- Office of State Auditor Suzanne M. Bump
Media Contact for Auditor Calls on Malden Physician to Repay $55K to MassHealth
Mike Wessler, Communications Director
Boston — Auditor Suzanne M. Bump today released an audit of MassHealth claims submitted by Dr. Kunwar S. Singh of Malden. The audit found that Singh billed MassHealth for services that are more costly than the services actually provided to patients, a practice known as upcoding. Singh overbilled MassHealth by approximately $55,390. Bump called on the physician to work with MassHealth to repay the overpayments to the state’s Medicaid program.
“Through our work, we’ve identified the practice of upcoding as a potentially significant and serious problem in the MassHealth program,” Bump said. “This behavior undermines the integrity of the program, and costs taxpayers money.”
Medicare and Medicaid audits conducted by federal and state agencies have identified upcoding of claims as a repeated problem throughout the country. Bump’s office used advanced data analytics to analyze millions of MassHealth claims and identified that Singh’s office billed for the most expensive level for evaluation and management claims at a significantly higher rate than other physicians. Singh used the highest-cost billing code 68 percent of the time, while the average physician billed at this rate only 5 percent of the time.
Specifically, the audit found that Singh billed at the highest rate for minor or low-complexity cases, such as coughs, sore throats, and headaches, when he should have billed at a lower rate. The audit examined evaluation and management claims submitted by Singh to MassHealth from January 1, 2010 through June 30, 2015.
MassHealth agreed with Bump’s findings, and stated their intention to recover the overpayments and work with Singh to ensure he implements proper billing practices going forward.
Today’s report follows similar audits Bump’s office has recently released that found medical providers in Springfield and Brockton were also upcoding MassHealth claims.
“MassHealth must take steps to address the problem of upcoding, including expanded oversight of providers to prevent risk,” Bump said. “In addition, MassHealth must continue to emphasize payment models that reduce risk of upcoding, while promoting cost savings, quality of service, and the health of clients.”
MassHealth recently announced an effort to move away from the traditional fee-for-service payment model and toward the use of Accountable Care Organizations (ACO)—a model that makes upcoding more difficult. ACOs are a type of alternative payment methodology (APM), which receive a set rate for each patient they serve that is intended to cover all services for these patients, with the goal of improving coordination of care, and reducing the need for expensive medical procedures. Earlier this year, Bump’s office released an audit that found that while MassHealth was not meeting benchmarks for adoption of APMs, it had taken steps to bolster adoption rates. Adoption rates of APMs were set by the 2012 Healthcare Cost Containment Law (Chapter 224).
In fiscal year 2015, MassHealth paid healthcare providers $13.6 billion. Massachusetts receives a reimbursement from the federal government for 50 percent of most services provided to MassHealth members. MassHealth expenditures account for roughly 38 percent of the state’s total annual budget.
The audit of MassHealthclaims submitted by Dr. Kunwar S. Singh is available here.