Medicaid Audit Unit Impact and Post-Audit Efforts, March 15, 2019 - March 14, 2020

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 follow-up surveys have 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 six months after the audit ends, some surveys have not yet been completed; therefore, not all of the audits conducted during the period covered by this report are included in this section.

According to the survey results, MassHealth reported that it has acted, or will act, on implementing 15 of 29 recommendations. Summaries of the audit surveys follow.

1. Office of Medicaid (MassHealth)—Review of Drug Testing Frequency

Audit No. 2017-1374-3M2    Issued July 27, 2018
Survey Response Received March 8, 2019

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit
7*	2	4	$408,073

*     No action was taken on one recommendation.

 

Findings from this audit include that MassHealth may have paid as much as $6.2 million for drug tests of its members that were not ordered for diagnosis, treatment, or other medically necessary purposes. In many instances, the agency paid for drug tests for members who were tested very frequently but did not receive medical treatment in a reasonable timeframe according to professional guidelines. Additionally, MassHealth may have improperly paid at least $741,621 for drug tests for 1,753 members living in either certified or noncertified privately owned sober or recovery homes licensed by the Bureau of Substance Abuse Services (BSAS) within the Department of Public Health (DPH). Further, MassHealth paid for $21,073 for 2,722 drug tests that were not supported by proper documentation.

In OSA’s six-month survey, MassHealth indicated that it had fully implemented the following two recommendations from this report:

1. MassHealth should perform periodic reviews of laboratory drug test order forms and laboratory result reports to monitor whether laboratories bill for medically necessary drug tests.
2. 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.

Further, MassHealth indicated that four recommendations were in the process of being implemented:

1. MassHealth should establish controls to ensure that it only pays for drug tests that are used for diagnosis, treatment, and otherwise medically necessary purposes.
   
   MassHealth stated, 
   
   MassHealth started reviewing providers in January, 2018 who consistently bill the two high level definitive testing codes (G0482 and G0483). For these providers, MassHealth has been suspending the relevant claims and requiring submission of additional documentation to ensure the claims meet applicable regulations and are medically necessary. MassHealth also has been reviewing utilization to identify those members that receive a high volume of drug testing, and has been developing strategies to ensure that those members’ claims are medically necessary by coordinating a workgroup to educate providers.
    
2. MassHealth should ensure that all claim submissions include the referring provider’s identification number. MassHealth should use this information to create a system edit and/or monitor claims to limit payments for drug tests to those ordered by authorized prescribers who are currently treating the members.
   
   MassHealth stated,
   
   MassHealth published All Provider Transmittal Letter 229 in October 2017 establishing a new enrollment process for ordering and referring providers. This process requires the national provider identification (NPI) number to be entered on claims establishing the provider’s eligibility to an order or referral. The change applies to services provided by independent clinical laboratory providers. At this time, MassHealth is editing claims against this requirement, though claims are not yet being denied. MassHealth is identifying and outreaching to providers who omit the ordering NPI on claim transactions before denials are fully implemented.

3. 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 officials at BSAS 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.
   
   MassHealth stated,
   
   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. Additionally in 2017 BSAS started participated in an ongoing workgroup to educate providers on MassHealth policies.

4. MassHealth should collaborate with the laboratory discussed in Finding 2 of the audit report to establish a plan for repayment of the $21,073 in overpayments for improper laboratory drug test billings.
   
   MassHealth stated,
   
   MassHealth requested and received the claim examples and supporting documentation identified by OSA as not having required documentation. MassHealth has reviewed the claims in question and if appropriate, MassHealth will proceed with recovery of any payments for claims lacking the necessary documentation.

MassHealth indicated that it had not taken any action on our recommendation to require laboratories to send all drug test results directly to the prescribing providers. MassHealth noted that DPH’s clinical laboratory regulations established reporting and recordkeeping standards for all licensed Massachusetts clinical laboratory providers and that Section 180.290 of Title 105 of the Code of Massachusetts Regulations stated that the laboratory report “shall be sent promptly to the licensed physician or other authorized person who requested the test.”

2. Office of Medicaid (MassHealth)—Review of Claims by Dr. Ileana Berman

Audit No. 2017-1374-3M7      Issued November 14, 2018
Survey Response Received June 17, 2019

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit
10*	0	1	N/A

*     Dr. Berman’s office disputes nine recommendations.

 

In our audit of claims submitted by Dr. Ileana Berman, an Attleboro-based MassHealth mental health and substance use disorder treatment provider, we found that Dr. Berman did not notify MassHealth of significant changes to her business operations. Specifically, Dr. Berman did not transmit information to the agency regarding changes to the types of substance use disorder treatment she offered to MassHealth members. Dr. Berman also billed MassHealth for $76,641 in drug tests that were not used to diagnose and treat patients, and she did not have adequate documentation to support $176,737 of billings for evaluation and management (E/M) services. Further, she did not maintain documentation for $31,287 in E/M and drug test services billed to MassHealth, and she billed 7,129 unbundled drug tests, totaling $75,261. Unbundled drug test billing has been prohibited by MassHealth since 2013. In total, Dr. Berman billed approximately $359,926 for questionable or unallowable claims.

In our six-month survey, Dr. Berman indicated that she disputed our findings and was in the process of implementing one of them:

1. Dr. Berman should cease ordering quantitative drug tests and qualitative drug screens for the same MassHealth member on the same day.
   
