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Dr. Nguyen Submitted $108,166 in Questionable Claims for Dispensing Services

Audit calls on optometrist to work with MassHealth to determine the amount of claims to be repaid.

Table of Contents

Overview

Dr. Nguyen was overpaid by as much as $108,166 on 3,858 billings for eyeglass dispensing services. Specifically, for 3,618 claims, totaling $101,460, Dr. Nguyen shipped eyeglasses ordered for youths in DYS and DCF custody to the facilities’ and programs’ addresses without fitting the eyeglasses to the youths (i.e., ensuring that the MassHealth members could clearly see with their new glasses). Additionally, for 114 claims, totaling $3,194, Dr. Nguyen billed for dispensing glasses with a service date before the eyeglasses had even been ordered. Further, for 92 claims, totaling $2,562, Dr. Nguyen submitted claims for multiple eyeglasses when only one pair was ordered. Finally, he submitted 34 claims, totaling $950, for dispensing eyeglasses when no eyeglasses were ordered.

As a result, MassHealth may have unnecessarily paid Dr. Nguyen $108,166 that it could have used to provide other necessary services to members. The table below summarizes the problems we identified with these billings.

Questionable Claims for Dispensing Services

Billing Problem

Number of Claims

Amount Overpaid

Dispensed When Mailed to the Member

3,618

$101,460

Dispensed Glasses Before Ordering

114

3,194

Dispensed Multiple Glasses for Only One Order

92

2,562

Dispensed When No Glasses Were Ordered

34

950

Total

3,858

$108,166

Authoritative Guidance

According to MassHealth Transmittal Letter VIS-37, dated May 2008,

The date of service for dispensing vision care materials is the date on which the vision care materials are delivered to the member, not the date of the initial eye exam, nor the date the materials are ordered.

Additionally, according to 130 CMR 402.416, providers should submit claims for dispensing services only after eyeglasses have been ordered from the optical supplier and properly fitted to the member:

(D) In order for a vision care provider to be paid for dispensing an eyeglass prescription involving ophthalmic materials [eyeglasses] and services available through the optical supplier, all such materials and services must be ordered from the optical supplier. . . .

(E) In order to receive payment for dispensing an item, the dispensing practitioner must take all necessary measurements, verify lens characteristics, and adjust the completed appliance [eyeglasses] to the individual.

Reasons for Improper Billing

Regarding billing for dispensing services without fitting the eyeglasses to the patients, Dr. Nguyen stated that he does not fit eyeglasses to the youths at DYS facilities and DCF programs because it would be too costly and time-consuming for him to travel to each site to make sure the eyeglasses fit. He stated that during the audit period, instead of traveling to the sites, he mailed the eyeglasses to each facility and made adjustments to youths’ eyeglasses in subsequent visits. He did not comment on why he submitted the remaining questionable billings.

Recommendations

  1. Dr. Nguyen should collaborate with MassHealth to determine the amount of dispensing services to be repaid.
  2. Dr. Nguyen should submit claims for dispensing services for a MassHealth member only upon fitting the new eyeglasses to that member.

Auditee’s Response

Regarding dispensing fees, our procedures according to Masshealth regulations [CMR 402.416] were to check the prescription, adjust the frame if they were bent, tighten all screws. We then packaged, and shipped to each child as soon as possible per request from all these facilities. If there were any defects on the lenses, we would remove them. We would [etch] the names of the patients on the side of the frames. Per requests from the chief medical staffs of these facilities from Greenfield to Brewster, we would mail these glasses to their residents since the majority of them were short-term residents. We needed to give them the spectacles before they leave, since many were missing spectacles for months or some cases years. . . . Therefore shipping these glasses out right away was the priority instead of waiting until I returned to the facility to dispense the eyeglasses in a month or two. We did adjust these eyeglasses on these kids when I went back to the facilities at a later date. We would prefer that DYS and DCF transporting these kids to us to be fitted on their faces. . . . In addition to dispensing these spectacles, we also fixed many old pairs of glasses at these facilities at no cost. We were allowed to bill for these repairs, but we never billed Masshealth for repairs since most were minor repairs like missing a screw or needing a new nosepiece or temple. . . . We sometimes we replaced a new frame for these kids who were in need of an unrepairable frame with our own expenses without billing Masshealth. We also made many pairs of glasses for free to the facilities with our own lab due to the slow process of manufacturing at Masscor facility without billing Masshealth for glasses.

MassHealth’s Response

  1. MassHealth will outreach to the provider to identify paid claims for improperly billed eyeglass dispensing. MassHealth will determine the overpayment amount and initiate recovery from Dr. Nguyen after the final audit report has been issued.
  2. MassHealth agrees that Dr. Nguyen should only submit a claim for eyeglass dispensing only upon fitting the eyeglasses to the MassHealth member.

Auditor’s Reply

Although Dr. Nguyen asserts that his dispensing procedures were in accordance with MassHealth regulations, 130 CMR 402.416 states that providers should submit claims for dispensing services only after eyeglasses have been ordered from an optical supplier and properly fitted to the member. Since this did not happen in the instances detailed above, Dr. Nguyen was not allowed to bill MassHealth for the services. Although the doctor asserts that he believes it was in the best interest of his patients to ship their glasses rather than have them wait for fitting, he must comply with MasHealth regulations in order to be compensated for his services. Further, we cannot comment on whether the facilities in question requested that Dr. Nguyen ship glasses without fitting, but again, he should have made sure that he performed a fitting and documented this fact before billing MassHealth. It should be noted that Dy. Nguyen did not comment on the fact that we identified 92 claims, totaling $2,562, that he submitted for multiple eyeglasses when only one pair was ordered, and another 34 claims, totaling $950, for dispensing eyeglasses when no eyeglasses were ordered.

Finally, Dr. Nguyen also states that he ordered many pairs of glasses from his own laboratory without using MassHealth’s optical supplier, Massachusetts Correctional Industries. If this is the case, he was not allowed to bill MassHealth for the glasses, because 130 CMR 402.416(D) states that optometrists must order eyeglasses from MassHealth’s optical supplier.

Date published: July 16, 2018
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