Overview
Of the 20 sampled MassHealth members to whom Liberty Adult Day Health provided adult day health (ADH) services during our audit period, records for 1 member (with claims totaling $32,407) lacked the properly authorized physician order necessary to substantiate the types and levels of service the member was authorized to receive. Without a physician order signed by a physician, there is a higher-than-acceptable risk that Liberty may not have provided the appropriate types and levels of service.
Authoritative Guidance
According to Section 404.406 of Title 130 of the Code of Massachusetts Regulations (CMR) as of March 2010, to initiate ADH services, providers must maintain physician documentation, including physician orders, for the services:
(D) Scope of Services. All adult day health programs participating in MassHealth must provide the following services as part of their adult day health services.
(1) Nursing Services and Health Oversight. . . .
(a)administration of medications and treatments prescribed by the member’s
physician. . . .(F) Documentation Requirements.
(2) Physician’s Documentation. . . .
(a) Before the member’s first attendance day, the ADH provider must obtain the necessary documentation from the member’s physician.
(b) The physician’s documentation must include(i) physician orders for adult day health services.
Reasons for Noncompliance
Liberty does not have any internal controls (e.g., policies or procedures) in place to ensure that it obtains properly signed physician orders. Additionally, during our discussions with the current program director, she stated that she was hired in 2018, after the audit period, and could not speak to what occurred before she arrived.
Recommendations
- Liberty should collaborate with MassHealth to repay the $32,407 discussed in this finding.
- Liberty should develop internal control policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.
MassHealth’s Response
OSA’s audit findings have triggered a need for MassHealth to conduct its own audit of Liberty ADH.
MassHealth agrees with [recommendation 2].
Auditee’s Response
It is a fact that the physician’s documentation form for [one member] was not found in her chart. I have been in contact with [the doctor’s] office and they checked [the member’s] chart and they did not have a copy of it either. I had hoped they did and we had just misplaced it. I was able to find preauthorization decisions from Fallon Navicare [a health organization sponsored by Fallon Community Health Plan]—stating she was approved for Day Care Services and Transportation to and from Liberty. . . . I feel Liberty provided services to this client and deserves to be paid for these services. I will ensure all Physicians Documentation forms are in ALL client charts moving forward.
Auditor’s Reply
In its response, Liberty states that although it did not have the physician order in the member’s records, it did have records of preauthorization decisions from Fallon Navicare, semiannual reports, and care plans with the member’s physician’s signature. Liberty also stated that its nursing staff members held several discussions with the member’s physician, who indicated that they approved of this healthcare. The Office of the State Auditor (OSA) did review the records of the preauthorization decisions from Fallon Navicare as well as the care plans Liberty mentions in its response; however, these records do not constitute a proper physician order, which, according to MassHealth regulations, is required before a member’s first attendance day.
Based on its response, Liberty is taking measures to address this problem.
| Date published: | March 15, 2019 |
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