Office of Medicaid (MassHealth) - Review of Evaluation and Management Claims Paid to Resil Medical Associates, P.C.

This is a Massachusetts State Auditor review of certain MassHealth payments made to Resil Medical Associates for patient office-visit services from 2011 through 2015.

“OSA has conducted an audit of selected evaluation and management (E/M) claims paid to Resil Medical Associates, P.C. (RMA) for the period January 1, 2011 through December 31, 2015.”

The auditor chose this area because MassHealth spends a large amount on these kinds of office-visit claims, and past audits found improper physician claims.

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

Incorrect Medicaid billing can waste public money and weaken trust in MassHealth, a major public healthcare program.

“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 whether public healthcare dollars were spent properly and whether patients received care from appropriately qualified and supervised staff.

“This supervision is essential for ensuring that members receive quality care and for enabling non-independent NPs to obtain clinical guidance directly from an onsite physician if necessary.”

The auditor concluded that RMA did not submit all claims according to the required rules.

“Did RMA submit claims to MassHealth for evaluation and management (E/M) services in accordance with applicable laws, rules, and regulations?”

The report recommends that RMA repay identified overpayments, fix its billing system and controls, ensure proper supervision, and create required arrangements for nurse practitioners.

“RMA should collaborate with MassHealth to repay the overpayment of approximately $17,346 that we identified.”

MassHealth is a large public program, so even provider-level billing problems matter because Medicaid spending is a major part of the state budget.

“Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.”

“E/M” means evaluation and management, which are office or outpatient visits. “NP” means nurse practitioner. “Modifier codes” are billing codes that tell MassHealth who actually provided the service so the right payment rate is used.

“NPs are nationally certified, state-licensed medical professionals who can practice medicine as part of a healthcare team and in collaboration with physicians and other healthcare professionals.”