Medicaid Audit Unit Impact and Post-Audit Efforts, March 15, 2018-March 15, 2019

During this time period, auditees implemented recommendations from the Office of State Auditor Suzanne M. Bump that will save taxpayer dollars and make the MassHealth program work better.

Overview

The objectives of the performance audits conducted by the Office of the State Auditor (OSA) at MassHealth and its providers are not only to identify improper payments for Medicaid services, but also to identify and resolve any systemic problems such as deficiencies in internal controls that may exist within the MassHealth system. Consequently, while measures such as referring cases to law enforcement for prosecution, recommending restitution, and taking other remedial actions against individual Medicaid vendors are typical results of OSA audits and serve as a deterrent, the systemic changes made by MassHealth as a result of OSA audits, in many instances, have a more significant effect on the overall efficiency of the operation of Medicaid-funded programs.

To assess the impact of our audits and the post-audit efforts made by auditees to address issues raised in our reports, OSA has implemented a post-audit review survey process that is conducted six months after the release of an audit. This process documents the status of the recommendations made by OSA, including any corrective measures taken by the auditee, as well as any estimates of future cost savings resulting from changes made based on our recommendations.

During the report period, OSA issued, and agencies completed, six post-audit surveys regarding Medicaid audits. This number reflects audits with findings issued at least six months ago for which a follow-up survey has been completed. The self-reported surveys are issued six months after an audit is issued to allow management time to plan and implement its corrective action. Because the voluntary surveys are sent to MassHealth or the audited provider six months after an audit ends, not all of the audits conducted during the period covered by this report are included in this section of the report, as those surveys have not yet been completed.

MassHealth or the audited providers have acted, or will act, on 25 of 27 recommendations according to the survey results. Of the 25, 21 are fully implemented, 3 are in progress, and 1 is planned. Two findings and recommendations were in dispute. These were related to the $396,962 in improper billings for vision care and $218,784 in questionable charges for dispensing eyeglasses by MassHealth vision-care provider Dr. Wensheng Yao.

According to all survey results, MassHealth will realize a fiscal benefit of up to $77,326,909.

MassHealth service provider Dr. Hooshang D. Poor did not submit a completed post-audit review survey, despite multiple attempts by OSA to obtain the survey. However, on February 21, 2019, Dr. Poor agreed to pay $265,896 to the Medicare program and $414,103 to MassHealth to resolve issues found in an audit released August 21, 2017: specifically, that his office routinely overbilled MassHealth for services at nursing homes.

Dr. Poor also agreed to be subject to a comprehensive compliance program implemented and overseen by an independent compliance monitor. This program will require Dr. Poor to update policies, procedures, and employee training to address his coding and billing practices and will further require annual onsite audits of Dr. Poor’s compliance with state and federal laws for the next three years

1. Office of Medicaid —Review of Evaluation & Management Claims Paid to Lawrence Family Doctors

Audit No. 2017-1374-3M6        Issued August 16, 2017
Survey Response Received March 1, 2018

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit	Selected Actions and Results
5*	4	0	N/A	Lawrence Family Doctors plans to work with MassHealth to repay $108,232 in overbilled evaluation and management (E/M) services.

*    Lawrence Family Doctors stated that it plans to implement the final recommendation.

 

In its survey response, Lawrence Family Doctors (LFD) stated that it had fully implemented four recommendations. LFD now bills nurse practitioner visits with a modifier that will trigger a lower rate than physician services, and it is reviewing MassHealth bulletins and billing regulations as required. It has also converted to Web-based electronic medical records, ensuring proper documentation of records and appropriate billing practices.

One recommendation was listed as “planned.” LFD noted that it planned to work with MassHealth to repay the $108,232 that it overbilled for E/M services.

Additional Resources

Audit of Office of Medicaid (MassHealth) - Review of Evaluation and Management Claims Paid to Lawrence Family Doctors

2. Office of Medicaid (MassHealth)—Review of Hospice Care Billing: HopeHealth Massachusetts, Inc.

Audit No. 2017-1374-3M1C      Issued September 21, 2017
Survey Response Received April 5, 2018

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit	Selected Actions and Results
2	2	0	N/A	HopeHealth Massachusetts, Inc. has implemented an electronic medical record system. HopeHealth Massachusetts now audits medical records for proper hospice documentation before their release.

Responding to the survey, HopeHealth Massachusetts, a certified MassHealth hospice provider in Brockton, stated that it had fully implemented both recommendations. HopeHealth Massachusetts has implemented an electronic medical record system, along with reviewing and updating all standing operational procedures regarding forms for hospice services. Its Medical Records Department also audits its medical records for proper hospice documentation before releasing the documentation.

Additional Resources

Audit of Office of Medicaid (MassHealth)—Review of Hospice Care Billing: HopeHealth Massachusetts, Inc.

3. Office of Medicaid (MassHealth)—Review of Hospice Care Billing: Good Shepherd Community Care

Audit No. 2017-1374-3M1D      Issued October 25, 2017
Survey Response Received May 4, 2018

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit	Selected Actions and Results
1	1	0	N/A	Required forms are now completed in compliance with laws and regulations.

Good Shepherd Community Care, a Newton-based MassHealth hospice provider, responded that it had fully implemented the single recommendation made in the audit. Certification of Terminal Illness Forms are now completed electronically by physicians and are checked for compliance upon completion. Staff members have also been educated on the need for accuracy on Hospice Election Forms.

