Evidence record
Office of Medicaid—Review of Capitation Payments With Multiple Identification Numbers
- Jurisdiction
- Massachusetts
- Publishing agency
- Massachusetts Office of the State Auditor
- Publication date
- December 31, 2024
- Source record
- Original document linked
Findings
1
Recommendations
3
Overall conclusion
MassHealth did not ensure that capitation payments were not made on behalf of Medicaid beneficiaries who were assigned multiple IDs.
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.
Findings (1)
Each finding has a stable link.
- F-605
MassHealth made capitation payments on behalf of members with multiple identification numbers.
Recommendations (3)
- R-532
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.
Related finding F-605 - R-533
MassHealth should investigate and resolve all instances where its data matches indicate that a member has been assigned more than one member ID.
Related finding F-605 - R-534
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.
Related finding F-605