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Audit Audit of the Office of Medicaid (MassHealth)—Review of Vision Care Claims Paid to Dr. Khuong Nguyen

Audit of MassHealth found that optometrist submitted questionable claims and provided inadequate documentation for dispensing vision care services. The audit examined the period July 1, 2011 through December 31, 2016.

Binder organization: Office of the State Auditor
Date published: July 16, 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 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 and 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 vision care claims paid to Dr. Khuong Nguyen for the period July 1, 2011 through December 31, 2016. During this period, MassHealth paid Dr. Nguyen $587,315 to provide vision care for 5,324 MassHealth members. The purpose of this audit was to determine whether these services provided to MassHealth members were properly supported by documentation and allowable in accordance with certain MassHealth regulations.

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, 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. Nguyen did not keep medical records at his office supporting services provided to youths residing in state-run facilities and programs.

Recommendations
 

  1. Dr. Nguyen should keep documentation, whether in his electronic medical record system or as hard copies, for vision care provided to youths residing in Department of Children and Families programs and make it available upon request.
  2. Dr. Nguyen should collaborate with MassHealth to determine the amount to be repaid for vision care that was not documented.

Finding 2
 

Dr. Nguyen submitted $108,166 in questionable claims for dispensing services.

Recommendations
 

  1. Dr. Nguyen should collaborate with MassHealth to determine the amount of dispensing services to be repaid.
  2. Dr. Nguyen should submit claims for dispensing services for a MassHealth member only upon fitting the new eyeglasses to that member.

Finding 3

 

Dr. Nguyen had inadequate documentation to support approximately $27,255 in vision care services.

Recommendations

 

  1. Dr. Nguyen should ensure that he properly documents the comprehensive medical history and comprehensive examination involved for each instance in which he uses evaluation and management (E/M) code 99328 or 99337.
  2. Dr. Nguyen should collaborate with MassHealth to determine the amount to be repaid for improperly documented E/M services.

A PDF copy of the audit of the Office of Medicaid (MassHealth)—Review of Vision Care Claims Paid to Dr. Khuong Nguyen is available here.

List of Abbreviations

CMR

Code of Massachusetts Regulations

CPT Codebook

Current Procedural Terminology Professional Edition 2017

DCF

Department of Children and Families

DYS

Department of Youth Services

E/M

evaluation and management

EMR

electronic medical record

MassCor

Massachusetts Correctional Industries

MMIS

Medicaid Management Information System

OSA

Office of the State Auditor

PREA

Prison Rape Elimination Act

RFR

Request for Response

Contact

Phone

Fax

(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133

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