Audit of the Office of Medicaid (MassHealth) - Review of Claims Submitted by Dr. Melissa Hamilton

This is a Massachusetts State Auditor review of dental claims that Dr. Melissa Hamilton submitted to MassHealth from July 1, 2015 through December 31, 2020.

“OSA has conducted an audit of MassHealth claims for dental services paid to Dr. Melissa Hamilton for the period July 1, 2015 through December 31, 2020.”

The audit began after the Auditor’s Bureau of Special Investigations flagged possible improper payments in Dr. Hamilton’s claims.

“The audit was initiated as the result of a referral from OSA’s Bureau of Special Investigations (BSI).”

MassHealth is a large public health program, so weak billing records can affect public trust and taxpayer money.

“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 resident, this report is about oversight of public healthcare spending that is partly funded by the Commonwealth.

“Medicaid expenditures represented approximately 39% of the Commonwealth’s total fiscal year 2020 budget of approximately $43 billion.”

The Auditor concluded that many sampled claims lacked required support, and estimated at least $2.06 million in unallowable dental claims.

“During our audit period, Dr. Melissa Hamilton did not have adequate documentation to support at least $2,063,481 in dental claims: they were either missing information or missing documentation.”

The report recommends that Dr. Hamilton work with MassHealth to decide how much money should be repaid and improve her recordkeeping policies.

“Dr. Hamilton should collaborate with MassHealth to determine how much of the $2,063,481 in unallowable dental claims should be repaid.”

This finding is significant because the audit questioned whether all billed services were actually needed or provided.

“The lack of adequate documentation calls into question whether all of the services were necessary or delivered.”

The key rule is simple: MassHealth only pays for dental work when the patient record clearly shows what was done, why it was needed, and required details like dates, X-rays, and anesthesia information when relevant.

“MassHealth pays for dental services only when there is complete documentation in the member’s dental record, and dentists are required to retain documentation for each member for a minimum of four years after the last date of service.”