Dr. Ileana Berman Did Not Properly Notify MassHealth About Significant Changes in Her Business Operations.

Audit encourages Dr. Berman to ensure information about her practice that is in her MassHealth provider file is accurate.

Overview

In 2001, Dr. Ileana Berman became a certified sole practitioner providing psychiatric services to MassHealth members. Beginning in 2010, she changed how she conducted business. Specifically, in 2010, she incorporated her business as a limited liability corporation named New England Center for Psychiatric and Addiction Disorders LLC (NECPAD); beginning in 2011, she operated a full-service laboratory certified in accordance with the Clinical Laboratory Improvement Amendment⁶ for drug testing, with three laboratory technicians; in 2015, she began hiring addiction treatment counselors; and in 2015, she indicated that she changed her primary business to a provider of substance use disorder (SUD) treatment. This is evidenced by annual reports filed with the Secretary of the Commonwealth: beginning in 2015, they describe NECPAD as an “outpatient substance abuse and mental health treatment facility.” Dr. Berman did not notify MassHealth of these significant changes in her organization’s structure and the types of SUD treatment she offered to MassHealth members. Because MassHealth was not provided with current information about Dr. Berman’s operations, it could not effectively assess her status as a MassHealth provider. 

Authoritative Guidance

According to Section 450.222 of Title 130 of the Code of Massachusetts Regulations (CMR),

A person or entity may become a participating provider only by submitting an Application for Provider Contract. If approved by [MassHealth], the application will be part of any subsequent provider contract between the applicant and [MassHealth]. Any omission or misstatement in the application will (without limiting any other penalties or sanctions resulting therefrom) render such contract voidable by [MassHealth].

In addition, according to 130 CMR 450.223(B),

Each MassHealth provider must notify [MassHealth] in writing within 14 days of any change in any of the information submitted in the application. Failure to do so constitutes a breach of the provider contract.

MassHealth’s website provides specific details on how and when providers are required to update information in their provider files:

Providers are required to maintain the accuracy of their provider file information with MassHealth. . . .

MassHealth Regulations at 130 CMR 450.223(B) require providers to submit any changes . . . to avoid any disruption in payments. . . .

Changes may include

• Ownership
• Tax identification
• Licensure
• Organizational structure; and
• Other credentials, such as certifications or qualifications that may affect your eligibility to participate in MassHealth.

According to our discussions with MassHealth officials, providers are required to recertify and revalidate their contracts when the information therein changes, such as when a provider changes their organizational structure. For example, providers certified as sole practitioners (provider type 01, Physician) must notify MassHealth and recertify and revalidate their contracts to operate SUD treatment facilities (provider type 28, Substance Abuse Program).

Reasons for Lack of Recertification

Dr. Berman’s legal counsel stated that the doctor is licensed by Massachusetts as a psychiatrist and, in the attorney’s opinion, does not need to be recertified with MassHealth because she is still practicing as a licensed physician who treats patients with medication as needed. Further, Dr. Berman’s legal counsel stated that the doctor is not operating a SUD treatment facility and that although she provides SUD treatment for some of her patients, her practice does not meet the criteria to be considered a SUD treatment facility by the Commonwealth. However, because the changes she made to her organizational structure (such as becoming a limited liability corporation) were significant, she should have notified MassHealth of them.

Recommendations

1. Dr. Berman should work with MassHealth to ensure that the information in her provider file is properly updated to reflect the changes in her organizational structure.
2. In the future, Dr. Berman should notify MassHealth of any changes that need to be made to her provider file within the timeframe prescribed by MassHealth regulations. 
3. Dr. Berman should consult with MassHealth to determine whether NECPAD is properly certified.

MassHealth’s Response

MassHealth agrees that Dr. Berman must ensure that the information in her MassHealth provider file is complete and up to date. . . .

MassHealth agrees that Dr. Berman must notify MassHealth of any changes that need to be made to her provider files within the timeframe specified by MassHealth regulations.

During our audit, MassHealth officials also told us that they agreed that Dr. Berman should work with MassHealth to ensure that her operation was properly credentialed.

Auditee’s Response

Dr. Berman’s legal counsel provided the following comments on this issue on her behalf:

Dr. Ileana Berman previously notified MassHealth’s vendors . . . of her changes in staff and structure since her employees are credentialed with the MassHealth vendors. Dr. Berman has only billed MassHealth itself in her individual capacity as a provider.

Auditor’s Reply

We cannot confirm that Dr. Berman notified MassHealth’s vendors of her changes in business operations; however, she was required to notify MassHealth of these changes and did not do so.

6.    This amendment to the federal Public Health Services Act in 1988 provided certification regulations for laboratory testing that is performed on human specimens. 

Date published:	November 14, 2018