Audit of the Office of Medicaid (MassHealth) - Review of Claims Submitted by Dr. Nicholas Franco
May 26, 2022 · Office of Medicaid (MassHealth) · Read the full official report on mass.gov ↗ · official site ↗
Published May 26, 2022 Audit covers July 1, 2015 – December 31, 2020 Under Suzanne M. Bump · 2011–2023
source
“Dr. Franco had inadequate documentation to support at least $2,528,147 in dental claims.”
Read the plain-English breakdown
This is a Massachusetts State Auditor review of dental claims Dr. Franco 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. Nicholas Franco for the period July 1, 2015 through December 31, 2020.”
The audit began after the auditor’s fraud-investigation unit flagged possible improper payments in Dr. Franco’s claims.
“The audit was initiated as the result of a referral from OSA’s Bureau of Special Investigations (BSI).”
MassHealth uses public money, so unsupported claims can mean taxpayer dollars were paid without enough proof that services were properly documented, needed, or provided.
“The lack of documentation and altered documentation call into question whether all of the services were necessary or delivered.”
If you rely on MassHealth or help fund it as a taxpayer, this audit is about making sure providers keep proper records and public healthcare money is spent correctly.
“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”
The auditor concluded that none of the 131 sampled claims had enough documentation, and estimated at least $2,528,147 in unsupported claims.
“Our review of patient records indicated that none of the 131 sampled claims had adequate documentation.”
Dr. Franco is expected to work with MassHealth on how much should be repaid, and MassHealth said it will review the sample and do a broader review before deciding on further recovery or sanctions.
“Dr. Franco should collaborate with MassHealth to determine how much of the $2,528,147 in unallowable dental claims should be repaid.”
The dollar amount is large, and the audit says MassHealth paid Dr. Franco over $3.4 million for more than 62,000 dental claims during the audit period.
“During this period, MassHealth paid Dr. Franco $3,464,028 for 62,426 claims for dental services provided to 1,866 MassHealth members.”
MassHealth is Massachusetts’ Medicaid program; Medicaid is a government health insurance program jointly run and funded by federal and state government.
“Medicaid is a joint federal-state program created by Congress in 1965 as Title XIX of the Social Security Act.”
2 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did Dr. Franco bill MassHealth for dental services in accordance with Sections 420.414(B) and 450.205(D) of Title 130 of the Code of Massachusetts Regulations (CMR) and the “How to Write in the Record” section of the American Dental Association’s (ADA’s) publication Dental Records?
What the Auditor found
Why it matters: The lack of documentation and altered documentation created a risk that services were not necessary or were not delivered.
Standard: Sections 420.414(B) and 450.205(D) of Title 130 of the Code of Massachusetts Regulations and American Dental Association Dental Records guidance. ( Section 420.414(B) of Title 130 of the Code of Massachusetts Regulations; 130 CMR 450.205(D); Dental Records, American Dental Association )
2 recommendations
- Dr. Franco should collaborate with MassHealth to determine how much of the $2,528,147 in unallowable dental claims should be repaid.
- Dr. Franco should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations and American Dental Association guidelines.agency: already implemented
Agency response & Auditor reply
Agency: "They also concurred with your assessment of our record keeping and we have already taken steps to ensure that all claims are properly documented according to MassHealth regulations and American Dental Association guidelines which you also have addressed in your audit."
Auditor: "Our concern is that, during our audit period, Dr. Franco and his staff did not maintain all the required documentation to support his bills to MassHealth; we have made recommendations to address this problem."
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