Massachusetts State Auditor Suzanne Bump released an audit Monday that flagged problems with how the state’s health insurance program for the poor paid claims for behavioral health services. The people who run the state’s Medicaid program dispute the audit’s conclusions.
MassHealth made almost $200 million in questionable or improper payments for mental health and substance abuse services between 2010 and 2015, according to the audit.
The claims MassHealth paid should have been covered under a contract with a managed care organization, according to Bump, who noted similar deficiencies turned up in a 2015 audit.
"We are talking about a systemic problem," said Bump. " There is a problem with the claims management system that is not allowing for proper administration of these managed care contracts."
MassHealth disputed the latest audit’s findings.
The audit released Monday looked at payments to The Massachusetts Behavioral Health Partnership, which had a contract to provide mental health and substance abuse services to MassHealth members at a fixed fee.
MassHealth paid the provider network $2.6 billion during the five-year period.
Bump said MassHealth should try to recover $93 million for claims it paid that were covered under the contract – essentially duplicate payments. Another $100 million in questionable payments arose from services not being explicitly spelled out in the contract.
In a conference call with reporters, Bump said there is no evidence of intentional double-billing or other fraud.
" We are not saying that a provider is being paid twice," explained Bump. " MassHealth is paying twice for the same service. Once under the contract and once on a fee-for-service basis. Under the rules of Medicaid and Medicaid auditing that makes it an improper payment."
Bump said MassHealth could save $27 million a year going forward by changing its practices.
"This audit is the latest example of a poorly run claims management system within the MassHealth program," Bump said.
A statement released by a spokesperson for MassHealth said Bump’s office had misinterpreted the claims data by failing to distinguish between behavioral health services and other medical services provided to patients with behavioral health conditions. The statement said a MassHealth analysis of the claims data for a two-year period found potential duplicate payments totaled less than $1 million.
" I believe notwithstanding the vehemence of ( MassHealth's) response to the audit, we know they are looking at some aspects of this problem," said Bump.
Asked by reporters at the State House Monday about the audit, Governor Charlie Baker said he had not read it yet.
" Some of that data is seven years old, but any opportunity to come up with solutions and savings in the MassHealth program is an opportunity for us," said Baker.
Baker and state legislators are trying to agree on ways to lower the costs of MassHealth, which this year accounted for 42 percent of the state’s budget, about $13 billion.
The program now covers one-in-four state residents. Enrollment has soared over the last few years as it appears low-income workers are increasingly dropping employer-offered health insurance coverage because of rising premiums and out-of-pocket costs.
