Audit of the Office of Medicaid (MassHealth) - Review of Claims Submitted by Dr. Joseph O’Connor
January 13, 2020 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published January 13, 2020 Audit covers January 1, 2015 – December 31, 2018 Under Suzanne M. Bump · 2011–2023
source
“Dr. Joseph O’Connor improperly billed MassHealth for $359,266 in physical therapy provided by physical therapy assistants.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of MassHealth physical therapy claims submitted by Dr. Joseph O'Connor from January 1, 2015 through December 31, 2018.
“OSA has conducted an audit of MassHealth claims for physical therapy paid to Dr. Joseph O’Connor for the period January 1, 2015 through December 31, 2018.”
The audit began after the Auditor's Bureau of Special Investigations flagged possible improper payments through data analysis.
“The audit was initiated as the result of a referral from OSA’s Bureau of Special Investigations (BSI).”
MassHealth is a major public program, so improper payments affect public money and trust in the Medicaid system.
“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 taxpayer or MassHealth member, this audit is about making sure Medicaid dollars are paid only for services that follow MassHealth rules.
“MassHealth provides access to healthcare services for approximately 1.9 million low- and moderate-income children, families, seniors, and people with disabilities annually.”
The auditor concluded that Dr. O'Connor did not correctly bill MassHealth for the reviewed services.
“Did Dr. O’Connor correctly bill for services provided to MassHealth members?”
The report recommends that Dr. O'Connor work with MassHealth on repayment and change billing practices so his provider ID is used only for services he personally provides.
“Dr. O’Connor should collaborate with MassHealth to establish a plan to repay the $359,266 in overpayments he received from improper physical therapy billings.”
The dollar amount was large compared with the total payments reviewed: MassHealth paid Dr. O'Connor $568,988 during the audit period, and the auditor identified at least $359,266 in overpayments.
“During this period, MassHealth paid Dr. O’Connor $568,988 to provide physical therapy for 1,129 MassHealth members.”
MassHealth is Massachusetts' Medicaid program, which pays for healthcare services for eligible people.
“Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth.”
1 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did Dr. O’Connor correctly bill for services provided to MassHealth members?
What the Auditor found
Why it matters: This resulted in at least $359,266 in overpayments during the audit period.
Standard: 130 CMR 432.412 and 130 CMR 450.301(A)(1) prohibit payment for services provided by supervised staff or another individual under the practitioner’s own provider ID. ( 130 CMR 432.412; 130 CMR 450.301(A)(1); Chapter 118E of the Massachusetts General Laws; Section 12 of Chapter 11 of the Massachusetts General Laws )
3 recommendations
- Dr. O’Connor should collaborate with MassHealth to establish a plan to repay the $359,266 in overpayments he received from improper physical therapy billings.agency: agreed
- Dr. O’Connor should bill MassHealth using his billing provider identification number only for services he personally provides.agency: agreed
- Dr. O’Connor should periodically review all the billing requirements in MassHealth’s regulations, as well as updates to these regulations that are described in MassHealth’s transmittal letters and provider bulletins, and ensure that he knows and adheres to these requirements when he bills for services provided to MassHealth members.agency: agreed
Agency response & Auditor reply
Agency: "Since its founding, [Advance Physical Therapy & Sports Rehabilitation] has always utilized both physical therapists and physical therapy assistants in a team approach when treating patients in its office."
Auditor: "As noted above, MassHealth regulations do not allow payment for therapy services provided by physical therapy assistants, even if they are provided under the supervision of a licensed therapist."
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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