MassHealth May Have Paid for Improper Drug Tests Provided to Members Residing in Sober Homes

Audit encourages periodic review of laboratory drug test order forms and laboratory result reports.

Overview

MassHealth may have improperly paid at least $741,621 for drug tests for 1,753 members living in either certified or non-certified privately owned sober homes or recovery homes licensed by the Bureau of Substance Abuse Services (BSAS). Since the members were not in treatment or receiving any medical services at or around the time of the drug tests,⁵ it appears that the tests were performed for residential monitoring purposes. To make this determination, we compared addresses of members whose drug tests appeared not to have been used for diagnosis, treatment, or other medically necessary reasons with addresses of BSAS-licensed recovery homes and other sober homes that we identified by researching DPH’s Massachusetts Alliance for Sober Housing (MASH) website, performing general Internet searches on sober homes in Massachusetts, and searching the business entity database for the Corporations Division of the Office of the Secretary of the Commonwealth. Based on this data analysis, we determined that MassHealth might have paid for drug tests used by BSAS-licensed recovery homes and other sober homes for residential monitoring. Below is a summary of the questioned drug tests for each member who was residing in a BSAS-licensed recovery home or other identified sober home and was drug tested when no other medical services were received that would necessitate the test.

Member Location	Number of Drug Tests When No Other Medical Services Were Received	Amount Paid	Members Identified
Certified or Non-Certified Privately Owned Sober Home	14,824	$294,273	694
BSAS-Licensed Recovery Home	17,672	447,348	1,059
Total	32,496	$741,621	1,753

 Some examples of members who lived in sober homes, were frequently drug tested, and did not receive any other medical services are as follows.

• One member living in a MASH sober home was drug tested on Mondays, Wednesdays, and Fridays, at an average of 9 times per month for 5 months, receiving a total of 46 drug tests costing $2,244. This member did not receive any other medical services during our audit period.
• One member living in a MASH sober home was drug tested an average of 5 times per month for 8 months, receiving a total of 37 drug tests costing $1,805. This member did not receive any other medical services during our audit period.
• One member living in a MASH sober home was drug tested on Tuesdays, Thursdays, and Sundays, at an average of 8 times per month, for 12 months, receiving a total of 92 drug tests costing $10,398. The only medical service this member received during our audit period was one routine medical exam in January 2013.
• One member living in a MASH sober home was drug tested on Mondays, Wednesdays, and Fridays, at an average of 9 times per month, for 72 months, receiving a total of 70 drug tests costing $4,419. The only medical services this member received during our audit period were one routine medical exam and two neurology services.

Another indicator of whether drug tests may have been for residential monitoring is whether they were routinely performed two to three days apart. When drug testing is performed in treatment settings (e.g., for SUD treatment and chronic opioid therapy), it is typically performed on random days instead and is not as frequent. Using data analysis, we found that some members were drug tested every two to three days on set schedules, e.g. every Monday, Wednesday, and Friday or every Tuesday, Thursday, and Saturday. The frequency and routine nature of these drug tests exactly matched drug testing schedules listed on numerous MASH sober homes’ websites. The routine nature of sober-home drug testing, in conjunction with the fact that many members are not receiving any other medical treatment from providers, demonstrates that this type of testing is for residential monitoring only. In fact, one medical provider we contacted stated that she submits 30-day standing orders, because sober-home residents that she treats are required to be drug tested one to three times per week on average. Her signature on drug test order forms provides laboratories with the supporting documentation required to bill MassHealth for drug tests.

The table below shows the drug testing history of MassHealth members living in three sober homes (one of each type of home). This illustrates the routine, scheduled nature of the drug tests paid for by MassHealth (e.g., each Monday, Wednesday, and Friday or Sunday, Tuesday, and Thursday) during the audit period.

	Tests Ordered at Certified Sober Home	Tests Ordered at Non-Certified Privately Owned Sober Home	Tests Ordered at BSAS-Licensed Recovery Home
Sunday	125	337	78
Monday	8	25	259
Tuesday	149	352	24
Wednesday	9	24	307
Thursday	143	301	25
Friday	5	13	264
Saturday	1	24	6

These sober homes may be performing these drug tests to create a safe and sober environment for all residents, many of whom are recovering from SUDs. However, because this type of drug testing is specifically related to residential monitoring, sober homes should ensure that the laboratories they use to perform these tests are aware that they are not allowed to bill MassHealth for these services. Further, there are drug test kits available that cost less than laboratory testing, and sober homes could use these test kits.

Authoritative Guidance

According to 130 CMR 401.411(B)(5), MassHealth does not pay for “tests performed for residential monitoring purposes.”

Reasons for Noncompliance

SUD treatment professionals stated that sober homes ask them to sign drug test order forms as authorized prescribers for members for routine residential monitoring. One professional stated that she and her staff members have experienced situations where their patients were asked by sober homes to change providers when the SUD treatment professionals would not sign the order forms.

In addition, MassHealth does not have controls in place to determine when providers order drug tests for residential monitoring purposes. MassHealth relies on laboratories to ensure that drug test order forms are signed by authorized prescribers. However, the signatures alone do not enable laboratories to determine whether the drug tests will be used for treatment of the patient or for residential monitoring purposes (unless the order form lists the address of the sober home, which indicates that it is for residential monitoring). This is a particular concern when medical professionals sign order forms as a courtesy for their patients whose sober homes require them to have the order forms signed.

