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  • Office of the State Auditor

MassHealth Paid $21,073 for Drug Tests That Were Not Supported by Proper Documentation

Audit encourages MassHealth to work with laboratories to ensure tests have proper documentation.

Table of Contents

Overview

MassHealth paid $21,073 for 2,722 drug tests that were not supported by proper documentation. Specifically, none of the drug test order forms for the 15 sampled members tested at one laboratory were prepared by an authorized prescriber; rather, the forms were prepared by the independent clinical laboratory. Additionally, some of the drug test results for these 15 sampled members were missing. Without this information, MassHealth cannot ensure that these tests are medically necessary and meet its requirements for covered services.

Authoritative Guidance

According to 130 CMR 401.416(A),

The independent clinical laboratory may not bill for a service unless it has received a written request to perform that specific service from an authorized prescriber who is treating the member and will use the test for the purpose of diagnosis, treatment, or an otherwise medically necessary reason. . . . Any independent clinical laboratory billing for a service must maintain such request in its records. . . . If the laboratory that billed for the service cannot produce the original request, the MassHealth agency may deny or recover payment for all services the laboratory provided based on that request.

Additionally, 130 CMR 401.416(C) states,

Requests for laboratory services must be written and include the following information . . .

(3)  the name and address of the authorized prescriber (if the authorized prescriber is a Massachusetts Department of Public Health licensed substance abuse treatment program for the sole purpose allowed pursuant to 130 CMR 401.402, the request must include the names and addresses of both the substance abuse treatment program and the physician initiating the request).

Finally, 130 CMR 401.417 states that MassHealth does not pay for drug tests for laboratories that do not maintain required documents to support these claims:

The laboratory record must contain the following information . . .

(J)  the results of each test, the name and address of all persons to whom each test result is reported, and the date of reporting.

Reasons for Noncompliance

Despite repeated requests, officials at the laboratory in question did not explain the lack of required documentation.

Recommendations

  1. MassHealth should work with drug test laboratories to ensure that they obtain and retain proper documentation of drug test orders and results for each drug test provided to a MassHealth member.
  2. MassHealth should collaborate with the laboratory in question to establish a plan for repayment of the $21,073 in overpayments for improper laboratory drug test billings.

Auditee's Response

MassHealth has been identifying providers with aberrant billing patterns and has been suspending relevant claims. MassHealth requires identified providers to submit additional documentation, including copies of written requests from authorized prescribers and supporting medical documentation, prior to payment. 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. . . .

MassHealth requested and received the claim examples identified by OSA as not having required documentation and will recover any payments for claims lacking the necessary documentation. 

Date published: July 27, 2018

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