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Audit Audit of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Ileana Berman

This audit of a MassHealth provider found issues with the physician's documentation to support claims and procedures related to drug tests and screens. It examined the period of January 1, 2014 through December 31, 2016.

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.

Finding 1

Dr. Berman did not properly notify MassHealth about significant changes in her business operations.

Recommendations

  1. Dr. Berman should work with MassHealth to ensure that the information in her provider file is properly updated to reflect the changes in her organizational structure.
  2. In the future, Dr. Berman should notify MassHealth of any changes that need to be made to her provider file within the timeframe prescribed by MassHealth regulations. 
  3. Dr. Berman should consult with MassHealth to determine whether her business, the New England Center for Psychiatric and Addiction Disorders LLC, is properly certified.

Finding 2

Dr. Berman billed MassHealth for $76,641 in drug tests that she did not use to diagnose and treat patients.

Recommendations

  1. Dr. Berman should review all drug test results she orders to ensure that MassHealth members comply with her treatment guidelines and should refer noncompliant members to other SUD treatment options.
  2. Dr. Berman should only bill MassHealth for drug tests that she will use to diagnose and treat members and should properly document them in members’ medical records.

Finding 3

Dr. Berman had inadequate documentation to support billing MassHealth for at least $176,737 in evaluation and management (E/M) services.

Recommendations

  1. Dr. Berman should repay MassHealth the $176,737 that we identified as lacking the required documentation.
  2. In the future, Dr. Berman should maintain proper documentation to support services billed.

Finding 4

Dr. Berman did not maintain any documentation to support $31,287 in E/M services and drug tests billed.

Recommendation

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.

Finding 5

Dr. Berman improperly billed MassHealth $75,261 for unbundled drug tests.

Recommendation

  1. Dr. Berman should cease ordering quantitative drug tests and qualitative drug screens for the same MassHealth member on the same day.
  2. Dr. Berman should collaborate with MassHealth to determine the appropriate amount to be repaid, which should be at least $75,261.

 

A PDF copy of the Audit of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Ileana Berman is available here.

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

Contact

Phone

Fax

(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133
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