Medicaid Audit Unit—Annual Report
- Jurisdiction
- Massachusetts
- Publishing agency
- Massachusetts Office of the State Auditor
- Publication date
- March 1, 2024
- Source record
- Original document linked
Findings
1
Recommendations
4
Overall conclusion
The audit identified an estimated $84,832,094 in capitation payments to MassHealth members residing outside Massachusetts. MassHealth has reported actions or planned actions on all four audit recommendations (three fully implemented and one in progress). Follow-up post-audit surveys indicate progress in implementing corrective actions. The findings underscore gaps in residency verification and data-matching controls, and point to opportunities for improved program integrity and cost recovery.
Scope
Scope: The performance audit examined MassHealth capitation payments made to managed care organizations for members who were residing and receiving benefits outside the Commonwealth of Massachusetts. The audit period covered January 1, 2018 through September 30, 2021. The audit was conducted by the Office of the State Auditor in collaboration with the US Department of Health and Human Services Office of Inspector General. The report also references post-audit recoupment efforts and follow-up surveys (PAR) that occurred in December 2023. The scope includes the MassHealth program, the Commonwealth of Massachusetts, and the data analytics framework used to identify ineligible capitation payments; findings informed potential cost recoveries and recommendations to enhance program integrity.
Findings (1)
Each finding has a stable link.
- F-606
MassHealth made an estimated $84,832,094 in capitation payments on behalf of members who were residing outside of Massachusetts.
Recommendations (4)
- R-535
MassHealth should revise its policies and procedures regarding its data matches for member eligibility. Specifically, MassHealth should require that all members flagged by data matches submit documentation to substantiate that they reside in Massachusetts. If the member does not provide this documentation, MassHealth should either pause this 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.
Related finding F-606 - R-536
MassHealth should investigate and resolve all instances where its data matches indicate that a member is enrolled in another state’s Medicaid program.
Related finding F-606 - R-537
MassHealth should provide members with written instructions during the annual enrollment process on how to unenroll from MassHealth if they move outside of Massachusetts.
Related finding F-606 - R-538
MassHealth should consult with CMS to see if it can gain access to the Transformed Medicaid Statistical Information System (T-MSIS), which MassHealth can use in its eligibility detection and residency verification process.
Related finding F-606