Overview
Dr. Wagner submitted improper claims for $8,176 of eyeglass dispensing and fitting services. Incomplete patient medical records not only raise concerns about the propriety of the related billings, but also can negatively affect continuity of care for the patient.
We found problems with 226 claims, totaling $5,847, that Dr. Wagner submitted to MassHealth for dispensing eyeglasses to members during our audit period. Specifically, we reviewed 1,987 claims, totaling $81,114, and found that for 226 claims, Dr. Wagner received payments from MassHealth for dispensing services and associated transportation that could not have occurred because the eyeglasses were never ordered from the optical supplier.
In addition, for 19 of the 180 claims sampled (10.6%), Dr. Wagner did not maintain documentation indicating that he took measurements for eyeglasses, verified the lens characteristics, described the materials ordered and dispensed, fitted the eyeglasses to the members, and conducted the required consultations with nursing facility staff members. We extrapolated the test results related to improperly documented dispensing services to the entire population of paid vision care claims. Based on this testing, the actual error rate in our sample was 10%, and when projecting this to the total population of paid vision care claims, we are 95% confident that at least 7%, or $2,329, of these 180 claims were overpaid.
Authoritative Guidance
According to 130 CMR 402.416, providers should submit claims for dispensing services only after the eyeglasses have been ordered from the optical supplier and properly fitted to the member (i.e., the doctor has ensured that the member can clearly see with the new glasses):
- In order for a dispensing practitioner to be paid for dispensing a prescription involving ophthalmic materials [including eyeglasses] and services available through the optical supplier, all such materials and services must be ordered from the optical supplier. . . .
- 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.
Regarding the recordkeeping requirements for member vision care medical records, including dispensing services, 130 CMR 402.417(A) states,
The record must fully disclose all pertinent information about the services furnished, including the date of service, the dates on which materials were ordered and dispensed, and a description of materials ordered and dispensed (including the frame style and the manufacturer’s name).
In addition, according to 130 CMR 402.418(B), a consultation is required and must be documented in MassHealth members’ records if eyeglasses are dispensed to them in nursing facilities:
If eyeglasses are to be dispensed to a member in the facility, the facility must document in the member’s record that a consultation has occurred between the facility’s staff member and the optometrist or ophthalmologist, and that they have determined that the member is able to benefit from eyeglasses.
Reasons for Improper Billing
Dr. Wagner stated that he must have mistakenly billed for dispensing services in the instances where no glasses were ordered. He said that he did have additional documentation regarding the questioned claims, but he did not provide us with that documentation.
Recommendations
- Dr. Wagner should collaborate with MassHealth to repay the $8,176 discussed in this finding.
- Dr. Wagner should only submit claims for dispensing services after he fits the new eyeglasses to a MassHealth member.
- Dr. Wagner should maintain proper documentation for dispensing services, including documenting a consultation with the nursing facility, measurements, and evidence that he fitted the eyeglasses to the individual.
Auditee’s Response
Dr. Wagner did not provide a response to this finding.
MassHealth’s Response
- . . . Consistent with MassHealth’s identification of similar issues with Dr. Wagner and referral of this matter to the OSA, MassHealth agrees with the OSA’s finding that Dr. Wagner should repay MassHealth the $8,176 in identified overpayments.
- MassHealth agrees with the OSA’s finding that Dr. Wagner may only submit claims for dispensing services for eyeglasses actually ordered from the optical supplier and in accordance with other applicable requirements of 130 CMR 402.416.
- MassHealth agrees with the OSA’s finding that Dr. Wagner should maintain proper documentation for dispensing services, including the documentation required in 130 CMR 402.417 and 418.
| Date published: | September 24, 2019 |
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