MA Medicaid Wrongly Paid $193M in Fee-for-Service Claims
An audit of the Massachusetts Medicaid program revealed that the agency paid millions of dollars in improper fee-for-service claims for behavior healthcare.
Source: Thinkstock
By - An audit of MassHealth, the Massachusetts state Medicaid program, found the agency improperly paid approximately $193 million in fee-for-service claims for behavioral healthcare between 2010 and 2015.
Questionable payments to the Massachusetts Behavioral Health Partnership (MBHP) for family therapy sessions and other behavioral health services accounted for $100 million in claims that misaligned with the MBHP Benefits Coverage Grid, said the Office of the State Auditor (OSA). The coverage grid identifies services through revenue and procedural codes.
The remaining $93 million in claims were found to be duplicated spending amounts. The $93 million was split between capitated premiums paid to MBHP and fee-for-service claims.
Because information systems were not properly managed, MassHealth doubled certain claims payments. Unintentional mismanagement led MBHP to avoid paying for behavioral services from their own revenues.
“In addition, by not ensuring proper payment for these behavioral-health claims, MassHealth creates a financial incentive for MBHP to allow its members to seek behavioral-health care in emergency rooms rather than through its network of managed-care providers,” OSA said.
“When behavioral-health services are improperly bundled into PAPE (payment amount per episode) payments, MBHP avoids paying for them out of its own contract revenue. MassHealth’s lack of differentiation between general medical care and behavioral-health services within PAPEs calls into question its controls over the adjudication process for behavioral-health claims.”
MassHealth acknowledged that the majority of fee-for-service claims involved members who paid for behavioral healthcare. However, MassHealth lacked the infrastructure to identify and redirect claims to MBHP for services that are covered and compensated by MBHP.
Other issues included improper payments to out-of-network providers and incorrectly coded claims from providers.
OSA found that 95 percent of all questionable claims were associated with at least one of seven major service category codes.
These include behavioral health procedure codes, postpartum-depression related diagnosis codes, behavioral health evaluation and management codes, and overlaps with inpatient behavioral health services..
Following the audit, OSA proposed three action items for MassHealth to take in order to amend their processes.
MassHealth should recoup the $93 million of payments OSA identified as improper, the auditors suggested. MassHealth should also review the $100 million in questionable claims to determine whether any of that total should be recouped from MBHP as contractually covered behavioral health services.
Finally, OSA recommended that MassHealth should develop a list of covered services and their respective procedure codes, revenue codes, diagnosis codes, places of service, and procedure code modifiers.
Using the list, MassHealth should then create system edits in its claim-processing infrastructure to ensure it only pays for claims that MassHealth and MBHP concretely identified as not covered under the MBHP contract.
In its response to the report, MassHealth stated that it does not believe the claims identified in the audit were improper, questionable, or duplicative.
OSA refuted MassHealth’s assertion in turn.
“Regardless, contrary to MassHealth’s assertion, all the claims identified in our audit are improper or questionable payments even if certain claims were not included in the MBHP capitation-rate calculation,” the auditors said.
“MassHealth’s fee-for-service payments for all of these claims were contrary to state and federal laws and regulations governing the delivery of behavioral-health services by state-contracted managed-care organizations (MCOs) such as MBHP.”
