Overview

Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services to approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities. In fiscal year 2016, MassHealth paid healthcare providers more than $14.8 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represent approximately 41% of the Commonwealth’s total annual budget.

According to Section 402 of Title 130 of the Code of Massachusetts Regulations, MassHealth pays for vision care provided to eligible MassHealth members. Dr. Khuong Nguyen, optometrist and sole proprietor of Westborough Eye Care LLC in Westborough, is a certified MassHealth service provider. He received a total of $587,315 for vision care provided to MassHealth members during the audit period.

MassHealth Payments Received by Dr. Nguyen

Fiscal Year

Number of
Members Served

Number of Claims

Amount Received from MassHealth

2012

1,610

3,840

$121,609

2013

1,376

3,311

105,263

2014

1,408

3,217

106,195

2015

1,628

3,873

129,046

2016

1,343

2,970

96,327

July 1, 2016–December 31, 2016*

526

919

28,875

Total

 

18,130

$587,315

*    Only the first six months of fiscal year 2017 were within our audit period.

Vision Care Services

The vision care services provided by opticians, optometrists, and ophthalmologists1 to eligible MassHealth members include performing eye exams; diagnosing, treating, and managing disorders of the eye and the associated structures; and fitting and ordering eyewear. MassHealth instructs providers to use specific procedure codes to bill for vision care services, such as dispensing services, eyeglass repairs, comprehensive eye examinations, and problem-specific eye examinations.

Dispensing services: The following are considered dispensing services: assisting a member in choosing appropriate frames, taking necessary measurements for ordering lenses and frames from the optical supplier, fitting the completed eyeglasses to the member, determining whether the member can see clearly through the eyeglasses, making necessary adjustments to the lenses and/or frames, and giving the member the eyeglasses. Dispensing also includes periodic readjustments and minor repairs of eyeglasses for the first six months from the date the member receives them.

Repairs: Members are entitled to have their broken eyeglasses repaired with replacement parts from the optical supplier. If the replacement parts are not available from the optical supplier, members are entitled to entire replacement frames.

Eye examinations: Members are entitled to comprehensive eye examination once per 12-month period if they are under the age of 21 and once per 24-month period if they are 21 or older.

Problem-specific eye examinations: Members are entitled to comprehensive eye examinations more than once per eligibility period when there are referrals from their physicians; when they complain of blurred vision, headaches, pain, or redness; or when they are diagnosed with conditions or chronic diseases that could impair vision, such as diabetes, hyperthyroidism, human immunodeficiency virus, cataracts, or infection.

Massachusetts Correctional Industries

MassHealth’s optical supplier is Massachusetts Correctional Industries (MassCor). For eligible Medicaid members, optometrists and opticians use MassCor’s online system to order eyeglass-related materials and services produced or provided by Massachusetts inmates, including eyeglass frames, eyeglass lenses, frame cases, lens tints and coatings, and replacement parts.

Vision Care Billing and Documentation Requirements for Evaluation and Management Procedure Codes

During the audit period, MassHealth paid Dr. Nguyen for 4,427 vision care services that he billed using evaluation and management (E/M) codes, primarily when providing services to members residing in Department of Youth Services (DYS) facilities and Department of Children and Families (DCF) programs. Based on the American Medical Association’s Current Procedural Terminology Professional Edition 2017 (the CPT Codebook), E/M services are divided into broad categories such as office visits, hospital visits, and domiciliary and rest home visits. Most categories are divided into two or more subcategories of E/M services. For example, for office visits, there are subcategories for new patients and established patients. These subcategories are further classified into levels of E/M services, broken down by the nature of the work, place of service, and patient status. The more complex the service, the more the physician is compensated; therefore, for complex services, more information must be documented. Medical providers must select the E/M procedure code that best represents the services rendered and ensure that the medical documentation for those services meets the requirements in the CPT Codebook.

During our audit period, Dr. Nguyen billed the following procedure codes for vision care provided to MassHealth members residing in DYS facilities and DCF programs:

Procedure Code

Description in CPT Codebook

99328

Domiciliary or rest home visit for E/M for a new patient, which requires these three key components:

  • a comprehensive history
  • a comprehensive examination
  • medical decision-making of high complexity

Typically, 75 minutes are spent face to face with the patient and/or family.

99337

Domiciliary or rest home visit for E/M for an established patient, which requires two of these three key components:

  • a comprehensive history
  • a comprehensive examination
  • medical decision making of moderate to high complexity

Typically, 60 minutes are spent face to face with the patient and/or family.

When billing for medical services using these higher-complexity procedure codes (99328 and 99337), physicians must ensure that their medical documentation of services rendered includes, at a minimum, the following key components:

Comprehensive History Comprehensive Examination High-Complexity Decision-Making
  • Chief complaint
  • Extended history of present illness
  • Complete review of systems performed
  • Complete past, family, and/or social history
  • Examination of all nine organs/systems
  • Examination of every element of one organ or system
  • Extensive number of diagnoses or management options
  • Extensive amount and/or complexity of data to be reviewed
  • High risk of significant complications, morbidity, and/or mortality

Services Provided at DYS Facilities and DCF Programs

During the audit period, Dr. Nguyen provided vision care to children who were in the custody of DYS and DCF. To do so, Dr. Nguyen traveled to various DYS facilities and DCF programs.2 According to DYS and DCF officials, the agencies typically enter into contracts with medical professionals to provide specialty medical services, such as vision care, at their facilities and programs. However, during the audit period, neither of these agencies had a contract for vision care with Dr. Nguyen.

As illustrated in the table below, 72% of the vision care services provided by Dr. Nguyen to MassHealth members were for youths residing in DYS facilities and DCF programs during the audit period.

Vision Care Provided by Dr. Nguyen to MassHealth Members

Location of Services

Number of Paid Claims

Amount Paid

Percentage of Total Services

DYS Facilities and DCF Programs

12,887

$ 423,559

72%

Westborough Eye Care

5,166

   161,426

27%

Other

77

       2,331

1%*

Total

18,130

$ 587,316

100%

*              Discrepancies in totals are due to rounding.

 

DYS officials stated that on April 29, 2016, they informed Dr. Nguyen that he could no longer perform vision care at DYS facilities until he submitted a bid in reply to a Request for Response (RFR)to provide vision care at those facilities. This RFR included a requirement to complete training on the federal Prison Rape Elimination Act of 2003.4 Although Dr. Nguyen ceased his visits to DYS facilities upon receiving the notification from DYS, DYS continued to transport some youths in facilities near his Westborough office to that location for vision care. He also stated that he still traveled to DCF programs to provide vision care.

1. Opticians specialize in filling lens prescriptions, helping patients choose eyeglasses, and fitting eyeglasses. Optometrists perform vision examinations, fit and prescribe contact lenses and eyeglasses, diagnose and treat eye-related conditions, and prescribe some medications. Ophthalmologists can perform all the same services as optometrists as well as eye-related surgeries.

2. The DCF programs are licensed by the Department of Early Education and Care, which houses the children who are in DCF custody.

3. Section 21.02 of Title 801 of the Code of Massachusetts Regulations defines RFRs as “the mechanism used to communicate Procurement specifications and to request Responses or interest from potential Bidders.”

4. The Prison Rape Elimination Act of 2003 was enacted to prevent the sexual abuse and sexual harassment of people in the custody of correctional facilities. Massachusetts was required to comply with this federal law, which includes adult prisons and jails, community confinement facilities, and juvenile facilities, starting in August 2012.

Date published: July 16, 2018
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