Overview
Our review of the medical records for a sample of 25 members found that in many instances, Dr. Berman’s medical records did not correctly reflect the results of the drug tests she had ordered. According to NECPAD’s Controlled Substance Treatment Policies, members are required to comply with drug testing requirements in order to continue receiving medications to help them recover from SUDs. Since the actual drug test results we examined conflicted with those Dr. Berman documented in the members’ records, her medical decision-making may have been based on inaccurate information when she was writing prescriptions for Suboxone.
Out of 1,338 MassHealth members whom Dr. Berman drug tested during the audit period, we selected a judgmental sample of the 25 members who received the most drug tests to determine whether Dr. Berman properly documented all services provided to them. We reviewed all drug test orders and results, as well as member medical records for each date of service each member was drug tested and given a new prescription to treat opioid dependence. In total, out of the 4,171 drug test results we reviewed, we found that 1,856, or 44%, were not accurately documented in the 25 members’ medical records we tested:
|
|
Number of Drug Tests |
Amount Paid |
|---|---|---|
|
Drug test results were abnormal (failed) but medical record stated either “in compliance” or “[results] pending” |
714 |
$30,144 |
|
Drug tests results were normal but medical record |
1,142 |
46,497 |
|
Total Conflicting Drug Test Results |
1,856 |
$76,641 |
Authoritative Guidance
According to 130 CMR 433.409(D)(1), results of drug tests must be documented in members’ medical records:
Medical records corresponding to office . . . services provided to members must include the reason for the visit and the data upon which the diagnostic impression or statement of the member’s problem is based, and must be sufficient to justify any further diagnostic procedures, treatments, and recommendations for return visits or referrals. Specifically, these medical records must include, but may not be limited to, the following . . .
(k) any tests administered and their results.
Without properly documenting the results of drug tests she ordered in members’ medical records, Dr. Berman cannot determine when it is time to refer them for alternative treatments, as described in her Controlled Substance Treatment Policies:
Patients who repeatedly fail to comply with the program requirements will be discharged from the program:
a. failure to provide [urine drug test, or UDT] in compliance with treatment despite reasonable attempts made to help the client achieve recovery (i.e., medication adjustment, frequent medication visits, referral to therapy, visiting nurses, community support program, partial hospitalization or [Intensive Outpatient Program] etc.).
The policies state that patients who are discharged will be provided with other treatment alternatives, such as admission to a detoxification center, transfer to a methadone clinic, or referral to a sober home.
Reasons for Noncompliance
Dr. Berman told us her records were not always updated to reflect drug test results received from the laboratory. She also stated that when a patient produces an abnormal drug test result but she knows that the patient typically produces normal drug test results, she gives them the “benefit of the doubt.” She further noted that she records patients with abnormal drug tests as compliant in her notes if, for instance, they tell her they have taken cough syrup with codeine.
Recommendations
- Dr. Berman should review all drug test results she orders to ensure that MassHealth members comply with her treatment guidelines and should refer noncompliant members to other SUD treatment options.
- Dr. Berman should only bill MassHealth for drug tests that she will use to diagnose and treat members and should properly document them in members’ medical records.
MassHealth’s Response
MassHealth agrees that Dr. Berman should review all drug test results she orders to improve MassHealth members’ adherence with her treatment guidelines. . . .
MassHealth agrees that Dr. Berman may only bill MassHealth for medically necessary drug tests, and must maintain records to support the medical necessity of those services.
Auditee’s Response
Counsel for Dr. Berman objects to the use of a “judgmental sample” for the results of this finding. Reviewing 25 patients out of 1,338 patients reflects only 1.8% of the overall patients that were drug tested during the audit period. Such a percentage is not statistically significant. Also, selecting the 25 MassHealth beneficiaries who received the most drug tests during the audit period is to cherry pick the extremes of patients treated, and it is misleading to use those 25 patients as indicative of the typical treatment Dr. Berman provides.
Dr. Berman orders and signs each presumptive drug test for patients according to need; NECPAD does not use standing orders for its patients for these tests. All results are reviewed directly by Dr. Berman. If drug testing is necessary for a particular patient, such as for patients who are coming in for a random appointment for opioid treatment, NECPAD’s goal is to have the drug test results ready prior to seeing Dr. Berman for the medical appointment; this is accomplished by having the patient leave a sample upon checking in for the appointment. Dr. Berman utilizes the results from drug testing in her treatment of patients, discussing the results of the drug tests with them and determining treatment of patients based on these tests. If the “pending results” ultimately come back abnormal, NECPAD reaches out to the patient as soon as possible and the patients must come back as soon as possible. The treatment plan is changed as necessary and future prescriptions may be put on hold, depending on the nature of the medication. Dr. Berman will confront the patient as soon as s/he comes back to discuss the incident and possible relapse. This process is one of the ways Dr. Berman strengthens the therapeutic relationship with patients and fosters honesty to allow more effective treatment of these difficult patients.
Dr. Berman has not and does not write prescriptions for Suboxone based on inaccurate information. Dr. Berman acknowledges that, in the past, she has not always been consistent with overtly documenting when the drug test results are no longer pending, and she has taken actions to prevent this for the future.
Auditor’s Reply
The Office of the State Auditor’s (OSA’s) sampling method was sound and consistent with applicable professional standards. To assess overall risk, OSA first used data analytics to analyze all the drug tests billed by Dr. Berman for MassHealth members during our audit period. 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.
This type of judgmental sampling is provided for in Section 6.64 of the United States Government Accountability Office’s (GAO’s) Government Auditing Standards, which recommends that auditors obtain judgmental samples based on isolated risk factors in certain situations:
When a representative sample is not needed, a targeted selection may be effective if the auditors have isolated risk factors or other criteria to target the selection.
Additionally, in accordance with audit sampling rules, we did not project the results of our testing in this area to the overall population. Rather, our conclusions were based solely on the documentation we reviewed that was related to our tested sample.
Dr. Berman’s legal counsel states that Dr. Berman reviews all drug test results that she signs for and that her goal is to have all drug test results available for review before patient appointments. Although this may be her goal, her medical records for MassHealth members did not always contain documentation of her review and discussion of drug test results with members. Further, as noted above, 1,856 (44%) of the 4,171 drug test results we reviewed were not accurately documented; this calls into question what results were actually discussed with members.
Dr. Berman’s legal counsel asserts that when pending results are abnormal (i.e., when results are positive for illicit substances and/or negative for prescribed drugs, such as Suboxone), Dr. Berman contacts the patient for an immediate appointment and changes the patient’s individual treatment plan (ITP) as necessary. However, OSA found no evidence in member medical records that she contacted members to set up appointments when pending drug test results were abnormal.
Finally, Dr. Berman’s legal counsel states that Dr. Berman revises members’ ITPs if members’ drug test results come back abnormal. However, during our audit, we performed an analysis comparing the 714 abnormal drug test results for the 25 members in our audit sample with information documented in the members’ ITPs and found that this was not always the case. Specifically, for 15 members, Dr. Berman could not locate any ITPs. On average, 47% of the drug tests provided to these 15 members during the audit period were abnormal. One member was drug tested 149 times, and 113 (76%) of the test results were abnormal, but none of them were documented as abnormal in the member’s medical record or in an ITP. For the 10 sampled members for whom we were able to obtain and review ITPs, abnormal drug tests averaged approximately 58% of all drug tests during the audit period. One of these members was drug tested 196 times, and 151 (77%) of the test results were abnormal, but none were documented as abnormal in the member’s medical record or ITP.
| Date published: | November 14, 2018 |
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