Dr. Melissa Hamilton Had Inadequate Documentation To Support at Least $2,063,481 in Dental Claims.

The lack of adequate documentation calls into question whether all of the services were necessary or delivered.

Overview

During our audit period, Dr. Melissa Hamilton did not have adequate documentation to support at least $2,063,481 in dental claims: they were either missing information or missing documentation. The lack of adequate documentation calls into question whether all of the services were necessary or delivered.

We extrapolated the test results from our sample of patient records to the population of “impossible” days. Based on this testing, we are 90% confident that the minimum amount of the overpaid dental claims (the lower limit) was $2,063,481 and the maximum amount (the upper limit) was $2,772,638. Our review of patient records indicated that 67 of the 131 sampled claims did not have adequate documentation. Specifically, records did not contain pertinent findings on examination and medical history, complete identification of treatment, dated radiographs, and/or properly completed anesthesia records. Also, 3 sampled claims did not have treatment notes for dates when procedures had been performed. A summary of the identified issues follows.

Issue	Number of Claims Affected*
No Pertinent Findings	46
No Complete Identification of Treatment	7
No Dated Radiographs	1
Incomplete Anesthesia Records	31
No Date of Service	3

*    A number of the claims had multiple documentation issues and were included in more than one issue category.

 

None of the 31 anesthesia-related claims was supported with properly completed anesthesia records in the patient records. A summary of the identified anesthesia issues follows.

Issue	Number of Claims Affected*
No Anesthesia Flowsheet	7
No Anesthesia Start and Stop Time	31
No Statement about Member’s Response to Anesthesia	30
No Prior History with Anesthesia (when applicable)	12

*    A number of the claims had multiple documentation issues and were included in more than one issue category.

Authoritative Guidance

According to Section 420.414(B) of Title 130 of the Code of Massachusetts Regulations (CMR),

Payment by the MassHealth agency for dental services listed in 130 CMR 420.000 includes payment for preparation of the member’s dental record, including electronic dental records. Services for which payment is claimed must be substantiated by clear evidence of the nature, extent, and necessity of care provided to the member. For all claims under review, the member’s medical and dental records determine the appropriateness of services provided to members. The written dental record corresponding to the services claimed must include, but is not limited to . . .

3. the date of each service . . .

5. pertinent findings on examination and in medical history . . .

7. a description of any anesthetic agent administered, the dosage given, and the anesthesia flowsheet;
8. a complete identification of treatment including, when applicable, the arch, quadrant, tooth number, and tooth surface;
9. dated digital or mounted radiographs, if applicable.

In 130 CMR 420.452(B), MassHealth requires providers to maintain a completed anesthesia flowsheet and additional anesthesia information in each member’s dental record:

Documentation. The provider must maintain a completed anesthesia flowsheet in the member’s dental record for each procedure requiring the use of anesthesia. In addition, the provider must document the following in the member’s dental record:

1. the beginning and ending times of deep sedation/general anesthesia, [intravenous] moderate sedation/analgesia, or inhalation of nitrous oxide analgesia procedure. . . . The level of anesthesia is determined by the provider’s documentation and consideration of the member’s history with anesthesia, and anesthetic effects upon the central nervous system and is not dependent upon the route of administration. . . .

5. a statement of the member’s response to the analgesic or anesthetic used, including any complication or adverse reaction; and
6. a record of the member’s prior history with anesthesia or analgesics.

Reasons for Issue

Dr. Hamilton did not have policies and procedures to ensure that all claims were properly documented according to MassHealth regulations.

Recommendations

1. Dr. Hamilton should collaborate with MassHealth to determine how much of the $2,063,481 in unallowable dental claims should be repaid.

1. Dr. Hamilton should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations.

Auditee’s Response

Dr. Hamilton’s legal counsel provided a written response on her behalf, dated April 27, 2022:

Dr. Hamilton has questions about the methodology of the audit. Specifically, the draft audit report states that 131 claims were sampled. In fact, in at least two instances of allegedly “deficient” charts, the same patient and same treatment date—the same claim—appear more than once: 8/31/15 and 9/26/17 are the dates of service for which there are duplicate claims. That means there were duplicate items in the sample frame. This is a flaw in the base sample, which renders the total estimated unsupported claims of $2,063,481 invalid. Of note, the duplicate charts were among those [the Office of the State Auditor, or OSA] claims to be deficient, skewing the estimated repayment number significantly upwards.

The statistical spread also assumes unchanged conditions for the period sampled from July 1, 2015 all the way forward to the end of the period extrapolated, on December 31, 2020. However, there was a critical changed condition in 2018, when for various reasons Dr. Hamilton reduced the number of overall cases (and particularly anesthesia cases) in her practice. Therefore, the extrapolated sample, which assumes the number of allegedly unsupported claims remained constant over time to generate the estimated $2,063,481, has an inadequate base design.

