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Overview of the Office of Medicaid (MassHealth)—Review of Claims Submitted by Dr. Ileana Berman

This section describes the makeup of Dr. Ileana Berman's practice and her history of billing MassHealth.

Table of Contents

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 annually. In fiscal year 2017, MassHealth paid healthcare providers more than $15.2 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.

Dr. Ileana Berman, owner of the New England Center for Psychiatric and Addiction Disorders LLC (NECPAD), is a certified MassHealth provider. As a limited liability company, NECPAD is required to file annual reports with the Secretary of the Commonwealth. Dr. Berman has also been licensed by the Massachusetts Board of Registration in Medicine since 2001, and she provides care to MassHealth members primarily at her office in Attleboro. She has also received certification from the federal Substance Abuse and Mental Health Services Administration to prescribe buprenorphine1 to patients who have developed opioid dependence.

NSCPAD

NECPAD is a privately held company that employs nine staff members at its main office in Attleboro and offers mental health services and treatment of substance use disorders. NECPAD states in its 2015 and 2016 annual reports that it operates as an “outpatient substance and mental health treatment facility.”

NECPAD’s Controlled Substance Treatment Policies state,

The mission of our [Suboxone] Program is to maintain patients free from using opiates and other drugs of abuse . . . each patient maintained in the program will be continuously assessed for his or her readiness to be detoxified from Suboxone.

The policy states that if patients experience challenges with decreasing their Suboxone dosages or discontinuing their prescriptions, they will be kept in the program indefinitely because there is a high risk of relapse.

The policy also puts great emphasis on the importance of drug testing for members who are prescribed Suboxone. It states that a drug test is a tool that helps to provide “clinically appropriate and cost-effective treatments in patients with [substance use disorders] and those who need controlled substances.”

It further states that all drug tests are performed at NECPAD’s on-site laboratory and that patients’ drug test results are interpreted during their visits: “All patients in the Suboxone program need to wait for their results so that results are discussed with them at the time of the visit.”

MassHealth Payments Received by Dr. Berman

The following table shows payments made by MassHealth to Dr. Berman each year of the audit period for services to MassHealth members:

Fiscal Year

Amount Paid

Number of Claims

Members Served

2014

$634,328

15,557

694

2015

613,172

20,505

748

2016

633,374

12,823

834

Total

$1,880,875*

48,885

 

*    Discrepancy in total is due to rounding.

Billing and Documentation for Evaluation and Management Procedure Codes

During the audit period, MassHealth paid Dr. Berman $860,417 for services that she billed using evaluation and management (E/M) codes. 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. 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, the place of service, and the patient status. The more complex the service, the more the physician is compensated; therefore, for more 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 of the CPT Codebook. During the audit period, Dr. Berman primarily (94% of the time) used E/M procedure code 99214 when billing for services provided to MassHealth members. That code is described in Section 317.04 of Title 101 of the Code of Massachusetts Regulations2 as follows:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

When billing for medical services using procedure code 99214, physicians must ensure that their medical documentation of services rendered includes, at a minimum, all of the following key components:

Detailed History

 

Detailed Examination

 

Moderate-Complexity Decision-Making

  • Chief complaint
  • Extended history of present illness
  • Extended review of systems performed
  • Pertinent past, family, and/or social history

 

  • Examination of all nine organs/systems
  • Examination of every element of one organ or system

 

  • Multiple diagnoses or management options
  • Moderate complexity of data to be reviewed
  • Moderate risk of significant complications, morbidity, and/or mortality

1.    Buprenorphine is a controlled substance used to treat addiction to narcotic pain relievers. It is sometimes sold under the brand name Suboxone.

2.    The quoted version of the regulation was in effect from August 2017 through March 2018.

Date published: November 14, 2018

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