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Audit Audit of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Joseph O’Connor

Audit found Dr. O'Connor improperly billed MassHealth for services that were actually provided by physical therapy assistants. Audit examined the period of January 1, 2015 through December 31, 2018.

Organization: Office of the State Auditor
Date published: January 13, 2020

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 physical therapy paid to Dr. Joseph O’Connor for the period January 1, 2015 through December 31, 2018. During this period, MassHealth paid Dr. O’Connor $568,988 to provide physical therapy for 1,129 MassHealth members. The purpose of this audit was to determine whether physical therapy provided to MassHealth members was properly supported by documentation and allowable in accordance with MassHealth regulations.

The audit was initiated as the result of a referral from OSA’s Bureau of Special Investigations (BSI). BSI is charged with investigating potential fraudulent claims or wrongful receipt of payment or services from public assistance programs. BSI conducted data analytics of Dr. O’Connor that identified potential improper payments.

The audit was also conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program. Several of our previously issued audit reports disclosed 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.

Finding 1

Dr. O’Connor improperly billed MassHealth for $359,266 in physical therapy provided by physical therapy assistants.

Recommendations

  1. Dr. O’Connor should collaborate with MassHealth to establish a plan to repay the $359,266 in overpayments he received from improper physical therapy billings.
  2. Dr. O’Connor should bill MassHealth using his billing provider identification number only for services he personally provides.
  3. Dr. O’Connor should periodically review all the billing requirements in MassHealth’s regulations, as well as updates to these regulations that are described in MassHealth’s transmittal letters and provider bulletins, and ensure that he knows and adheres to these requirements when he bills for services provided to MassHealth members.

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Contact

Phone

Fax

(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133
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