Office of Medicaid (MassHealth) - Review of Evaluation and Management Claims Paid to Lawrence Family Doctors

This is a Massachusetts State Auditor performance audit of MassHealth payments to Lawrence Family Doctors for evaluation and management services from January 1, 2011 through June 30, 2016.

“OSA has conducted an audit of evaluation and management (E/M) claims paid to Lawrence Family Doctors (LFD) for the period January 1, 2011 through June 30, 2016.”

The auditor reviewed this provider because MassHealth spends heavily on these kinds of medical visit claims, and earlier audits had found possible improper billing in this area.

“Because of the significant amount of these expenditures, as well as prior OSA audits that identified potential improper billings for E/M services, OSA is continuing to audit this type of claim.”

Incorrect billing can waste public Medicaid money and reduce public confidence in MassHealth.

“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 correctly and whether patient records supported the care billed.

“MassHealth provides access to healthcare services to approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities.”

The auditor concluded that Lawrence Family Doctors did not properly bill MassHealth for nurse practitioner services and should repay the identified overpayments.

“LFD should collaborate with MassHealth to establish a plan to repay the $108,232 in overpayments it received from improper E/M service billings.”

The report recommends that Lawrence Family Doctors repay MassHealth, bill nurse practitioner services correctly going forward, review billing rules, and improve medical record access and documentation.

“LFD should bill for NPs’ services using either the SA modifier or NPs’ servicing provider identification numbers.”

The issue is significant because the audited provider received more than $1.2 million from MassHealth for these visit-related services during the period reviewed, and the auditor projected a high error rate in the claims tested.

“During this period, LFD was paid approximately $1,233,444 to provide E/M services for 1,763 MassHealth members.”

E/M means routine medical evaluation and management services, such as office visits, and NP means nurse practitioner.

“Based on the American Medical Association’s Current Procedural Terminology Professional Edition 2014 (CPT Codebook), E/M services are divided into broad categories such as office visits, hospital visits, and consultations.”