Additional Resources

Audit of Office of Medicaid (MassHealth)—Review of Hospice Care Billing: Good Shepherd Community Care

4. Office of Medicaid (MassHealth)—Review of Vision Care Claims Paid to Dr. Wensheng Yao

Audit No. 2017-1374-3M4        Issued December 22, 2017
Survey Response Received July 12, 2018

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit	Selected Actions and Results
6*	4	0	N/A	Dr. Yao and Community Optics dispute the $396,962 we identified as improper billings for vision care and the $218,784 we identified as questionable charges for dispensing eyeglasses. Dr. Yao implemented changes to accurately reflect the service provider and submit claims that are consistent with MassHealth requirements.

*    Dr. Yao disputes two findings.

Audit findings from the review of Lawrence-based MassHealth vision-care service provider Dr. Wensheng Yao (at Community Optics) stated that Dr. Yao improperly billed MassHealth for $396,962 in vision care provided by other optometrists. Dr. Yao also submitted $218,784 in questionable charges for dispensing eyeglasses and did not always use the correct date of service when billing MassHealth for vision care. In the survey response, Dr. Yao disputed these findings.

Dr. Yao stated that his practice had fully implemented four recommendations. Dr. Yao and Community Optics have implemented changes to accurately reflect the service provider and submit claims that are consistent with MassHealth requirements. Community Optics is in the process of being credentialed as a single group provider. Dr. Yao and Community Optics also now regularly check MassHealth regulations, transmittal letters, provider bulletins, and other sources for changes or updates. Further, Dr. Yao and Community Optics now use the correct date of service on each type of claim submitted to MassHealth.

Additional Resources

Audit of Office of Medicaid (MassHealth)—Review of Vision Care Claims Paid to Dr. Wensheng Yao

5. Office of Medicaid (MassHealth)—Review of Claims for Drug Testing and Screening Services

Audit No. 2017-1374-3M2A      Issued April 19, 2018
Survey Response Received November 19, 2018

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit	Selected Actions and Results
9	6	3	$77,218,677	MassHealth has saved $72,360,658 ($70,084,343 one-time savings, and $2,276,315 year-over-year) because of system edits. MassHealth could recover $4,381,089 in overpayments for improperly billed claims. MassHealth has realized savings of $476,930 because of enhanced analysis of claim trends and activity. MassHealth has implemented internal work plans and regular meetings that have improved the timeliness of procedure code updates and has taken steps to minimize the number of missed NetReveal claims.

Responding to the post-audit review survey, MassHealth stated that it had fully implemented six recommendations. MassHealth continues to monitor, and enhance when appropriate, system edits in the Medicaid Management Information System (MMIS) and its NetReveal system to ensure proper identification and payment denial for quantitative drug testing when qualitative drug testing is performed on the same day.

As a result of these edits, MassHealth has seen and will continue to see cost savings. MMIS has denied $65,827,000 of claims with dates of service on or after January 1, 2013 for quantitative drug testing or drug screening billed on the same date of service by the same provider. Additionally, between August 1, 2015 and June 30, 2018, NetReveal denied $4,257,343 of claims for the same tests, by different providers. For fiscal year 2019, projected savings from the NetReveal edit total $2,276,315. From these edits, MassHealth will see a cost savings of $72,360,658; $70,084,343 is from one-time savings and the remaining $2,276,315 is year-over-year savings.

Additionally, MassHealth has implemented internal work plans and regular meetings that have improved the timeliness of procedure code updates and has taken steps to minimize the number of missed NetReveal claims. Further, the agency has enhanced efforts to identify providers with aberrant billing patterns, providers that exhibit unusual claim activity compared to their peers, and providers that consistently bill definitive³ drug testing rather than the less expensive presumptive⁴ drug testing. As a result, between fiscal years 2017 and 2019, MassHealth will see a cost savings of $476,930. MassHealth also continues to monitor its suspect-duplicate reports.

MassHealth is in the process of recovering overpayments for the improperly billed claims. Specifically, MassHealth could recover $2,294,369 in unallowable, unbundled drug tests and screens performed on the same day; $1,888,620 for drug tests that may also represent unbundled billing; and $198,100 for duplicate drug tests provided to members on a single date of service.

Additional Resources

Audit of the Office of Medicaid (MassHealth)—Review of Claims for Drug Test and Screen Services

Audit Shows MassHealth Still Overpaying for Drug Tests and Drug Screens

6. Office of Medicaid (MassHealth)—Review of Claims by Reen & Reen, DMD, P.C.

Audit No. 2018-1374-3M2        Issued June 8, 2018
Survey Response Received January 15, 2019

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit	Selected Actions and Results
4	4	0	N/A	Reen & Reen is now ensuring that it bills using the provider identification number of the actual servicing provider, including when more than one person provides orthodontic treatment.

Responding to the post-audit survey, Reen & Reen, DMD, P.C., a West Springfield-based MassHealth orthodontic service provider, stated that it had fully implemented all four recommendations. Reen & Reen now ensures that it bills using the provider identification number of the actual servicing provider in all cases, including when more than one person provides orthodontic treatment. In addition, it now only bills MassHealth after sending claims to, and receiving explanations of benefits from, the private insurance carriers of MassHealth members. Further, Reen & Reen fully understands the MassHealth billing requirements.

Additional Resources

Audit of the Office of Medicaid (MassHealth)—Review of Claims by Reen & Reen, DMD, P.C.

3.  A definitive drug test, also known as a quantitative drug test, is a test that determines how much of a specific substance, or drug class, is in the person’s system.

4.  A presumptive drug test, also known as a qualitative drug test, is a test that produces a positive or negative result for each substance, or drug class, tested. Providers typically use this type of test when treating members for substance use disorders, since they only need to determine whether any illicit substance is present in a member’s sample.

Date published:	March 15, 2019