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R&R Improperly Billed MassHealth when Members had Private Insurance.

Auditors identified claims that were submitted and paid in full by both MassHealth and the members' private insurance carrier.

Table of Contents

Overview

For 13 (7.2%) of the 180 sampled claims, R&R billed MassHealth and the members’ private insurance carriers at the same time instead of billing MassHealth after receiving an explanation of benefits (EOB) from the private insurer showing that the insurer either paid or denied the service. As a result, there is a higher-than-acceptable risk that R&R could receive and retain payments from MassHealth to which it is not entitled.

We examined the billing notes in the members’ dental records and the EOBs to determine whether R&R billed MassHealth only after it settled with the private insurers. In 6 of the 13 questioned claims, R&R billed MassHealth and the private insurance at the same time and was paid in full by both. R&R eventually notified MassHealth that it had received payment from the members’ private insurance companies and submitted claims to adjust the amounts it received from MassHealth. For 7 out of the 13 questioned claims, R&R billed MassHealth and the members’ private insurance, but the private insurance did not cover the services; R&R did not wait for the EOB before billing MassHealth.

Authoritative Guidance

According to 130 CMR 450.316(G), providers must bill all other insurers before billing MassHealth so that MassHealth is the payer of last resort: “If a member is covered by more than one health insurer, the provider must request payment from all of the other insurers prior to submitting a claim to the MassHealth agency.”

Additionally, 130 CMR 450.316 states, “All providers must make diligent efforts to obtain payment first from other resources . . . so that the MassHealth agency will be the payer of last resort.”

Finally, according to 130 CMR 450.309(A), providers must submit claims within 90 days after either the date of service or the date of the EOB from another insurer:

In accordance with M.G.L. c. 118E, § 38, all claims must be received by the MassHealth agency within 90 days from the date of service or the date of the explanation of benefits from another insurer. When a service is provided continuously on consecutive dates, the date from which the 90-day deadline is measured is the latest date of service.

Reasons for Noncompliance

The billing administrator at R&R explained that a representative at DentaQuest, LLC advised her that she could bill both insurances at the same time because MassHealth does not pay claims submitted more than 90 days after the date of service and it sometimes takes more than 24 months to receive an EOB from the member’s private insurance showing that the member’s benefits have been exhausted. However, this was incorrect advice because, as shown above, MassHealth regulations state that claims must be received within 90 days after either the date of service or the date of the EOB, so R&R’s claims should not be denied. The billing administrator gave us the name of the representative at DentaQuest who she said gave her this information, and we reached out to this DentaQuest employee in an attempt to verify the billing administrator’s assertion but got no response.

Recommendations

  1. R&R should not bill MassHealth for any orthodontic services for a member until it has received an EOB from the member’s private insurance carrier.
  2. R&R should collaborate with MassHealth and DentaQuest to ensure that it understands and follows MassHealth’s billing requirements under these circumstances.

Auditee's Response

Our office makes every effort to coordinate benefits when a subscriber has multiple insurances. We will collaborate with Masshealth and DentaQuest to ensure we are following their billing requirements.

MassHealth's Response

  1. MassHealth agrees that R&R should not bill MassHealth for any orthodontic services for members with private insurance until it has received an EOB from the member’s private insurance carrier.
  2. MassHealth will require R&R to complete mandatory training on MassHealth billing rules, and will coordinate the training with DentaQuest to ensure all parties understand the policy and procedure for submitting claims to MassHealth when a member has a private insurance carrier. MassHealth intends to monitor this provider for compliance with these requirements, and will impose appropriate sanctions for noncompliance.
Date published: June 8, 2018
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