   Dr. Berman’s legal counsel stated, 
   
   Dr. Berman was previously billing in accordance with the policies as required by Medicare and one of the MassHealth Vendors, BMC HealthNet. . . . Dr. Berman orders these tests as are clinically necessary and records them both on the claim form. Dr. Berman has now taken measures to ensure that no presumptive tests are billed to MassHealth on dates when definitive tests are also ordered and billed.

3. Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Liberty Adult Day

Audit No. 2018-1374-3M10D      Issued March 15, 2019
Survey Response Received October 7, 2019

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit
3*	2	1	N/A

*     One recommendation is listed as “planned.”

 

In our audit of Liberty Adult Day Health, a Hopkinton-based MassHealth adult day health (ADH) service provider, we found that Liberty did not properly document physician orders in members’ files and did not always obtain physician orders detailing the assistance with activities of daily living that members required. In our six-month survey, Liberty indicated that it had fully implemented two of our recommendations:

1. Liberty should develop internal control policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.
2. Liberty should develop policies and procedures for the review of physician orders to ensure that they contain the necessary information to develop adequate care plans for MassHealth members.

Liberty indicated that it was working with MassHealth on the following recommendation:

1. Liberty should collaborate with MassHealth to repay the $32,407 discussed in Finding 1.

4. Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Cozy Corner Adult

Audit No. 2018-1374-3M10B       Issued March 15, 2019
Survey Response Received October 11, 2019

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit
2*	0	1	N/A

*     No action was taken on one recommendation.

 

Plymouth-based Cozy Corner Adult Day Health, a MassHealth ADH service provider, stated in its survey response that one recommendation was in progress. Although the provider disagreed with the determination that it provided ADH services for MassHealth members before physician orders and clinical authorizations were in place, Cozy Corner did state that it constantly reviewed its practices and updated them when necessary to ensure accuracy in its practices.

In response to our six-month survey, Cozy Corner indicated that for two of our three recommendations, it was not providing an update. In one case, this was because the recommendation was directed at MassHealth:

1. MassHealth should determine how much of the $955,587 discussed in this finding should be repaid and seek reimbursement.

In another case, Cozy Corner did not agree with the recommendation:

1. If Cozy Corner believes that any of the requirements established by MassHealth regulations are unclear, it should contact MassHealth for guidance and clarification.

However, Cozy Corner indicated that it was in the process of implementing the following recommendation:

1. Cozy Corner should ensure that completed and authorized physician orders and clinical authorizations are in place before it provides ADH services to MassHealth members. The orders should indicate which activities of daily living, and/or skilled nursing services, members require and be used to develop members’ individual care plans.
   
   Cozy Corner stated,
   
   Cozy Corner denies that it ever provided ADH services to MassHealth members before completed and authorized [physician orders] and clinical authorizations were in place for such members. Cozy Corner has always aimed to ensure that its patient intake, record-keeping, and billing practices comply with MassHealth regulations for ADH services. Cozy Corner views this action as “In Progress” because, while it denies that it ever failed to comply with MassHealth regulations, it constantly reviews its practices and updates them when necessary to remain as thorough and accurate as possible.

5. Review of Counseling Provided to MassHealth Members Receiving Receiving Treatment for Opioid Use

Audit No. 2016-1374-3M13     Issued March 21, 2019
Survey Response Received October 22, 2019

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit
4*	0	2	N/A

*     One recommendation was listed as “planned” and one is being disputed.

 

In this audit, we found that MassHealth and its prescribers did not effectively facilitate participation in, and access to, necessary counseling for MassHealth members receiving medication-assisted treatment (MAT) for opioid use disorders (OUDs). In addition, some MassHealth members did not receive OUD counseling from healthcare professionals who either were certified or specialized in addiction treatment. Further, prescribers did not always maintain documentation for medical visits in which they gave buprenorphine prescriptions to MassHealth members.

In response to our six-month survey, MassHealth indicated that it disputed our finding and recommendation concerning the training, skills, and knowledge of OUD treatment providers and therefore had not given information on how it would address our concerns or recommendation.

MassHealth stated that it was in the process of implementing two recommendations:

1. MassHealth should take additional measures to ensure that prescribers effectively facilitate member participation in OUD counseling.
2. MassHealth should further investigate the reasons that were provided to OSA during this audit for members’ not having access to counseling and take whatever measures it can to minimize these barriers to access.

MassHealth indicated that it planned to implement the following recommendation:

MassHealth should conduct a review of the medical records of prescribers of MAT for OUDs and recover any payments for services that were not properly documented.

6. Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Norwood Adult Day

Audit No. 2018-1374-3M10C     Issued June 6, 2019
Survey Response Received December 23, 2019

Number of Recommendations	Fully Implemented	In Progress	Fiscal Benefit
3*	2		N/A

*     Action taken for Recommendation 1.1 was cited in the audit report.

 

In our audit of Norwood Adult Day Health Center (NADHC), a MassHealth ADH service provider, we found that NADHC did not obtain physician orders to support as much as $92,644 of ADH services provided to three MassHealth members. Additionally, NADHC did not always properly document claims submitted to MassHealth by its billing agents to ensure that the correct ADH location was indicated.

In its response to our six-month survey, Norwood stated that it disagreed with our finding about its not obtaining physician orders for $92,644 of billings and therefore did not indicate what action it would take on our recommendation that it collaborate with MassHealth to determine how much of the $92,644 should be repaid.

NADHC indicated that it had fully implemented two recommendations:

1. NADHC should develop policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.
2. NADHC should enhance its policies and procedures to make sure that it properly monitors claims submitted to MassHealth by its billing agents to ensure that all the claims they submit indicate the locations where services were provided.

Date published:	March 13, 2020