| Organization: | Office of the State Auditor |
|---|---|
| Date published: | November 14, 2018 |
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 state’s Medicaid program, known as MassHealth. 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 and Medicaid Services, within the federal 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 substance use disorder (SUD) treatment paid to Dr. Ileana Berman for the period January 1, 2014 through December 31, 2016. During this period, MassHealth paid $1,880,875 to Dr. Berman for services provided to 1,443 MassHealth members. The purpose of this audit was to determine whether the SUD treatment that Dr. Berman provided to MassHealth members was properly supported by documentation in accordance with MassHealth regulations. During this audit, OSA worked with MassHealth’s Program Integrity Unit to obtain an understanding of MassHealth’s documentation requirements.
This audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program. As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program. To ensure that claims for drug tests and screens are paid properly, MassHealth must have effective controls in place, including program regulations, operating policies and procedures, control activities, claim-processing system edits, monitoring activities, and enforcement actions.
Below is a summary of our findings and recommendations, with links to each page listed.
|
Dr. Berman did not properly notify MassHealth about significant changes in her business operations. |
|
|
|
|
Dr. Berman billed MassHealth for $76,641 in drug tests that she did not use to diagnose and treat patients. |
|
|
|
|
Dr. Berman had inadequate documentation to support billing MassHealth for at least $176,737 in evaluation and management (E/M) services. |
|
|
|
|
Dr. Berman did not maintain any documentation to support $31,287 in E/M services and drug tests billed. |
|
|
Dr. Berman should repay MassHealth for E/M services and drug tests that were not documented in members’ medical records and maintain adequate documentation to support all services claimed. |
|
|
Dr. Berman improperly billed MassHealth $75,261 for unbundled drug tests. |
|
|
List of Abbreviations
|
CMR |
Code of Massachusetts Regulations |
|
CMS |
Centers for Medicare and Medicaid Services |
|
CPT Codebook |
Current Procedural Terminology Professional Edition 2017 |
|
DW |
Data Warehouse |
|
E/M |
evaluation and management |
|
GAO |
Government Accountability Office |
|
ITP |
individual treatment plan |
|
MMIS |
Medicaid Management Information System |
|
NECPAD |
New England Center for Psychiatric and Addiction Disorders LLC |
|
OSA |
Office of the State Auditor |
|
SUD |
substance use disorder |
Table of Contents
- Overview of Audited Entity
- Audit Objectives, Scope, and Methodology
-
- Dr. Ileana Berman Did Not Properly Notify MassHealth About Significant Changes in Her Business Operations.
- Dr. Berman Billed MassHealth for $76,641 in Drug Tests That She Did Not Use to Diagnose and Treat Patients.
- Dr. Berman Had Inadequate Documentation to Support Billing MassHealth for at Least $176,737 in Evaluation and Management Services.
- Dr. Berman Did Not Maintain Any Documentation to Support $31,287 in E/M Services and Drug Tests Billed.
- Dr. Berman Improperly Billed MassHealth $75,261 for Unbundled Drug Tests.
Contact
Phone
Online
Fax
Address
Room 230
Boston, MA 02133