Audit of the Office of Medicaid (MassHealth) - Review of Claims Submitted by Dr. Ileana Berman
November 14, 2018 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published November 14, 2018 Audit covers January 1, 2014 – December 31, 2016 Under Suzanne M. Bump · 2011–2023
source
“Below is a summary of our findings and recommendations, with links to each page listed.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of MassHealth claims submitted by Dr. Ileana Berman for substance use disorder treatment from 2014 through 2016.
“OSA has conducted an audit of MassHealth claims for substance use disorder (SUD) treatment paid to Dr. Ileana Berman for the period January 1, 2014 through December 31, 2016.”
The audit checked whether the services Dr. Berman billed to MassHealth were backed up by the records MassHealth requires.
“The purpose of this audit was to determine whether the SUD treatment that Dr. Berman provided to MassHealth members was properly supported by documentation in accordance with MassHealth regulations.”
MassHealth is a large public healthcare program, and the auditor says strong oversight is needed so public money is spent properly.
“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”
If you are a Massachusetts taxpayer or MassHealth member, this audit is about whether public healthcare dollars were paid only for properly documented and allowed services.
“In fiscal year 2017, MassHealth paid healthcare providers more than $15.2 billion, of which approximately 50% was funded by the Commonwealth.”
The audit found several problems: failure to update MassHealth about business changes, unsupported services, drug tests not used or documented properly, missing records, and unbundled drug test billing.
“Dr. Berman improperly billed MassHealth $75,261 for unbundled drug tests.”
MassHealth said it agreed with key findings and would seek repayment for overpayments after the final report was issued.
“MassHealth will recover any overpayments related to this finding after the auditor’s final report has been issued.”
The report is significant because it says the auditor found at least hundreds of thousands of dollars in questioned MassHealth payments tied to documentation and billing problems.
“Therefore, she received overpayments totaling approximately $176,737 from MassHealth during the audit period for the services discussed in this finding.”
A presumptive or qualitative drug screen mainly says whether a drug appears to be present or absent; a definitive or quantitative drug test gives a specific amount.
“Presumptive drug screens, also known as qualitative drug screens, produce a positive or negative result for each type of drug for which a sample is tested.”
2 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did Dr. Berman maintain proper documentation in members’ files to support the services for which she billed MassHealth?
What the Auditor found
Why it matters: MassHealth could not effectively assess her status as a MassHealth provider.
Standard: 130 CMR 450.222 and 130 CMR 450.223(B) ( Section 450.222 of Title 130 of the Code of Massachusetts Regulations; 130 CMR 450.223(B) )
3 recommendations
- Dr. Berman should work with MassHealth to ensure that the information in her provider file is properly updated to reflect the changes in her organizational structure.
- In the future, Dr. Berman should notify MassHealth of any changes that need to be made to her provider file within the timeframe prescribed by MassHealth regulations.
- Dr. Berman should consult with MassHealth to determine whether NECPAD is properly certified.
Agency response & Auditor reply
Agency: "Dr. Ileana Berman previously notified MassHealth’s vendors . . . of her changes in staff and structure since her employees are credentialed with the MassHealth vendors."
Auditor: "We cannot confirm that Dr. Berman notified MassHealth’s vendors of her changes in business operations; however, she was required to notify MassHealth of these changes and did not do so."
Why it matters: Her medical decision-making may have been based on inaccurate information when prescribing Suboxone.
Standard: 130 CMR 433.409(D)(1) ( 130 CMR 433.409(D)(1) )
2 recommendations
- Dr. Berman should review all drug test results she orders to ensure that MassHealth members comply with her treatment guidelines and should refer noncompliant members to other SUD treatment options.
- Dr. Berman should only bill MassHealth for drug tests that she will use to diagnose and treat members and should properly document them in members’ medical records.
Agency response & Auditor reply
Agency: "Dr. Berman has not and does not write prescriptions for Suboxone based on inaccurate information."
Why it matters: MassHealth overpaid approximately $176,737 for services that were not properly substantiated.
Standard: 130 CMR 450.205(A), 101 CMR 317.04, and CMS Documentation Guidelines for Evaluation and Management Services ( 130 CMR 450.205(A); 101 CMR 317.04 )
2 recommendations
- Dr. Berman should repay MassHealth the $176,737 that we identified as lacking the required documentation.agency: disagreed
- In the future, Dr. Berman should maintain proper documentation to support services billed.agency: partially agreed
Agency response & Auditor reply
Agency: "Dr. Berman has provided E/M services that qualified for CPT Code 99214 because she typically documented the detailed medical examination and medical decision making of moderate to high complexity as required by the 1997 CMS Guidelines for E/M Services."
Auditor: "During our review of the medical records of the members in question, there was no evidence that Dr. Berman documented a detailed history or conducted a detailed medical examination at the time of their visit."
Why it matters: MassHealth may have paid for services that were not provided or not substantiated.
Standard: 130 CMR 450.205(A) ( 130 CMR 450.205(A) )
1 recommendation
- Dr. Berman should repay MassHealth for E/M services and drug tests that were not documented in members’ medical records and maintain adequate documentation to support all services claimed.agency: partially agreed
Agency response & Auditor reply
Agency: "Dr. Berman acknowledges that the other main cause for the remaining lost documentation was that the documentation was lost in the process of transitioning from paper records to electronic medical records in 2014."
Auditor: "Our audit found that Dr. Berman had not retained any of the required documentation for some E/M services and drug tests for the members whose records we reviewed; therefore, she should not have been paid for these services."
Why it matters: The billing practice represented an excessive, unallowable cost to the Commonwealth.
Standard: 130 CMR 450.307 and MassHealth Physician Bulletin 94 ( 130 CMR 450.307; Physician Bulletin 94 )
2 recommendations
- Dr. Berman should cease ordering quantitative drug tests and qualitative drug screens for the same MassHealth member on the same day.agency: disagreed
- Dr. Berman should collaborate with MassHealth to determine the appropriate amount to be repaid, which should be at least $75,261.agency: disagreed
Agency response & Auditor reply
Agency: "Due to the nature of the services NECPAD provides, it is clinically necessary to conduct definitive testing."
Auditor: "MassHealth disallowed this type of drug testing because it determined that definitive drug tests were not necessary when a presumptive drug screen was medically sufficient and because it believed the practice was a form of unbundling."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
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