Overview
Dr. Berman did not maintain any documentation in members’ medical records to support her billing for $31,287 in E/M services and drug tests provided to MassHealth members during the audit period. We selected a judgmental sample of the top 25 members for whom MassHealth paid Dr. Berman for the most drug tests during the audit period to determine whether she maintained the necessary documentation for all services for which she billed. We determined that she had not retained any of the required documentation for some E/M services and drug tests in members’ medical records. As a result, MassHealth may have paid Dr. Berman for E/M services she did not provide.
Further, in our review of documentation for E/M services and drug tests, we determined that a total of 650 records were missing, as illustrated below.
|
Year |
Number of Missing E/M Services |
Amount Paid |
Number of Missing Drug Tests |
Amount Paid |
|---|---|---|---|---|
|
2014 |
181 |
$12,793 |
151 |
$6,584 |
|
2015 |
29 |
2,221 |
145 |
4,262 |
|
2016 |
20 |
1,596 |
124 |
3,830 |
|
Totals |
230 |
$16,610 |
420 |
$14,677* |
* Discrepancy in total is due to rounding.
Authoritative Guidance
According to 130 CMR 450.205(A), to be paid by MassHealth, providers must maintain proper documentation supporting the services billed:
[MassHealth] will not pay a provider for services if the provider does not have adequate documentation to substantiate the provision of services payable under MassHealth. All providers must keep such records, including medical records, as are necessary to disclose fully the extent and medical necessity of services provided.
Reasons for Lack of Proper Documentation
In a letter to OSA, Dr. Berman explained that throughout 2014, her staff did not scan all paper medical records into her new electronic recordkeeping system. She also cited laboratory instrument failures in 2014 as a reason for the missing documentation. However, OSA’s review of these claims noted documentation issues in every year of our audit period. Additionally, on February 5, 2018, Dr. Berman provided a letter to OSA acknowledging the 650 missing records.
Recommendation
Dr. Berman should repay MassHealth for E/M services and drug tests that were not documented in members’ medical records and maintain adequate documentation to support all services claimed.
MassHealth’s Response
MassHealth agrees with this finding and will recover any overpayments related to this finding after the auditor’s final report has been issued.
Auditee’s Response
The Office of the State Auditor’s representatives informed Dr. Berman and her counsel that the auditors were unable to locate documents for approximately 650 claims. Dr. Berman’s staff was able to locate approximately half of the missing documentation, which Dr. Berman faxed to the Office of the State Auditor, but it does not appear that the final data was updated. According to Dr. Berman’s data, NECPAD is missing the following documentation.
Year
Number of Missing E/M (Reported)
Number of Missing E/M (Corrected)
Number of Missing Drug Tests (Reported)
Number of Missing Drug Tests (Corrected)
2014
181
181
151
137
2015
29
19
145
60
2016
20
19
124
11
Total
230
219
420
208
. . .
Dr. Berman notes that there are two primary reasons for the remaining lost documentation. One of these reasons is the actions of Dr. Berman’s two employees, her office manager and her lab technician, who were largely responsible for the lack of organization of patient documentation at NECPAD. As a corrective action, both employees were terminated in early 2015 due to poor performance. Dr. Berman acknowledges that the other main cause for the remaining lost documentation was that the documentation was lost in the process of transitioning from paper records to electronic medical records in 2014.
NECPAD has continuously improved the system of providing clinical care and storing and retrieving documentation. NECPAD is developing processes to ensure that documentation is stored correctly and that documentation will no longer be lost. NECPAD also identified a possible future cause of lost documentation, and implemented a procedure that will help ensure all documentation is filed properly with each patient file. Because Dr. Berman has some patients come randomly for appointments to ensure compliance with drug treatment, there is a chance that the patient may leave prior to checking out with the front desk. As a corrective action, NECPAD has developed an improved system to verify that the schedule is fully reconciled each day with the type of services rendered on that date.
Auditor’s Reply
Although Dr. Berman’s legal counsel states that Dr. Berman was able to provide us with approximately 50% of the 650 missing documents, this statement is not accurate. In fact, our audit originally identified 769 missing documents, of which Dr. Berman could only locate 119, or 15%. Our final audit report accurately states the number of missing documents as 650.
Dr. Berman’s legal counsel responded that most of the missing documentation was due to two employees of Dr. Berman who did not maintain the necessary medical documentation, as well as her office’s transition in 2014 to electronic medical records. However, regardless of the reasons, MassHealth does not pay a provider for services if the provider does not have adequate documentation to substantiate the provision of the services, as noted above. Our audit found that Dr. Berman had not retained any of the required documentation for some E/M services and drug tests for the members whose records we reviewed; therefore, she should not have been paid for these services.
| Date published: | November 14, 2018 |
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