BOSTON (STATE HOUSE) – A state health care agency paid more than $35 million in questionable or unallowed medical claims over an 18-month period, according to an audit released Wednesday.
The audit concluded that MassHealth, the state’s largest health care coverage program, “routinely” allowed claims to be paid for non-emergency services under the MassHealth Limited Program, which is supposed to be restricted to coverage of emergency medical services. The program provides services only to eligible non-citizens.
Auditor Suzanne Bump’s office believes about 89 percent of the 45,000 Limited Program members were undocumented immigrants during the period of the audit.
In a statement, Bump said MassHealth “regularly substituted its own judgment for that of the medical professional in determining whether to cover a service.”
The questionable or unallowed claims for procedures such as speech therapy, physical therapy and fluoride treatments represent 45 percent of total program spending between July 2011 and December 2012, the period when the program was reviewed by auditors.
During that period of time, MassHealth leadership transferred from Terry Dougherty to Julian Harris. Harris subsequently left the Patrick administration for the Obama administration, and Kristin Thorn now runs the program, which uses state money and federal Medicaid dollars.
Bump’s office reported that MassHealth believes federal regulations give it discretionary authority to consider which services constitute emergencies. The agency agreed with “some” of the audit findings and said it has changed its claims system to identify and deny payment for non-emergency dental and rehabilitation and therapy services, according to the auditor’s office.
“If MassHealth were to rely on the [state auditor’s] assumptions… MassHealth would deny the treatment of kidney failure, the setting of broken bones, or the treatment of acute pneumonia,” MassHealth wrote in a response included in the audit. “This is not in line with federal guidelines, and is not in line with state law and regulation either.”
The $35 million that Bump identified represents 45 percent of the $77.6 million spent by MassHealth’s Limited Program during the audit period. Bump detailed $27.8 million in questionable or wrong payments for inpatient or outpatient services, $3.6 million in medicine or medical supplies, $1.7 million in dental services and $1.9 million in rehabilitation or therapy.
Bump listed $384,206 in paid claims for dental X-rays, $770 for development of cognitive skills, and $5,983 for physical performance tests.
The auditor said Limited Program members can access non-emergency services at “free or low-cost clinics,” which offer preventative care, dental and vision services, and said the state office should make changes to its claim-processing system and update a bulletin for providers that discusses services eligible for reimbursement.
The audit says payments for unallowable dental services dropped off after April 2013 when MassHealth instated “new system edits” to deny ineligible claims.
Copyright 2014 State House News Service