Further, the draft audit report stated: “We selected a statistical, random sample of 131 claims (totaling $15,115) from the population of 45,073 claims (totaling $5,015,493) that occurred on days we considered impossible (more than 12 hours worked). . . . we determined which days were “impossible” by using durations associated with certain dental procedure codes to determine the number of hours worked per day. . . .” Dr. Hamilton objects to this methodology for identifying so-called “impossible” days. As the draft audit does not identify specific dates that are impossible, there is no direct way to address this allegation.

However, a breakdown of the 2016 MassHealth payment year for Dr. Hamilton’s practice indicates that her office billed an average of $5683.975 per day. Given that billing for the extraction of, as an example, 4 full-boney impacted “wisdom” teeth in a one-hour session under [procedure codes] D7240, D9329 x1 and D9243 x2 = $1815, Dr. Hamilton would exceed $5683.975 in a day if she performed just three such procedures in a day and saw one other patient—a little over three hours of direct patient care. These numbers do not reflect that “impossible” days would generally be required to reach the level of payment that the draft report calculates. There may of course be isolated, individual outlier days of heavy patient caseloads, but the total payment noted does not support the conclusion that Dr. Hamilton routinely had days with “impossible” loads.

Additionally, in the afternoons Dr. Hamilton often has multiple patients in the office at once for overlapping procedures not done under sedation. For instance, she may place Novocain for a patient and then use the five to 10 minutes required for the patient to become numb to step into the next treatment room and start a consultation with a patient who has come in for pretreatment evaluation. Finally, MassHealth does not forbid a provider from working more than twelve hours in a day. While Dr. Hamilton typically schedules patient appointments between 8AM and 4PM, if a procedure required a longer period of time and she had to work a longer day, she would and is permitted to do so.

From a recordkeeping standpoint, the draft audit report notes “incomplete anesthesia records”. OSA claims that 31 records had no anesthesia start and stop times. However, the start and stop time for each procedure is the same as the monitoring time, which is recorded with the case vital signs on the monitor documentation appended inside the front cover of each and every anesthesia record. A sample strip was provided to the audit team, but this fact is not reflected in the draft audit report.

The report further claims that there was no dated radiograph for one (1) case sampled. The report fails to mention that this was acknowledged as human error, reported to MassHealth, and that the claim has already been submitted for voluntary repayment/recoupment.

The draft report also states that Dr. Hamilton’s office had inadequate policies and procedures to ensure that MassHealth claims are properly documented according to MassHealth guidelines. However, Dr. Hamilton relies on the DentaQuest MassHealth Program Office Reference Manual, which is published under the aegis of the Commonwealth of Massachusetts.

Last, OSA also asserts that there are no treatment notes for a handful of patients, or no dates on certain notes. However, notes for some of these patients do appear in the paper chart, or on the [electronic medical record] system trialed in the office.

Dr. Hamilton denies that there has been any overpayment or that repayment is indicated. Nonetheless, Dr. Hamilton always strives to improve, and without admitting the validity of the audit findings or conceding that any claims were improperly billed or inadequately supported, she has taken the following steps to maximize the completeness of charts and the accuracy of her billing:

• Dr. Hamilton has begun using [speech-to-text software that] allows her to dictate directly into the record. This allows her to provide more detail for each note in an efficient manner.
• Each morning before reporting to the office, Dr. Hamilton logs in remotely to the scheduling system, and reviews the surgeries booked for the day in order to prepare her day, budget her time, and anticipate the documentation required for each case.
• At noon every day, the charts for the past 24 hours are personally reviewed for completeness by Dr. Hamilton. She checks her own work, as well as ancillary entries made by staff.
• At the end of each day, Dr. Hamilton checks the dictated notes for all patients and signs and finalizes. Once signed electronically, the entries are locked and cannot be edited.
• Start and stop times and vital signs from the monitor strips in each chart are now also separately recorded on the anesthesia record.

Furthermore, Dr. Hamilton has retained the services of Affiliated Monitors to prepare a compliance package specifically tailored to oral surgery, and to the needs of her office. This compliance package is anticipated to include:

• Development of additional standards regarding the content of patient treatment records
• Goal timelines for completion of patient treatment record entries
• Designation of which staff members are responsible for completion of particular record components
• Periodic self-auditing of randomly selected samples
• Staff training on the content and implementation of the compliance package.

Auditor’s Reply

Dr. Hamilton’s legal counsel asserts that there were duplicate claims in our sample that rendered our audit results invalid. That is incorrect. There were two instances where a member and date of service appeared twice in the sample of 131 claims. Although our sample included two claims for each of these members on the same dates of service, they received multiple procedures on those dates. These are not considered the same claim. Each of these claims has a separate individual claim number, which MassHealth defines in its “Guide to the Remittance Advice for Paper Claims and Electronic Equivalents” as a “unique number used to identify and track a claim processed through the system.”

