Office of Medicaid (MassHealth)—Review of Drug Testing Frequency Audit Objectives, Scope and Methodology

An explanation of what this audit examined and how it was conducted.

Overview

In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor (OSA) has conducted a performance audit of drug test claims paid by MassHealth for the period July 1, 2012 through June 30, 2016.

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Below is our audit objective, indicating the question we intended our audit to answer, the conclusion we reached regarding the objective, and where the objective is discussed in the audit findings.

Objective	Conclusion
Did MassHealth only pay for drug tests that were used for diagnosis, treatment, or otherwise medically necessary purposes?	No; see Findings 1, 2, and 3

We interviewed officials at MassHealth and the Bureau of Substance Abuse Services (BSAS) to obtain an understanding of drug test policies and practices, which we then applied when reviewing claim submissions for MassHealth members living in BSAS-licensed recovery homes and other sober homes. Additionally, we met with a substance use disorder (SUD) treatment professional at Boston Medical Center to discuss various aspects of sober-home drug testing.

We gained an understanding of internal controls for laboratory drug testing at MassHealth and evaluated the design of the controls over MassHealth’s billing process that we deemed significant to our audit objective.

We queried the Medicaid Management Information System (MMIS) to extract all fee-for-service claims and encounter services² provided to members who received drug tests. Additionally, we extracted members’ address information to compare their addresses with those of BSAS-licensed recovery homes and other sober homes.

To assess the reliability of the data obtained from MMIS, we relied on the work performed by OSA in a separate project that tested certain information system controls in MMIS, which is maintained by the Executive Office of Health and Human Services. As part of the work performed, OSA reviewed existing information, tested selected system controls, and interviewed knowledgeable agency officials about the data. Additionally, we performed validity and integrity tests on all drug test claim data during our audit period, including (1) testing for missing data, (2) scanning for duplicate records, (3) testing for valid data, (4) looking for dates outside specific periods, and (5) tracing a sample of claims queried to source documents. Based on these procedures, we determined that the data obtained were sufficiently reliable for the purposes of this report.

We performed the following data analyses on all drug test claims paid by MassHealth:

• We performed summarization analyses of the laboratories with the largest billings for drug tests.
• We performed summarization analyses of the 150 members with the most drug tests, out of all 240,711 members drug tested during the audit period, and performed reviews of these members’ addresses to identify possible sober-home addresses.
• We used data analytics to compute the days between one drug test and the next for each of the 240,711 members drug tested during the audit period. This analysis helped us identify how frequently members were drug tested, as well as the number of times a member was drug tested within one day of a previous drug test, two days, three days, etc.
• We used data analytics to calculate the number of drug tests received by members who received no other medical services within 7 days and 15 days before or after the drug test. We selected 7 days and 15 days for our analyses because most members who require frequent drug testing are receiving SUD treatment. Follow-up visits with patients are scheduled either weekly or monthly, and a 31-day period (15 days before and after a given date) should encompass monthly visits, according to industry guidelines on addiction treatment services from the federal Substance Abuse and Mental Health Services Administration’s Technical Assistance Publication 32 and Treatment Improvement Protocols 40, 43, and 47; the American Society of Addiction Medicine’s Drug Testing: A White Paper; the Centers for Medicare & Medicaid Services’ Local Coverage Determination for Urine Drug Testing; MassHealth regulations; and our discussions with SUD treatment professionals.
• For the 74,347 members, out of the previously mentioned 240,711, who were drug tested during the audit period but did not have any other medical services, we performed a query to calculate all drug tests paid for while the members lived in sober homes certified by the Massachusetts Alliance for Sober Housing (MASH), in privately owned sober homes, or in BSAS-licensed recovery homes.

When comparing member drug tests to determine whether the members received other medical services, OSA developed a list of 168 procedure codes for services that members might also have received at the time of their drug tests. We developed this list from Section 346 of Title 101 of the Code of Massachusetts Regulations (CMR) for all substance-related and addictive-disorder-related procedure codes, 101 CMR 306 for all mental-health services provided in community health centers and mental-health centers, and 101 CMR 317 for all evaluation and management (E/M) services and other medical services. This exhaustive list included all behavioral-health services, all psychiatry and psychotherapy services, all emergency-room and crisis-intervention services, and all E/M services that OSA determined a member might have received in conjunction with the drug testing. We provided this list to MassHealth officials.

We developed a master table of all sober-home addresses to test whether members might have received drug tests for residential monitoring. We created this table by researching the Department of Public Health’s MASH website, performing general Internet searches on sober homes in Massachusetts, and searching the business entity database for the Corporations Division within the Office of the Secretary of the Commonwealth of Massachusetts. This is not a complete list of sober homes in Massachusetts, since a comprehensive list is not readily available.

We selected a judgmental sample of three laboratories for site visits based on an isolated risk factor: these laboratories were among the top 10 providers that performed drug tests for the most frequently tested members during the audit period. From these 10 providers, we selected various provider types (e.g., hospitals, SUD treatment centers, or independent clinical laboratories) to gain an understanding of drug testing at different provider types. Then we selected a judgmental sample of 45 members who received the most drug tests (15 from each of the three laboratories) out of the 332 most frequently drug tested members. We obtained paper or online copies of laboratory order forms and result reports to review for prescriber authorizations and compare dates of drug tests to other medical services the members received. Since this test used nonstatistical sampling, we did not project any identified errors to the population of drug test claims.

2.    Encounter services are services provided by MassHealth’s managed-care organizations.

Date published:	July 27, 2018