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

An overview of the purpose and process of auditing the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Melissa Hamilton

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 certain claims by Dr. Melissa Hamilton for the period July 1, 2015 through December 31, 2020.

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 our audit objective, indicating the question we intended our audit to answer, the conclusion we reached regarding the objective, and where the objective is discussed in this report.

Objective	Conclusion
Did Dr. Hamilton bill MassHealth for dental services in accordance with Sections 420.414(B) and 420.452(B) of Title 130 of the Code of Massachusetts Regulations (CMR) and the “How to Write in the Record” section of the American Dental Association publication Dental Records?	No; see Finding 1

To achieve our objective, we gained an understanding of the internal control environment related to the objective by reviewing policies and procedures, as well as conducting inquiries with Dr. Hamilton. We also evaluated the design of the relevant controls over MassHealth billing.

To obtain sufficient, appropriate evidence to address our audit objective, we conducted further audit testing as described below.

We selected a statistical, random sample of 131 claims (totaling $15,115) from the population of 45,073 claims (totaling $5,015,493) for services that occurred on days we considered “impossible” (containing more than 12 hours worked). We had narrowed the population of claims to those for “impossible” days because this is a high-risk area; we determined which days were “impossible” by using durations associated with certain dental procedure codes to determine the number of hours worked per day. To select the sample, we used an expected error rate of 50%, a desired precision rate of 15%, and a confidence level of 90%. We reviewed patient records for the claims to determine whether the claims were documented in accordance with 130 CMR 420.414(B) and 420.452(B), as well as the “How to Write in the Record” section of Dental Records. Specifically, we determined whether each patient record included the following, as required by 130 CMR 420.414(B):

1. the member’s name, date of birth, and sex;
2. the member’s identification number;
3. the date of each service;
4. the name and title of the individual servicing provider furnishing each service, if the dental provider claiming payment is not a solo practitioner;
5. pertinent findings on examination and in medical history;
6. a description of any medications administered or prescribed and the dosage given or prescribed;
7. a description of any anesthetic agent administered, the dosage given, and the anesthesia flowsheet;
8. a complete identification of treatment including, when applicable, the arch, quadrant, tooth number, and tooth surface;
9. dated digital or mounted radiographs, if applicable; and
10. copies of all approved prior authorization requests or the prior-authorization number.

For anesthesia claims, we determined whether the patient record included a completed anesthesia flowsheet and/or a record of the following: (1) the beginning and end times of anesthesia; (2) the member’s vital signs; (3) administered medications, including dosage and route (such as oral or intravenous); (4) the system used to monitor the member’s vital signs; (5) a statement about the member’s response to the anesthesia; and (6) the member’s prior history with anesthesia, if applicable. In addition, during our review of patient records, we inspected the documentation for alterations (such as text that had been “whited out” with correction fluid or crossed out).

Data Reliability Assessment

We obtained data from the state’s Medicaid Management Information System (MMIS) for testing purposes. To test the reliability of the data, we relied on the work performed by OSA in two separate projects, completed in 2015 and 2019, that tested certain information system controls in MMIS. As part of these projects, OSA interviewed knowledgeable MassHealth officials about the data, reviewed existing information, and tested selected system controls. As part of our current audit, we performed validity and integrity tests on all claim data from the audit period, including (1) testing for blank fields, (2) scanning for duplicate records, (3) looking for dates outside the audit period, and (4) determining that each tooth had a required associated number. We also selected a judgmental sample of 30 hardcopy supporting documents (such as patient records) and traced information from them to MMIS data (such as member first names, member last names, dates of service, and procedure codes) for agreement. Additionally, we selected a judgmental sample of 30 claims from MMIS and traced them to hardcopy supporting documents (such as patient records) for agreement. Based on these procedures, we determined that the data obtained were sufficiently reliable for the purposes of our audit.

Date published:	May 26, 2022