Overview
During our audit period, MassHealth paid 148 providers as much as $1.8 million for drug tests that may represent unbundled billing (the practice of billing using multiple procedure codes instead of a single designated comprehensive code). These funds could have been used to pay for other medical services to MassHealth members.
As part of our audit, we performed data analytics on all drug test claims processed by MassHealth during our audit period to obtain an understanding of the payment trends in this area. For the most part, as illustrated below, the amounts paid for testing of more than seven drug classes significantly increased during the years covered by our audit.
|
|
Amount Paid 2013 |
Amount Paid 2014 |
Amount Paid 2015 |
Amount Paid 2016 |
Amount Paid |
|---|---|---|---|---|---|
|
1–7 classes |
$ 8,730,925 |
$ 8,417,783 |
$ 7,354,594 |
$ 1,907,061 |
$ 1,310,623 |
|
8–14 classes |
1,115,328 |
55,013 |
111,749 |
346,148 |
219,724 |
|
15–21 classes |
621 |
0 |
881 |
210,632 |
156,297 |
|
22 or more classes |
0 |
0 |
0 |
255,982 |
75,716 |
|
Total |
$ 9,846,874 |
$ 8,472,796 |
$ 7,467,224 |
$ 2,719,823 |
$ 1,762,360 |
* While performing these audit procedures, we were only able to review claims from January 1, 2017 through June 30, 2017 because they were the only ones available for analysis.
Based on these results and the fact that MassHealth established a requirement that providers bill using comprehensive procedure codes for bundled drug tests rather than billing for individual drug tests, we performed detailed reviews of laboratory billing patterns for evidence of potential unbundling. Our analysis seemed to indicate that in most cases, when we found potential unbundling of drug tests, a provider appeared to have billed for multiple drug tests for a member on the same day rather than using one comprehensive billing procedure code established by MassHealth. We also identified another type of unbundled billing, in which providers billed for drug tests using two different comprehensive procedure codes rather than the appropriate single comprehensive procedure code. For example, as illustrated below, some providers billed for both G0480 (1–7 drug classes) and G0481 (8–14 drug classes) for the same member on the same day, but should have only billed one procedure code, G0482 (15–21 drug classes).
|
Potential Unbundled Billings Scenarios |
Years |
Number of Instances |
Amount Improperly Paid |
|---|---|---|---|
|
Five or more quantitative drug test procedure codes in place of a qualitative drug screen procedure code |
2013–2015 |
121,801 |
$ 1,869,005 |
|
G0480 (1–7 drug classes) and |
2016–2017 |
184 |
9,485 |
|
G0480 (1–7 drug classes) and |
2016–2017 |
129 |
5,000 |
|
G0480 (1–7 drug classes) and |
2016–2017 |
17 |
716 |
|
G0481 (8–14 drug classes) and |
2016–2017 |
5 |
459 |
|
G0481 (8–14 drug classes) and |
2016–2017 |
6 |
513 |
|
G0482 (15–21 drug classes) and |
2016–2017 |
45 |
3,442 |
|
Total |
|
122,187 |
$ 1,888,620 |
Authoritative Guidance
From March 1, 2013 through December 31, 2015, laboratories were required to bill in accordance with 130 CMR 450, which states that unbundled billing is an unacceptable billing practice:
- No provider may claim payment in a way that may result in payment that exceeds the maximum allowable amount payable for such service under the applicable payment method.
- Without limiting the generality of 130 CMR 450.307(A), the following billing practices are forbidden . . .
2. overstating or misrepresenting services, including submitting separate claims [e.g., multiple drug test procedure codes] for services or procedures provided as components of a more-comprehensive service [e.g., the comprehensive drug screen procedure code] for which a single rate of payment is established.
Additionally, in December 2011, MassHealth issued Transmittal Letter PHY-132, which specifically cautions laboratories against using unbundled billing for drug tests:
Providers should not routinely bill for the quantification of drug classes [using multiple drug test procedure codes] . . . being tested as part of the drug screen service [one procedure code].