Finally, BSAS does not monitor its licensed recovery homes to ensure that they do not perform drug testing for residential monitoring. Likewise, BSAS’s vendor, MASH, does not monitor its certified sober homes to ensure that drug tests performed for residential monitoring are not billed to MassHealth. When we met with BSAS regarding this concern, its officials told us they were not aware of the MassHealth regulation that prohibits payment for drug tests for residential monitoring. Once we notified BSAS of this requirement, it immediately alerted MASH, which modified its website to inform sober-home directors that billing MassHealth for residential monitoring drug tests is not allowed.

Recommendations

1. If MassHealth wants to continue to enforce its current regulations and not allow providers to bill for drug tests for residential monitoring, it should work with BSAS officials to ensure that it does not pay for such tests. Sober homes may want to explore the possibility, if practical, of using low-cost drug test kits that can be used on site to provide immediate results rather than having laboratories perform these tests.
2. MassHealth should perform periodic reviews of laboratory drug test order forms and laboratory result reports to monitor whether laboratories are billing for medically necessary drug tests.

Auditee's Response

MassHealth disagrees with the finding that it may have improperly paid $741,621 for members residing in sober homes. The amount represents payments for drug tests identified as unnecessary in Finding 1 that OSA determined were for MassHealth members residing in sober homes. . . . The issue is compounded by OSA’s flawed method for determining sober home residency (i.e., manual comparison of member addresses with addresses of sober homes OSA was “able to identify”) and its unjustified assumption that drug testing for individuals residing in sober homes is only performed for residential monitoring purposes (which is not payable under MassHealth regulations), and is not medically necessary testing for members receiving SUD treatment, for instance. . . .

MassHealth does not plan to change its policy regarding drug tests for residential monitoring at this time. MassHealth has met with DPH/BSAS to educate staff regarding payment limitations governing residential monitoring. BSAS staff has used the information provided by MassHealth to outreach to sober home providers certified by the Massachusetts Association of Sober Homes regarding MassHealth payment policies. Additionally, BSAS participates in a workgroup MassHealth has established to evaluate drug testing policies. . . .

As described above, MassHealth has been identifying providers with increased billing activity or aberrant billing practices. For certain providers, MassHealth has been suspending these providers’ claims prior to payment and requiring submission of additional documentation, including written requests from authorized prescribers. Further, MassHealth has been reviewing providers who consistently bill high level definitive testing. For these providers, MassHealth plans to suspend the relevant claims and require submission of additional documentation, including written requests from authorized providers, to ensure the claims meet applicable regulations and are medically necessary. The Non-Institutional Provider Review program within the MassHealth Office of Clinical Affairs periodically reviews certain providers to ensure they meet all applicable regulations and requirements. These reviews, which include providers who perform drug testing services, requires providers to submit documentation, including written requests from authorized prescribers, to verify that the provider followed all applicable regulations and requirements for selected claim transactions.

Auditor's Reply

Our audit found that MassHealth may have improperly paid at least $741,621 for drug tests for members living in either certified or non-certified privately owned sober homes or recovery homes. This amount was included in Finding 1, but OSA also determined specifically that these members lived in sober homes and appeared to have received frequent drug testing without any other related medical services for extended periods; therefore, the testing appeared to be for the purpose of residential monitoring.

The process OSA used to determine that these members lived in sober homes was based on sound analysis using publicly available records and information from DPH, the Corporations Division of the Office of the Secretary of the Commonwealth, and the Medicaid Management Information System. OSA developed a credible master list of sober-home addresses from DPH’s MASH website, DPH’s list of BSAS-licensed recovery homes, the Corporations Division’s business entity database, and general Internet searches on sober homes in Massachusetts. OSA recognizes that this list may not include all possible sober homes in Massachusetts, since there is no publicly available official list of privately owned sober homes. However, our list includes all the sober homes we were able to positively identify. Based on our process, we believe we came up with accurate addresses of sober homes to use in our testing.

OSA only questioned drug tests of members living in these sober homes if the members were not receiving any other medical services for which a healthcare professional could have used the tests within a reasonable timeframe. Specifically, using data analytics, OSA identified hundreds of instances where many MassHealth members sharing the same sober-home address received frequent and routine (e.g., Monday, Wednesday, and Friday) drug testing on the same dates, with no other medical service provided within the 7 days before or after the drug test. For example, in one case, five MassHealth members lived in the same sober home and were routinely drug tested every Monday, Wednesday, and Friday. This routine drug testing schedule matched the sober home’s published drug test policy, but none of these five members received any other medical service in the seven days before or after each test. Based on these facts, it appeared to us that these tests were performed for residential monitoring.

MassHealth believes that our recommendation regarding temporarily waiving the coverage limitation on drug testing for residential monitoring is not within the scope of our audit. On the contrary, OSA made this recommendation in consideration of the current opioid crisis; if a doctor believed that it would benefit a member s/he was treating to be allowed to stay in this type of environment, then MassHealth might want to discuss this matter with DPH and consider, if necessary, waiving this regulatory requirement to accommodate the medical professional’s determination. However, if MassHealth does not consider our recommendation feasible, then it should create its own methods to ensure that it does not pay for drug tests for residential monitoring through more effective monitoring activities.  

During our audit, MassHealth did not communicate to OSA the non-institutional provider reviews that its Office of Clinical Affairs performed. Therefore, we cannot comment on whether these reviews occurred for claims we examined for this audit.

5.    To determine whether members who were drug tested had any other medical services provided to them at or around the times of the drug tests, OSA used the same 15- and 30-day periods discussed in Finding 1. 

Date published:	July 27, 2018