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Audit  Audit of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Frederick Wagner Jr.

Audit calls on Dr. Frederick Wagner Jr., an optometrist in Carlisle, to reimburse the MassHealth program for $310,112 in claims he submitted that lacked adequate documentation or were otherwise improper. The audit examined the period of January 1, 2014 through December 31, 2017.

Organization: Office of the State Auditor
Date published: September 24, 2019

Executive Summary

The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to help prevent and identify fraud, waste, and abuse in the Commonwealth’s Medicaid program. This program, known as MassHealth, is administered under Chapter 118E of the Massachusetts General Laws by the Executive Office of Health and Human Services, through the Division of Medical Assistance. Medicaid is a joint federal-state program created by Congress in 1965 as Title XIX of the Social Security Act. At the federal level, the Centers for Medicare & Medicaid Services, within the US Department of Health and Human Services, administer the Medicare program and work with state governments to administer state Medicaid programs.

OSA has conducted an audit of MassHealth claims for vision care services paid to Dr. Frederick Wagner Jr. for the period January 1, 2014 through December 31, 2017. During this period, MassHealth paid Dr. Wagner approximately $1,045,556 to provide vision care services for 3,741 MassHealth members. The purpose of this audit was to determine whether Dr. Wagner properly billed MassHealth for these services, including traveling to nursing facilities and ordering and dispensing eyeglasses for MassHealth members.

The audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program. Several of our previously issued audit reports disclosed significant weaknesses in MassHealth’s claim-processing system and improper billing practices by MassHealth providers, which resulted in millions of dollars in potentially improper payments. As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.

Below is a summary of our findings and recommendations, with links to each page listed. In addition to our findings, we identified an issue we believe warrants MassHealth’s attention, which we have disclosed in the “Other Matters” section of this report.

Finding 1
 

Dr. Wagner had inadequate documentation to support at least $301,936 in vision care claims.

Recommendations
 
  1. Dr. Wagner should collaborate with MassHealth to repay the $301,936 discussed in this finding.
  2. Dr. Wagner should document the chief complaint or reasons for the services provided in members’ medical records.
  3. Dr. Wagner should properly document the required patient medical history, as well as details about the exam and medical decision-making, when billing for vision care using evaluation and management codes; otherwise, he should bill using eye exam codes.
  4. Dr. Wagner should submit claims to MassHealth using the actual dates on which the vision care is provided to members.

Finding 2
 

Dr. Wagner submitted improper claims for eyeglass dispensing and fitting services totaling $8,176.

Recommendations
 
  1. Dr. Wagner should collaborate with MassHealth to repay the $8,176 discussed in this finding.
  2. Dr. Wagner should only submit claims for dispensing services after he fits the new eyeglasses to a MassHealth member.
  3. Dr. Wagner should maintain proper documentation for dispensing services, including documenting a consultation with the nursing facility, measurements, and evidence that he fitted the eyeglasses to the individual.

A PDF copy of the audit of the Office of Medicaid (MassHealth) - Review of Claims Submitted by Dr. Frederick Wagner Jr. is available here.

Table of Contents

Downloads

Open PDF file, 1.09 MB,  Audit of the Office of Medicaid (MassHealth) - Review of Claims Submitted by Dr. Frederick Wagner Jr. (English, PDF 1.09 MB)

Contact

Phone

Main (617) 727-2075

Online

Auditor@MassAuditor.gov

Fax

(617) 727-3014

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Massachusetts State House
Room 230
Boston, MA 02133
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