Retroactively effective for the period January 1, 2016 through December 31, 2016, in Transmittal Letter LAB-45 (issued in April 2017), MassHealth instructed laboratories to bill for drug testing using procedure codes newly approved by CMS (presumptive/qualitative drug screen procedure codes and definitive/quantitative drug test procedure codes):
Effective for dates of service beginning January 1, 2016, providers are instructed to bill drug screening using the following new codes for presumptive [qualitative] drug testing:
- G0477—Drug test(s), presumptive, any number of drug classes; . . . read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) . . .
- G0478—Drug test(s), presumptive, any number of drug classes; . . . read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges) . . .
- G0479—Drug test(s), presumptive, any number of drug classes; . . . procedures by instrumented chemistry analyzers. . . .
In addition, providers are instructed to bill quantitative related drug testing using the following new codes for definitive drug testing:
- G0480—Drug test(s), definitive, . . . 1–7 drug class(es) . . .
- G0481—Drug test(s), definitive, . . . 8–14 drug classes . . .
- G0482—Drug test(s), definitive, . . . 15–21 drug classes . . .
- G0483—Drug test(s), definitive, . . . 22 or more drug classes.
Reasons for Improper Payments
The MMIS and NetReveal system edit established by MassHealth to detect unbundled billing for drug screens and tests was based on a specific set of procedure codes that MassHealth determined were used by certain providers for this purpose. However, since that time, based on our analysis of billing for these tests, it appears that some providers have begun using new combinations of procedure codes to unbundle billings for these services. The system edits MassHealth originally designed to detect this are no longer effective. In addition, MassHealth did not perform any other monitoring of drug screen and drug test claim activity for new combinations of claims billed.
Recommendations
- MassHealth should determine how much it should recover of the $1,888,620 that we identified in potential unbundled drug test payments improperly paid to laboratories and should take the necessary measures to recoup funds as appropriate.
- MassHealth should monitor claim activity to identify unacceptable billing practices related to unbundled drug tests and should program system edits in MMIS and/or NetReveal to deny any unbundled claims billed.
Auditee’s Response
MassHealth reviewed the methodology and data used by OSA, and determined that $1,869,004.83 of the $1,888,620 OSA identified in its finding did not constitute improper payment for unbundled services. However, MassHealth agrees that $19,615.17 of the payments OSA identified potentially constitute payment for duplicate claims. MassHealth will validate the remaining claims comprising this finding and recoup payments as it deems appropriate.
MassHealth has determined that a majority of the claims OSA has characterized as unbundled drug tests are for multiple quantitative (definitive) drug test codes performed on the same date of service and paid collectively at a rate greater than $48.78. . . . MassHealth disagrees with that characterization. It assumes that a provider submitting claims for any combination of quantitative drug tests paid for at a rate greater than the drug screen rate was required to submit a claim for a drug screen instead. To support this assumption, OSA cites Transmittal Letter PHY-132, which instructs: “Providers should not routinely bill for the quantification of drug classes (e.g., chemistry section 82000-84999 or therapeutic drug assay section 80150-80299) being tested as part of the drug screen service.” OSA has ignored a critical limitation on this instruction: It only applies to drug tests being performed as part of the drug screen service. In fact, drug tests serve medical purposes other than the purposes served by drug screens. . . . There are clinical scenarios in which a provider would require a quantitative drug test that was not “part of the drug screen service.” One example is testing patients who have been prescribed controlled substances to assess adherence to a medication regimen. A test to determine the amount of a controlled substance is needed, and a determination that the substance is present is not sufficient. As long as the drug tests being performed were medically necessary, such that a drug screen would not be sufficient, the claims were not “unbundled,” and MassHealth’s payment for the tests is not improper.
MassHealth does agree with OSA’s finding on scenarios in which multiple providers were paid for multiple definitive drug test codes (procedure codes G0480–G0483) performed on the same date of services. Those scenarios involve potentially duplicate services. MassHealth will be establishing edits within the NetReveal system to systematically deny such claims. MassHealth anticipates the edits will be incorporated in March 2018. . . .
The way in which the data is displayed in the table [on p. 17] is . . . potentially misleading because procedure codes corresponding to the drug class divisions in the table above (1–7 classes, 8–14, and so on) only became effective on January 1, 2016, likely explaining the negligible payment amounts in the first three years of the audit period. . . .
