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Prescribers Did Not Always Maintain Documentation Supporting Medical Visits Where Prescriptions Were Given to MassHealth Members.

The audit recommends MassHealth conduct a review of prescribers' medical documentation practices.

Table of Contents

Overview

Prescribers from our sample did not always maintain documentation for medical visits in which they gave buprenorphine prescriptions to MassHealth members. Specifically, five prescribers wrote a total of 72 prescriptions for 6 members (for a total of $22,733 paid to pharmacies by MassHealth) but did not keep any kind of documentation, such as prescriptions issued or medical services provided. The lack of documentation that buprenorphine, a highly addictive controlled substance, was prescribed to the members in question creates a risk of their misusing the substance.

Authoritative Guidance

According to Section 433.409(D)(1) of Title 130 of the Code of Massachusetts Regulations (CMR), a physician must maintain documentation of all medications prescribed to members, and this documentation must include dosage and strength:

Medical records corresponding to office, home, nursing facility, hospital outpatient department, and emergency department services provided to members must include the reason for the visit and the data upon which the diagnostic impression or statement of the member’s problem is based, and must be sufficient to justify any further diagnostic procedures, treatments, and recommendations for return visits or referrals. Specifically, these medical records must include, but may not be limited to, the following . . .

(g)  any medications administered or prescribed, including strength, dosage, and regimen.

In addition, according to 130 CMR 450.205(A), MassHealth will not pay a provider for services if the provider does not have adequate documentation of the services.

Reasons for Issues

None of the five prescribers provided a reason for not maintaining documentation.

Recommendation

MassHealth should conduct a review of these prescribers’ medical documentation and recover any payments for services that were not properly documented.

Auditee’s Response

MassHealth agrees with OSA’s recommendation that an additional review of these five prescribers is warranted based on the apparent lack of medical documentation. Once the final draft of the audit is issued and the five prescribers are identified, MassHealth intends to conduct an audit to further investigate the lack of documentation for these providers. If MassHealth determines that these prescribers systematically lack documentation in their practice, MassHealth will take appropriate actions, which may include recovery of payments.

Date published: March 21, 2019
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