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Audit of the Office of Medicaid (MassHealth)—Review of Counseling Provided to MassHealth Members Receiving Medication-Assisted Treatment for Opioid Use Disorders Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Office of Medicaid (MassHealth)—Review of Counseling Provided to MassHealth Members Receiving Medication-Assisted Treatment for Opioid Use Disorders.

Table of Contents

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 opioid use disorder counseling provided to MassHealth members who received buprenorphine as part of their medication-assisted opioid use disorder treatment for the period January 1, 2011 through December 31, 2015. The audit included interviews with sampled member prescribers that were conducted between February 6, 2017 and August 16, 2017.

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 the audit findings.  

Objective

Conclusion

  1. Do MassHealth members who are treated with buprenorphine for opioid use disorders receive, or have access to, appropriate and necessary counseling?

No; see Findings 1 and 2

 

To achieve our audit objective, we reviewed and analyzed medical claim data from the state’s Medicaid Management Information System (MMIS) and used the data when selecting our sample population for testing. 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 the work performed, OSA reviewed existing information, tested selected system controls, and interviewed knowledgeable agency officials about the data. Additionally, we performed validity and integrity tests on all claim data related to our audit objective, including (1) testing for missing data, (2) scanning for duplicate records, (3) testing for values outside a designated range, (4) looking for dates outside specific time periods, and (5) tracing a sample of claims queried to source documents. We identified an issue (Finding 3) when tracing a sample of claims to source documentation maintained by prescribers. Specifically, prescribers for six of the sampled members tested did not maintain any documentation for services provided. Based on our procedures, despite the issue discussed in Finding 3, we determined that the data obtained were sufficiently reliable for the purposes of this report.

From discussions with MassHealth officials, we gained an understanding of internal controls over MassHealth’s process for ensuring that members have access to opioid use disorder counseling. 

We conducted 12 informational interviews with healthcare professionals and personnel at healthcare programs, such as Duffy Health Center, who specialize in treating opioid use disorders. We also met with behavioral health professionals at the six managed-care organizations MassHealth had under contract at the time of our audit (Health New England, Boston Medical Center HealthNet, Fallon, Tufts Health Plan, Neighborhood Health, and Celticare) to provide care for some of its members. Finally, we met with representatives from the Massachusetts Association for Behavioral Healthcare. This research gave us an understanding of current practices for the treatment of MassHealth members with opioid use disorders, the various healthcare settings in which members can be treated, and the other issues associated with members accessing counseling.

Given the sensitivity and confidentiality of the information we used in selecting a sample of members for testing, we will not disclose specific members’ personal information in this report.

We selected a statistical sample of 103 MassHealth members who were given at least one prescription for buprenorphine between January 1, 2011 and December 31, 2015. We identified a prescribing physician for each of the 103 sampled members and conducted interviews to determine whether each member had access to necessary counseling. We shared our sample and test plans with MassHealth officials at the audit entrance conference and in meetings during audit fieldwork. We did not extrapolate the results of our findings to the population of members because 20 of the sampled prescribers did not respond to our requests for interviews.

When determining whether members had access to counseling for opioid use disorders, we reviewed claim data from January 1, 2011 through December 31, 2015 for all members who had obtained at least one prescription for the following drug names, to which we will refer as buprenorphine:

  • Buprenorphine
  • Suboxone
  • Zubsolv
  • Bunavail

When determining whether members received any services associated with counseling for their opioid use disorders, we considered the following procedure codes, many of which are not specifically for counseling and therapy, but are sometimes used by providers when treating members for opioid use disorders: 99201–99205, 99211–99215, 99408, 99409, H0001, H0004, H0005, T1006, 90882, 90486, 90791, 90792, 90832–90834, 90836–90840, 90863, 90887, 90889, S9485, 90847, 90853, H2015, H2019, H2027, H0038, 90806, H2018, and G0463. For 83 sampled members, we interviewed the prescribers and reviewed the medical files for evidence of medical services provided, such as individualized treatment plans. If a member had more than one prescriber during the audit period, we selected the one who made the highest number of prescriptions, prescribed the highest number of units, or made prescriptions that resulted in the highest amount paid to the pharmacy that filled the prescriptions.

Additionally, for the 103 sampled members, we reviewed fee-for-service and encounter claim data in MMIS and from Member All Service Reports (reports listing all medical services provided to a member within a certain time period) to determine whether the members received counseling while they were prescribed buprenorphine. We also performed data analytics on the prescriptions and counseling that all members received during the audit period to determine whether any members received prescriptions without counseling.

To determine whether members had access to appropriate counseling, we researched each prescriber for our audit sample to verify that they obtained certifications and/or medical specialties in addiction medicine, using physician locator search tools on the websites of the American Society of Addiction Medicine, the Substance Abuse and Mental Health Services Administration, the American Board of Preventive Medicine, the American Board of Addiction Medicine, and the American Board of Psychiatry and Neurology.

Date published: March 21, 2019
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