MassHealth agrees with the auditor’s recommendation to monitor claim activity to identify unacceptable billing practices. MassHealth has been identifying providers with aberrant billing patterns, providers exhibiting unusual claims activity relative to their peers, and providers who consistently bill high level definitive testing. For certain providers in the first two categories, MassHealth has been suspending claims prior to payment and requiring submission of additional documentation prior to payment to ensure compliance with regulations and medical necessity. MassHealth intends to do the same for certain providers in the third category. MassHealth has also been reviewing utilization to identify those members that receive a high volume of drug testing and discussing strategies to ensure that the members’ claims are medically necessary.
Auditor’s Reply
MassHealth is correct in stating that that our analysis focused on any combinations of drug tests that were paid at a rate greater than $48.78 (generally five or more drug tests). However, as discussed with MassHealth officials, we applied the $48.78 threshold only in instances where providers billed any combination of quantitative drug tests listed in MassHealth’s Independent Clinical Laboratory Bulletin 9, dated February 2013. We used this bulletin, which lists all quantitative drug tests that providers should not unbundle, to design our tests to identify new unbundling scenarios. Also, when determining whether a billing might have involved unbundling, OSA applied the definition of unbundling in Version 12.3 of CMS’s National Correct Coding Initiative Policy Manual for Medicare Services:
Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code.
Two types of practices lead to unbundling. The first is unintentional and results from a misunderstanding of coding. The second is intentional and is used by providers to manipulate coding in order to maximize payment.
Based on this definition and the design of our audit testing, we determined that during our audit period MassHealth paid 148 providers as much as $1.8 million for drug tests that might represent unbundling. For example, one laboratory in our sample routinely billed several combinations of six or more quantitative drug tests that should have been billed under one comprehensive code.
MassHealth states that our use of Transmittal Letter PHY-132 as a criterion to question some of the billings was not entirely accurate. We agree that this criterion may only apply to certain billings. However, in our analysis of the billings for these services, we applied MassHealth Independent Clinical Laboratory Bulletin 9, dated February 2013, which states,
Providers should not bill for quantitative tests in lieu [emphasis added] of drug screen services or as a routine supplement to drug screens.
This criterion warns providers not to routinely bill for multiple quantitative drug tests “in lieu of” a qualitative drug screen. Using this criterion, we tested for scenarios in which drug tests were billed this way and found that 99% of the questioned $1,888,620 related to this type of billing.
In its response, MassHealth states that our analysis of drug tests did not consider clinical scenarios in which a provider would require quantitative drug tests only. However, OSA did consider such scenarios. In fact, when performing our analysis of the billing data, we specifically excluded certain quantitative drug tests that appeared to be related to specific clinical treatments. For example, we filtered out billings for drug tests related to crisis intervention (when providers test for alcohol, salicylate, and acetaminophen).
Further, when a provider requires a quantitative drug test that is not part of the drug screen service, the provider typically orders drug tests to detect different drugs within one drug class. For example, if a provider wanted to test a member for evidence of opioid substances if s/he were undergoing chronic opioid therapy, the drug test would involve testing for substances such as morphine, oxycodone, fentanyl, or hydrocodone. However, the majority of our questioned billings were for laboratories that billed for a wide range of drug classes, not just different types of drugs within one class, as when they billed repeatedly for the following different drug classes:
- amphetamines
- barbiturates
- benzodiazepines
- cocaine
- creatinine
- opiates
- methadone
Finally, we do not agree with MassHealth that the information in the table on p. 17 of our report is misleading because there were no drug test procedure codes that covered some drug classes between 2013 and 2016. Although we acknowledge that there were no procedure codes for some drug classes during the period in question, OSA used the “number of units” data field in MassHealth’s claim-processing system when creating this table. The “number of units” data field was widely used by laboratories before 2016 to identify how many drug classes were tested; it was similar to the newly activated procedure codes that have been available since 2016. Therefore, we believe the table in question presents an accurate depiction of drug testing during this period.
Based on its response, MassHealth is taking measures to address some of our concerns in this area.
| Date published: | April 19, 2018 |
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