Dr. Hamilton’s legal counsel states, “There was a critical changed condition in 2018. . . . Therefore, the extrapolated sample . . . has an inadequate base design.” This is inaccurate. The audit sampling method OSA used to select and extrapolate the sample to obtain the results is clearly described in the “Audit Objectives, Scope, and Methodology” section of this report and is based on sound statistical sampling techniques. OSA will share this information with MassHealth and Dr. Hamilton in the process of resolving the issues identified in this report. Specifically, in conducting our sampling, we used RAT-STATS, a statistical sampling program created by the Office of Audit Services within the United States Office of Inspector General in the United States Department of Health and Human Services. This program determines a statistically appropriate sample, giving consideration to the total size of the population, expected error rate, confidence level, and desired precision, which for this audit are defined in the “Audit Objectives, Scope, and Methodology” section of this report. RAT-STATS is widely used by audit agencies and is recognized by MassHealth as the sampling software of choice for evaluating provider claims when using a statistical sampling method. Once we determined the sample size, we used Audit Command Language, which is a data analysis software program recognized statewide, to select a random sample of claims paid to Dr. Hamilton. Our sampling method was sound and consistent with applicable professional standards. Also, our sample of 131 claims is representative of the population. For each fiscal year, the percentage of claims in relation to the total number of claims for the population is similar to the percentages for our sample. For example, claims for fiscal year 2020 represented 9% of the total population of claims and 7% of the claims in our sample. See the full breakdown below.

Fiscal Year	Percentage of Claims within the Total Claim Population	Percentage of Claims within the Total Claim Sample
2016	24%	21%
2017	26%	25%
2018	19%	24%
2019	15%	17%
2020	9%	7%
2021*	6%	6%

*  This row only includes the first six months of fiscal year 2021 (July 1, 2020 through December 30, 2020).

Dr. Hamilton’s legal counsel states, “MassHealth does not forbid a provider from working more than twelve hours in a day.” We acknowledge that MassHealth does not forbid this practice, and we did not use the definition of “impossible days” to determine whether the claims Dr. Hamilton submitted for such days were questionable. Rather, as stated in the “Audit Objectives, Scope, and Methodology” section of this report, we deemed “impossible” days to be a high-risk area and therefore used them as the population of days from which to select our statistical sample. As noted above, for claims to be reimbursable, providers such as Dr. Hamilton must properly document the services provided in accordance with MassHealth regulations. This was the requirement we used to test the claims in our sample and find issues with 67 (51%) of the 131 claims tested.

Dr. Hamilton’s legal counsel asserts, “The stop and start time for each procedure is the same as the monitoring time, which is recorded with the case vital signs on the monitor documentation.” This monitoring documentation is in the form of paper electrocardiogram (EKG) strips inside some patient records. OSA acknowledges that these EKG strips contain patient vital signs and monitoring times. However, the start and stop times of anesthesia should be documented on the anesthesia flowsheet as well. The anesthesia flowsheets provided to us contained sections for anesthesia start time, operative start time, operative end time, anesthesia finish time, and recovery time. However, this information was not completed on the flowsheets or documented in the patient record as required by 130 CMR 420.452(B).

Dr. Hamilton’s legal counsel writes that there was one instance where there was no dated radiograph. OSA acknowledges that Dr. Hamilton previously stated that this was billed in error and that she would initiate a repayment. However, we cannot verify that she reported the matter to MassHealth and submitted the claim for repayment, because no documentation was provided for this assertion.

Dr. Hamilton’s legal counsel states that the doctor “relies on the DentaQuest MassHealth Program Office Reference Manual” for her policies and procedures. However, this reference manual is not specific to Dr. Hamilton’s dental practice and does not specifically state which employees are responsible for documentation.

Dr. Hamilton’s legal counsel states that “notes for some of these patients [those without treatment notes] appear in the paper chart, or on the [electronic medical record] system trialed in the office.” However, in the patient records provided to us, there were no treatment notes for dates when procedures had been performed, and there was no indication that any additional documentation was maintained in the system.

MassHealth Response

1. MassHealth agrees with the OSA’s first recommendation that Dr. Hamilton should collaborate with MassHealth as it determines the amount of overpayments due. Specifically, MassHealth will review the 131-claim sample that the OSA reviewed for this audit. Assuming MassHealth agrees with the OSA that these claims constitute overpayments based on violations of MassHealth regulations, MassHealth will recoup the overpayments which resulted from these claims and will also impose appropriate sanctions. However, while MassHealth is very concerned by the findings in the OSA’s report, MassHealth does not believe it would be appropriate at this time to extrapolate an overpayment determination based on the OSA’s 131-claim sample to every claim submitted by the provider over a five-year period and therefore does not presently agree with the OSA’s finding that the provider had “inadequate documentation to support at least $2,063,481 in dental claims” or that such amount currently constitutes an overpayment. Therefore, MassHealth will conduct a broader review of the provider’s claims. At that point, MassHealth will recoup additional overpayments, impose sanctions, and take other action against Dr. Hamilton as appropriate.
2. MassHealth agrees with the OSA’s second recommendation that Dr. Hamilton should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations and [American Dental Association] guidelines.

Date published:	May 26, 2022