The state’s health insurance program for poor people paid about $85 million health care for people who don’t live in Massachusetts, the state auditor found.
The estimate is for so-called “capitation payments” that MassHealth, which includes the state’s Medicaid and Children’s Health Insurance Program, made during a 45-month period between January 1, 2018 and September 30, 2021, according to a report issued by the office of Massachusetts state auditor Diana DiZoglio.
State law requires that MassHealth recipients live in Massachusetts.
“It is unacceptable that due to a lack of appropriate oversight by MassHealth, nearly $85 million in overpayments went to MCOs for out-of-state residents who were concurrently enrolled in another state’s healthcare program,” ,” DiZoglio said in a written statement statement accompanying the 22-page report.
“MCO” stands for “managed care organization.”
State officials in Governor Maura Healey’s administration called the estimates inflated.
The Massachusetts Executive Office of Health and Human Services called the state auditor’s survey method flawed, saying it focuses “only on the highest dollar amounts” instead of “apportioning the sample in a manner that reflects the distribution of MassHealth members” in each managed-care-organization rating category – which the agency said “does not appear representative of the overall” managed-care-organization population “and will greatly inflate the dollar amount of the extrapolated finding.”
The state auditor’s report recommends that MassHealth do a better job of nailing down whether a potential user of the system lives in Massachusetts.
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