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Dr. Khuong Nguyen Did Not Keep Medical Records at His Office Supporting Services Provided to Youths Residing in State-Run Facilities and Programs

Audit found that the optometrist did not have documentation of medical records supporting the medical services claimed to have been provided.

Table of Contents

Overview

Dr. Khuong Nguyen did not keep adequate medical records at his office for all services he provided at Department of Youth Services (DYS) facilities and Department of Children and Families (DCF) programs during our audit period. Specifically, for our test sample of 180 medical records, Dr. Nguyen could not provide us with adequate documentation for 130 claims (72%) for members residing in those locations. When a MassHealth provider does not keep medical records supporting medical services, it raises concerns about whether the services were actually provided.

Authoritative Guidance

According to Section 402.418(C) of Title 130 of the Code of Massachusetts Regulations (CMR), Dr. Nguyen must keep all associated medical records at his office for vision care provided at facilities outside his office:

The MassHealth agency pays for vision care services provided to a member residing in a public or private facility, if payment for these services is not included in the facility's rate. A medical record must be kept on file at the provider’s office.

Reasons for Insufficient Documentation

Dr. Nguyen stated that he preferred to leave all documentation for services he provided to members residing in DYS facilities or DCF programs at the facilities or programs, since he did not want the personally identifiable information in the patient files to leave those locations. However, it should be noted that we asked staff members at DYS facilities and DCF programs where Dr. Nguyen provided vision care to provide us with any documentation they had regarding 39 of the above-mentioned 130 claims, but neither agency was able to locate 8 (21%) of the 39 files5 requested, so there is no evidence that those services were provided.

Dr. Nguyen stated that he no longer travels to DYS facilities and that for youths in DCF programs, he now maintains the medical records using electronic medical record (EMR) software.

Recommendations

  1. Dr. Nguyen should keep documentation, whether in his EMR system or as hard copies, for vision care provided to youths residing in DCF programs and make it available upon request.
  2. Dr. Nguyen should collaborate with MassHealth to determine the amount to be repaid for vision care that was not documented.

Auditee’s Response

We kept a written copy of the medical record at the facility and an encrypted electronic record in the office. We kept a written copy of the exam form at the facility and a secured electronic version in our office. We already provided all 180 (100%) medical records to the State Auditors last year. . . . We will provide the state auditor again if needed with the 8 (21%) missing records from the facilities. We spend thousands of dollars to upgrade our computer system and EMR to provide remote access from anywhere around the world since we provided in home visits.

MassHealth’s Response

  1. MassHealth agrees that Dr. Nguyen must maintain appropriate records for all patients, including patients that reside in DCF programs, as required by 130 CMR 402.417 and 418, and make the patient records available upon request.
  2. MassHealth will outreach to the provider to identify paid claims for which the provider did not maintain documentation required under 130 CMR 40417 and 418. MassHealth will determine the overpayment amount and initiate recovery from Dr. Nguyen after the final audit report has been issued.

Auditor’s Reply

Although Dr. Nguyen states that he kept written records at the facilities and electronic records at his office, he could not produce a complete medical record (written or electronic) for 130 of the 180 sampled claims upon request. The documentation he produced to support these claims consisted only of printed screenshots of the claims he had submitted to MassHealth and was therefore inadequate.

The 8 files Dr. Nguyen mentions in his response are included in the 130 missing medical records that we requested. As noted above, Dr. Nguyen, DYS, and DCF could not locate the files during our audit, and therefore there was no evidence that the services in question were performed. Dr. Nguyen told us he had begun using an EMR system in order to maintain complete medical records in the future.

5. The payments associated with these 39 claims are questioned in Finding 3.

Date published: July 16, 2018
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