Overview
For 6 of the 111 MassHealth members tested, United Cerebral Palsy (UCP) lacked proper physician or primary care clinician authorizations for day habilitation (DH) services. As a result, there is a higher-than-acceptable risk that UCP may not provide the appropriate types and levels of service to these members. During our audit period, UCP received a total of $122,357 from MassHealth for DH services provided to these six members.
Authoritative Guidance
According to Section 419.407(D)(3) of Title 130 of the Code of Massachusetts Regulations, to receive payment for DH services, providers must obtain documentation, including physician or primary care clinician authorizations, for the services, ensuring that “the day habilitation services have been authorized by the member’s physician or primary-care clinician.”
Reasons for Noncompliance
UCP does not have any policies or procedures that require its staff to ensure the completion of physician or primary care clinician authorizations before it provides DH services for MassHealth members.
Recommendations
- UCP should collaborate with MassHealth to determine how much of the $122,357 discussed in this finding should be repaid.
- UCP should update its policies and procedures to require its staff to ensure the completion of physician or primary care clinician authorizations before it provides DH services for MassHealth members.
Auditee’s Response
UCP has, in fact, periodically obtained subsequent authorization from each member's [primary care practitioner, or] PCP to provide [DH] services or otherwise relied on such authorization from the skilled nursing facility at which certain members resided, which were endorsed by each resident's PCP. In particular, consistent with the regulations, UCP maintains and periodically updates a comprehensive, individualized treatment plan for each member. As a matter of policy, each time UCP's interdisciplinary team recommends an update to a member's treatment plan, UCP obtains approval from the member's PCP. In effect, each member's PCP periodically authorizes UCP to provide the specific [DH] services that are detailed on the member's individualized service plan, mooting any initial authorization given upon the member's enrollment.
In so giving such periodic approvals, each member's PCP reviews the member's treatment plan for that time period and authorizes the provision of those particular [DH] services to the member during the related time period. Effectively, this protocol makes these periodic approvals more meaningful than initial PCP authorizations, which generally only assert that the member "requires and would benefit" from [DH] services and do not reflect members' progress and changes in condition over time.
These periodic authorizations clearly suffice to satisfy the regulation that governed [DH] providers during the Audit Period, which did not require a [DH] provider to indefinitely rely on the PCP authorization obtained upon initial enrollment. Rather, the regulations at the time simply required the [DH] services to "have been authorized by the member's physician or primary care clinician." 130 [Code of Massachusetts Regulations, or CMR] 419.407 (pre-September 11, 2018). In fact, requiring a [DH] provider to indefinitely rely on initial PCP authorizations is inconsistent with the regulations as they related to record retention, which only required a [DH] provider to maintain member records for four (4) years after the date of service. 130 CMR 419.446(A)(1) (pre-September 11, 2018).
Further, MassHealth has periodically audited UCP, having done so as recently as 2014. At no point has MassHealth alleged that UCP failed to obtain PCP authorization to provide services to these particular members, providing further confirmation that the initial prior authorizations did, in fact, exist as required. Even if they did not previously exist (which they did), the nature of UCP's clients' disabilities is such that, as a practical matter, their respective disabilities do not "improve" such that they would no longer have a need for [DH] services. Accordingly, if clients' physicians approved services recently, they likely would have also approved services upon the clients' initial admission several years ago.
Moreover, various UCP clients were residents of a skilled nursing facility that was owned by [the Department of Developmental Services]. For each such client, through a Preadmission Screening and Resident Review ("PASRR"), the skilled nursing facility determined that these residents required and would benefit from [DH] services, and such determinations were endorsed by these residents' PCPs. This is the same information that would be included on the initial authorization form.
MassHealth’s Response
MassHealth is committed to continual improvement of program integrity and has endeavored to strengthen the integrity of the Day Habilitation program through increased oversight and education of Day Habilitation providers. Specifically, MassHealth has undertaken the following program integrity initiatives in the Day Habilitation program.
- In September 2018, MassHealth promulgated the revised Day Habilitation provider regulations. The revised regulations, among other things, clarified eligibility requirements.
- In November 2018, MassHealth began development of an audit tool to be used for systematic monthly on-site audits of Day Habilitation providers. These systematic audits will begin in September 2019.
- In early spring 2020, MassHealth will implement Prior Authorization (PA) requirements for the provision of Day Habilitation services. With the advent of PA requirements, Day Habilitation providers will be required to (1) provide documentation justifying a member’s eligibility and level of care needed for DH services, as well as (2) submit physician authorization to provide Day Habilitation services to the member prior to rendering and billing for Day Habilitation services provided to the member.
Regarding the audit finding and recommendations in the audit, MassHealth agrees with the recommendations. . . .
MassHealth will conduct its own audit of UCP.
Auditor’s Reply
In its response, UCP asserts that there was documentation in each of the six member files in question. In UCP’s opinion, this indicates that the members’ medical providers knew and approved of the members’ attending UCP. However, none of this documentation included physician or primary care clinician authorizations for DH services. As noted above, MassHealth regulations state that a physician or primary care clinician authorization must be obtained before the member’s first attendance day. Although the documentation that existed in these member files, which included such records as treatment plans and member service plans, can substantiate that members received prescribed medical services from UCP, they are not a substitute for the physician or primary care clinician authorizations that MassHealth regulations require. Although the Office of the State Auditor (OSA) cannot speak to past audits of UCP conducted by MassHealth, we found some problems in this area during our audit, and we are recommending measures that we believe will address them.
OSA is not asserting that UCP should “indefinitely rely on the PCP authorization obtained upon initial enrollment” and acknowledges that sometimes a member’s treatment plan may need to be updated, at which point subsequent authorization would be needed. However, the physician or primary care clinician authorization is the document that supports the need for a member to receive DH services, and MassHealth regulations specifically require physician documentation before a member’s first day of service. Therefore, regardless of whether UCP and a member’s medical provider have communicated about specific services the member receives, OSA believes that without proper authorization, there is a higher-than-acceptable risk that the member may not be provided with the appropriate types and levels of service. Although we acknowledge that documents can be misfiled, we believe that the controls over these authorizations could be strengthened; therefore, we again urge UCP to implement our recommendation to update its policies and procedures to require its staff to ensure that completed physician or primary care clinician authorizations are in place before it provides DH services for MassHealth members.
| Date published: | September 19, 2019 |
|---|