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Norwood Adult Day Health Center Did Not Obtain Physician Orders to Support As Much As $92,644 of Adult Day Health Services Provided to Three MassHealth Members.

The audit calls on NADHC to improve its documentation for future claims and to work with MassHealth to determine what amount should be repaid back to the state.

Table of Contents

Overview

For 3 of the 50 sampled MassHealth members tested, Norwood Adult Day Health Center (NADHC) lacked properly authorized physician orders for adult day health (ADH) services, totaling $92,644. Because physician orders substantiate the types and levels of service a member is authorized to receive, there is a higher-than-acceptable risk that NADHC may not have provided the appropriate types and levels of service to MassHealth members.

Authoritative Guidance

According to Section 404.406(F)(2) of Title 130 of the Code of Massachusetts Regulations (CMR) as of March 2010, to initiate ADH services, providers must obtain physician documentation, including physician orders, for the services:

(a)  Before the member’s first attendance day, the ADH provider must obtain the necessary documentation from the member’s physician.

(b)  The physician’s documentation must include

(i)   physician orders for adult day health services.

Reasons for Noncompliance

Regarding the three missing physician orders, NADHC’s program director stated,

The order for those members does not normally come from the primary physician; instead it often comes from the physician of record in the facility that is responsible for coordinating the discharge plan.

However, when reviewing the medical records of all of the members in our sample, we did not find physician orders for ADH services from any physician.

In addition, NADHC does not have internal controls (e.g., policies and procedures) in place to obtain physician orders from members’ physicians when nursing facilities or inpatient hospitals discharge members enrolled in MassHealth.

Recommendations

  1. NADHC should collaborate with MassHealth to determine how much of the $92,644 discussed in this finding should be repaid.
  2. 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.

Auditee’s Response

[Client #1] was admitted to NADHC on July 13, 2016. A copy of the medical provider’s progress note dated June 19, 2016 states “may return to day program.” . . . This date of June 19, 2016 is prior to the start date of July 13, 2016. Although the provider’s words state “return” to day program, this client was never a previous client prior to July 13th, and we cannot be held liable for the wording that a provider chooses. The intent was clearly there to establish the order for the client to attend adult day health (day program). . . .

[Client #2] was admitted to NADHC on March 27, 2014. On 3/14/14, NADHC social service staff sent a fax request to [the] physician to complete the necessary forms/documentation needed to admit [client #2]. On 3/21/2014, prior to the admission date of March 27th, instead of sending back NADHC’s forms, the physician sent her own medical information/documentation back to NADHC . . . implying agreement to attend adult day health. . . .

[Client #3] was admitted to NADHC on February 23, 2015. A copy of the signed physician’s medical information about [client #3] was faxed to NADHC on 2/9/2015 from [the] physician office which is prior to the date of admission to adult day health. . . .

In all three cases, there is clear evidence that each of the medical providers for each of the clients had very clear knowledge of and were in full agreement with their clients attending NADHC. As such, we do believe that there is sufficient evidence to support the requirement of a physician order to attend adult day health. It is also important to note that documents can get misfiled due to human error. In 47 of the 50 sampled members reviewed, all the necessary documentation was in order. That is certainly acknowledgement that the NADHC staff is aware of the requirement for the need for a physician order for adult day health services and they do have a process for obtaining it. . . .

Lastly, we strongly disagree with a statement made in the audit report . . . Because physician orders substantiate the types and levels of service a member is authorized to receive, there is a higher than acceptable risk that [NADHC] may not have provided the appropriate types and levels of service to MassHealth members.” It is unclear as to how such a conclusion of this magnitude can be made when there is documentary evidence in each case of the client’s physician knowing his/her client was attending NADHC, was in agreement with his/her client attending NADHC, and that there was ongoing communication, collaboration and documentation between the NADHC staff and the physician about each of their clients.

With its response, NADHC also provided a number of documents related to each member, such as a copy of a medication verification list signed by a member’s physician and a copy of a physician visit summary signed by the member’s physician, as well as copies of other medical records, which NADHC says confirm that the members’ physicians knew and agreed with the members’ attending NADHC.

MassHealth’s Response

In its response, MassHealth states that ADH is a program that it has identified for increased oversight and that since 2016, it has taken a number of measures to increase program integrity in this area. These measures include such things as conducting audits of ADH providers, revising its ADH regulations, and conducting a statewide training for ADH providers. MassHealth also provided the following comments:

Future program integrity efforts include:

  • In May 2019, MassHealth will submit a request to the Center for Medicare and Medicaid Services (CMS) for a temporary moratorium on the enrollment of new ADH providers into the MassHealth program. The temporary moratorium will enable MassHealth to strengthen program integrity of existing ADH providers.
  • In July 2019, MassHealth will implement Prior Authorization (PA) requirements for the provision of ADH services. ADH providers will be required to (1) provide documentation justifying a member’s clinical eligibility for ADH services, as well as (2) submit physician orders to obtain authorization to provide ADH services to the Member and prior to rendering and billing for ADH services provided to the member.

Regarding the audit finding and recommendations in the audit, MassHealth agrees with the recommendations. . . .

OSA’s audit findings have triggered a need for MassHealth to conduct its own audit of Norwood ADH.

Auditor’s Reply

In its response, NADHC asserts that there was documentation in each of the three member files in question. In NADHC’s opinion, this indicates that the members’ medical providers knew and approved of the members’ attending NADHC. However, none of this documentation included physician orders for ADH services. As noted above, MassHealth regulations state that a physician order must be obtained before the member’s first attendance day. Although the documentation that existed in these member files, which included such records as progress notes, medication lists, and care plans, can substantiate that members received prescribed medical services from NADHC, they are not a substitute for the physician orders that MassHealth regulations require. The physician order is the document that supports the need for a member to receive ADH services, and MassHealth regulations specifically require physician documentation before a member’s first day of service. Therefore, whether or not NADHC and a member’s medical provider have communicated about specific services such as medication that the member receives, unless the need for ADH services is formally established and documented in the member’s file and used to develop their treatment plan, the Office of the State Auditor believes there is a higher-than-acceptable risk that the member may not be provided with the appropriate types and levels of service. Although we acknowledge that documents can be misfiled, we believe that the controls over this activity could be strengthened; therefore, we again urge NADHC to implement our recommendation to develop policies and procedures to ensure that completed and authorized physician orders are in place before it provides ADH services to MassHealth members.

Date published: June 6, 2019
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