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EXECUTIVE SUMMARY:
The objective of this audit was to determine whether costs claimed for school-based health services by the Massachusetts Division of Medical Assistance (DMA) were reasonable, allowable, and adequately supported in accordance with the terms of the State Medicaid plan and applicable Federal regulations. Based on our review of claims data at the eight selected local education agencies (LEA), we estimated that at least $2,997,268 (Federal share) was ineligible for reimbursement. In this regard, we found that: (1) sufficient documentation was not always maintained to ensure that services prescribed in the students' individualized education plans (IEP) were delivered; (2) school-based health services were rendered by health care providers that did not have the qualifications required by DMA; (3) claims were submitted for students who were absent; (4) IEPs were not available to cover periods in which the Medicaid program was billed; and (5) the school-based service type was sometimes billed incorrectly.
We recommended that DMA: (1) provide training and technical assistance to LEAs, (2) review all guidance issued to LEAs relative to the school-based health program for clarity and completeness and reissue, as needed, (3) design a monitoring/audit system to ensure that LEAs comply with Medicaid requirements, (4) develop a new fee-for-service methodology for school-based health services that complies with Federal documentation requirements, (5) discontinue providing listings of Medicaid eligible students to LEAs, (6) establish procedures consistent with Centers for Medicare and Medicaid Services (CMS) requirements regarding electronic transmission of data which contain uniquely identifying information, and (7) refund to CMS the $2,997,268 (Federal share) that was inappropriately paid by the Medicaid program to the eight LEAs.