Overview
In the records of 9 out of 20 sampled members from our population of 72, the physician orders did not detail the assistance with activities of daily living (ADLs) and/or skilled nursing services that the members required. For these 9 members, Liberty billed MassHealth for, and was paid, a total of $380,257. Because the physician orders did not include lists of services the members required, the individual care plans that Liberty developed for these members may be inadequate.
Authoritative Guidance
According to 130 CMR 404.406(F)(3) as of March 2010,
(a) Care Plan Development. Within six business days after a member’s date of service commencement, the ADH provider’s staff must complete an adult day health care plan for the member. The ADH provider’s registered nurse must coordinate the development of the member care plan. The plan must include
(i) a treatment plan based on the member’s physician’s orders
Reasons for Noncompliance
Liberty’s program director stated that she was hired in 2018, after the audit period, and could not speak to what occurred before she arrived. She stated that she was ensuring that physician orders for newly enrolled MassHealth members complied with MassHealth regulations. However, OSA found that Liberty does not have any internal controls (e.g., policies or procedures) in place to ensure that physician orders contain the necessary information to develop adequate care plans for MassHealth members.
Recommendation
Liberty should develop policies and procedures for the review of physician orders to ensure that these orders contain the necessary information to develop adequate care plans for MassHealth members.
MassHealth’s Response
MassHealth does not agree with the findings or the recommendation. The OSA reads MassHealth’s transmittal letter ADH-25, together with 130 CMR 404.406(F)(2)(a)–(c) to establish the requirement that a physician order must list the member’s ADL impairment(s) in order to demonstrate medical necessity for ADH services. This is not an accurate interpretation of the regulation. The physician order is not required to list a member’s ADL impairment(s) to demonstrate medical necessity for ADH services. The ADH program conducts a clinical assessment that establishes the member’s specific care plan, including skilled services and assistance with ADLs, as necessary. The physician order should confirm a member’s mental status and continence status but does not need to include a list of a member’s specific ADL impairment(s).
Auditee’s Response
I absolutely agree with the recommendation of developing policy and procedure [to ensure] the physician’s documentation contains the necessary information. Liberty has an admission checklist in which the documentation required before admission is listed and initialed by the Nursing Department. Not only is Physicians Documentation Form Signed but also we have added Physicians details necessary for developing [a] care plan and directing staff on what the client’s needs are. The documentation will also be reviewed by The Program Director prior to admission.
We have implemented this and unfortunately there is a much longer delay in the time it takes before someone is admitted to Liberty. For example: we have held up the admission of a client because her Primary Care Physician has not completed the documentation in detail.
Auditor’s Reply
OSA is not asserting that that a physician order must list the member’s ADL impairment/s to demonstrate medical necessity for ADH services. If this were the case, OSA would have recommended that MassHealth seek reimbursement of some, if not all, of the $380,257 Liberty received from MassHealth for treating the nine sampled members whose physician orders did not contain this information. Rather, OSA believes that because MassHealth regulations specifically require that “a treatment plan based on the member’s physician’s orders” be developed, physician orders should document sufficient detail about what services the physician believes are medically necessary, which will supplement the information in the clinical assessment and facilitate the development of a comprehensive treatment plan for the member. This is apparently a best practice, as the majority of the physician orders that OSA reviewed did contain this level of information. In further support of this, Liberty states in its response that it agrees with our finding and has implemented new forms to gather this information.
OSA acknowledges that ADH providers are responsible for conducting clinical assessments to establish members’ specific care plans. However, OSA believes that physician orders should provide sufficient detail to document members’ service needs. Because ADH providers are in a position both to assess a member’s needs and to provide the specified services, a detailed physician order could prevent ADH providers from prescribing excessive and/or unnecessary services.
| Date published: | March 15, 2019 |
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