Audit of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Ileana Berman Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the claims submitted by Dr. Ileana Berman to the Office of Medicaid (MassHealth).

Overview

In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor (OSA) has conducted a performance audit of claims submitted by Dr. Ileana Berman for the period January 1, 2014 through December 31, 2016.

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Below is a list of our audit objectives, indicating the question we intended our audit to answer, the conclusion we reached regarding the objective, and where the objective is discussed in the audit findings.

Objective	Conclusion
Did Dr. Berman maintain proper documentation in members’ files to support the services for which she billed MassHealth?	No; see Findings 1, 2, 3, 4, and 5

Methodology

We gained an understanding of the internal controls at Dr. Berman’s practice, the New England Center for Psychiatric and Addiction Disorders LLC, and evaluated the design of controls over the billing process that we deemed significant to the audit objective.

To perform our audit procedures, we obtained data from MassHealth’s Medicaid Management Information System (MMIS). To test the reliability of these data, we relied on the work performed by OSA in a separate project that tested certain information-system controls in MMIS, which is maintained by the Executive Office of Health and Human Services. As part of that project, OSA reviewed existing information about security policies for data, tested selected information-system controls, and interviewed knowledgeable agency officials about the data. During the current audit, we performed validity and integrity tests on all claim data, including (1) testing for missing data, (2) scanning for duplicate records, (3) testing for valid data, (4) looking for dates outside specific time periods, (5) tracing samples of claims stored in MassHealth’s Data Warehouse³ (DW) to source documents and MMIS, and (6) tracing a sample of prescription claims from the DW to Dr. Berman’s electronic medical records. Based on these procedures, we determined that claim data obtained from MMIS were sufficiently reliable for the purposes of this report.

Out of 1,338 MassHealth members whom Dr. Berman drug tested during the audit period, we selected a judgmental sample of 25 members, based on an isolated risk factor: members who received the most drug tests. Specifically, we reviewed all documentation in the members’ medical records for evaluation and management (E/M) services to determine whether Dr. Berman properly documented all the services she provided to them. Some of the documentation was maintained in hardcopy form and some was maintained in Dr. Berman’s electronic medical record system, Isalus.⁴ For drug tests, we reviewed the result reports in Dr. Berman’s electronic laboratory system, LabTrak, and the members’ medical records. Since this was not a statistical sample, we did not extrapolate any errors identified to the population of all Dr. Berman’s claims.

For each of the 25 sampled members, we obtained the individual treatment plan (ITP) and reviewed it to ensure that it included the 11 elements required by Section 164 of Title 105 of the Code of Massachusetts Regulations (CMR), such as (1) a statement of the patient’s strengths, needs, and abilities; (2) evidence of the patient’s signature attesting agreement to the plan; (3) a list of services to be provided and goals to be achieved; (4) evidence that the ITP has been reviewed annually; and (5) a description of discharge plans and aftercare needs and goals.

For the period January 1, 2015 through December 31, 2016,⁵ we selected a statistically random sample of 129 out of 8,882 E/M claims that Dr. Berman billed using procedure code 99214, using an expected error rate of 50%, a desired precision range of 15%, and a confidence level of 90%, to determine whether Dr. Berman properly documented the services provided. Expected error rate is the anticipated rate of occurrence of the error of improper billing for services; 50% is the most conservative. Desired precision is a measure of how precise the actual error rate is. Confidence level is the numerical measure of how confident one can be that the sample results reflect the results that would have been obtained if the entire population had been tested. For this audit, we designed our sample so that we would be 90% confident that the actual error rate in the sample of 129 claims would be within a range of +/– 7.5%, or 15%, of the error in the population of 8,882 claims.

To determine whether Dr. Berman properly documented the services for which she billed MassHealth, we reviewed members’ medical records to determine whether they included all of the required key components for billing for an E/M service using procedure code 99214 in accordance with the Centers for Medicare and Medicaid Services’ 1997 Documentation Guidelines for Evaluation and Management Services.

The statistical sampling method described above allows us to extrapolate the sampled findings to all the E/M claims billed using procedure code 99214 in 2015 and 2016. Based on our testing, the actual error rate in our sample was 100%, and when projecting this to the total population of paid claims, we are 90% confident that at least 92% (the lower limit) or at most 100% (the upper limit) of Dr. Berman’s claims were overpaid. In OSA’s opinion, the lower limit of 92% (the most conservative amount) is the minimum amount that Dr. Berman must repay to the Commonwealth.

We performed data analytics to identify any instances where Dr. Berman’s laboratory billed for a qualitative drug screen and a quantitative drug test for the same member on the same day. This is considered unbundling, and MassHealth instructed providers not to bill this way in its Independent Clinical Laboratory Bulletin 9, dated February 2013.

We searched the federal Substance Abuse and Mental Health Services Administration’s website to determine whether Dr. Berman obtained the proper federal certification to treat opioid dependency with buprenorphine.

We obtained and reviewed a MassHealth certified provider contract provided by MassHealth officials that lists Dr. Berman as a sole practitioner of psychiatry. We determined whether she obtained a license to provide substance use disorder counseling from the Massachusetts Department of Public Health as required by 130 CMR 408.404(A), 130 CMR 408.405, and 105 CMR 164.012.

During this audit, OSA worked with MassHealth by communicating our audit objectives, scope, and methodology. MassHealth shared with OSA the results of an earlier contracted audit review of Dr. Berman’s claims for the period March 1, 2011 through February 29, 2012.

3.    The Data Warehouse is MassHealth’s central repository for Medicaid member identification and claim payment information.

4.    Dr. Berman began transitioning to this system in 2015.

5.    Supporting documentation for services provided in 2014 could not always be located for other audit procedures we conducted during this audit. Therefore, we selected our sample from only 2015 and 2016 E/M claims billed using the 99214 code. As a result, when extrapolating the error to the population of claims, we did not consider missing documentation in our error rate regarding whether the key medical components were properly documented in members’ medical records.

Date published:	November 14, 2018