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Audit  Audit of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Melissa Hamilton

During the period of July 1, 2015 through December 31, 2020 the audit found Dr. Hamilton had inadequate documentation to support dental claims. The audit recommends Dr. Hamilton collaborate with MassHealth to determine how much of the $2,063,481 in unallowable dental claims should be repaid. Additionally, Dr. Hamilton should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations.

Organization: Office of the State Auditor
Date published: May 26, 2022

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 United States Department of Health and Human Services, regulate Medicaid services and work with state governments to administer state Medicaid programs.

OSA has conducted an audit of MassHealth claims for dental services paid to Dr. Melissa Hamilton for the period July 1, 2015 through December 31, 2020. During this period, MassHealth paid Dr. Hamilton $5,998,275 for 53,990 claims for dental services provided to 8,174 MassHealth members. The purpose of this audit was to determine whether Dr. Hamilton properly billed MassHealth for dental services and maintained documentation in members’ dental records to support the services.

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. Hamilton’s claims that identified potential improper payments.

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 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 finding and recommendations, with links to each page listed.

Finding 1
 

Dr. Hamilton had inadequate documentation to support at least $2,063,481 in dental claims.

Recommendations
 

  1. Dr. Hamilton should collaborate with MassHealth to determine how much of the $2,063,481 in unallowable dental claims should be repaid.
  2. Dr. Hamilton should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations.

 

A PDF of the Audit Report - Office of Medicaid (MassHealth) Review of Claims Submitted by Dr. Melissa Hamilton is available here.

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(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133

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