MassHealth paid $198,100 for duplicate drug tests.

Audit encourages MassHealth to improve its claims processing system to ensure it does not pay for duplicate tests.

Table of Contents

Overview

During our audit period, MassHealth paid $198,100 for duplicate drug tests provided to members on a single date of service. Our audit found instances in which MassHealth paid a single laboratory for duplicate drug tests, in addition to instances in which two different laboratories were paid for the same tests for the same member on the same day. In both types of case, MassHealth paid for more than one drug test per member per day of service.

The results of our analysis are outlined below.

Duplicate Payment Problem

Total Amount Paid

Amount of Overpayment

Same drug tests paid to the same laboratory

$   46,421

$   25,282

Same drug tests paid to two different laboratories

   385,432

   172,818

Total

$ 431,853

$ 198,100

Authoritative Guidance

According to 130 CMR 450.307(B)(1), MassHealth does not allow duplicate billing, which it defines as follows:

[Duplicate billing] includes the submission of multiple claims for the same service, for the same member, by the same provider or multiple providers.

Reasons for Overpayments

MassHealth officials told us that MMIS has a system edit function that identifies and flags potential duplicate billings as “suspect duplicates” and that this function does not deny or delay the payment of the identified potential duplicate services. The officials told us that this edit was programmed to allow MassHealth’s Claims Operations staff to research the reported suspected duplicates later, but that this is not done because of resource constraints.

As discussed in the Post-Audit Action section of this report, MassHealth is using NetReveal to detect and deny duplicate drug tests. However, MassHealth officials told us that in certain situations, such as when drug tests are performed by hospital emergency departments, it does not want to deny payments for drug tests that may appear to be duplicate but are medically necessary. Therefore, they explained, NetReveal is not programmed to deny duplicate drug tests and screens billed by two different laboratories for the same member on the same day.

Recommendations

  1. MassHealth should determine how much it can recover of the $198,100 that we identified in duplicate drug test and screen payments and should take the necessary measures to recoup these funds.
  2. MassHealth should ensure that its Claims Operations staff members research its suspect-duplicates report for duplicate drug tests paid for and make recoupments for such tests.
  3. MassHealth should update its NetReveal system edit to deny payment for duplicate drug tests and screens, including those that are billed by two different laboratories that are not for emergency hospital drug tests.

Auditee’s Response

MassHealth is investigating the potential duplicate claim scenarios provided by OSA. For instances in which a provider was paid for the same service code on the same date of service, MassHealth will recoup any payments determined to be duplicate payments. For other suspected duplicate claim scenarios, MassHealth will review and take further action if necessary. . . .

Claims Operations continues to review lab codes on a post payment basis in order to identify possible duplicate claims. MassHealth is in the process of cross training additional staff members in order to improve the review time to better align with the 90 day claim submission deadline. . . .

MassHealth will review its duplicate claim logic concerning drug tests and make any appropriate updates.

Date published: April 19, 2018

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