May 1st, 2017

State auditor’s office cites issues with MassHealth payments

In April, the Office of the State Auditor (OSA) released a report that evaluated payments MassHealth made for mental health services rendered between July 1, 2010 and June 30, 2015. The report cited improper or questionable payments in the amount of $193 million.

Mike Wessler, director of communications, Office of Auditor Suzanne Bump, provided a statement, noting, “MassHealth paid doctors directly for providing mental health services that should have been paid for by the Massachusetts Behavior Health Partnership (MBHP),” which is the managed care organization that coordinates mental health care for MassHealth members.

The report cited 282,327 claims that were not properly identified by MassHealth’s Medicaid Management Information System (MMIS) edits at a cost of $92,021,777.

Another 17,981 claims in the amount of $896,786 were identified as covered by the MBHP Benefits Coverage Grid and 611,054 claims were not aligned with MMIS edits or with MBHP Benefits Coverage Grid for a total of $99,582,014.

The OSA report explains that the MMIS system edits identifies and denies behavioral health claims that MBHP should pay for members of MassHealth’s Primary Care Clinician Plan; the MBPH Coverage Grid identifies services that are covered, based on procedure code and any modifiers, the revenue and diagnosis codes and the place of service.

When presented with the results, MassHealth acknowledged that most fee-for-service claims were related to members who received behavioral health care. However, the agency noted that it did not have “…adequate systems in place to identify and redirect…” claims to MBHP, according to the OSA report.

Michelle Hillman, director of communications, Executive Office of Health and Human Services (EOHHS), issued a written statement, noting that MassHealth ” …strongly disagrees with the OSA’s 2015 managed care organization audit and, based on rigorous analyses of claims provided, found the majority of the findings to be inaccurate.”

The statement continued, “The Baker-Polito Administration and MassHealth take the integrity of the Massachusetts Behavioral Health Partnership (MBHP) program seriously, and since 2015, have implemented major integrity initiatives and internal controls to better manage and evaluate claims within the MassHealth program’s structure, saving over $350 million.”

“MassHealth disagrees with the State Auditor’s Office analysis of the MBHP program from 2010-2015 as the findings do not recognize the important distinction between behavioral health and medical services delivered to individuals with behavioral health conditions. The OSA report acknowledges that over 50 percent of their own finding is inconclusive, while MassHealth has analyzed the claims the OSA reviewed over a two-year period and found less than $1 million to be potentially duplicative.”

The statement noted, “The OSA fails to recognize the importance of integrating physical and behavioral health for individuals with complex needs. Coordinated, high quality care for individuals with both physical and behavioral health needs often results in the delivery of both types of treatment within one health care setting. For example, physical health care during behavioral health treatment (e.g., during a psychiatric hospital stay) and vice versa (e.g., post-partum depression screening during an OB/GYN visit) is expected and does not indicate inappropriate adjudication of claims.”

“Medical services such as these are not included in the rates paid to MBHP and therefore do not constitute duplicative payments. The OSA also incorrectly suggests claims for State Agencies (such as the Department of Mental Health) should have been paid by MBHP,” according to the statement.

By way of explanation, the statement noted, “DMH services are explicitly excluded from the MBHP contract. DMH claims are submitted through MassHealth in order to claim federal revenue; they are not managed by or meant to be paid for through MBHP.”

Requests for comment from MBHP were referred to EOHHS. 

By Phyllis Hanlon

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