Office of Medicaid (MassHealth) Review of Evaluation and Management Claims Submitted by Asaker Medical Associates

This is a state audit of MassHealth claims submitted by Asaker Medical Associates for certain medical office visits from 2013 through 2014.

“The Office of the State Auditor has conducted an audit of evaluation and management (E/M) claims submitted to MassHealth by Asaker Medical Associates for the period January 1, 2013 through December 31, 2014.”

The auditor checked whether the practice followed MassHealth rules when billing for services provided to MassHealth members.

“The purpose of our audit was to determine whether Asaker Medical Associates submitted claims for services provided to MassHealth members in compliance with certain state regulations and MassHealth policies and procedures.”

MassHealth is a major public program serving many Massachusetts residents and using a large share of the state budget, so billing errors affect public money and trust.

“Medicaid expenditures represent approximately 38% of the Commonwealth’s total annual budget.”

For an ordinary resident, this audit is about whether taxpayer-supported healthcare dollars are being paid correctly and whether providers are following the rules.

“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”

The practice was told to fix its billing and repay MassHealth for overpayments tied to nurse practitioner services.

“Asaker Medical Associates should repay MassHealth for overpayments for all services performed by an independent NP but billed at the physician rate.”

MassHealth said it would start another review of Dr. Asaker based on this report and earlier audit findings.

“MassHealth will re-initiate a review of Dr. Asaker based on the State Auditor’s report and MassHealth’s previous audit findings.”

The audit found a concrete dollar impact: MassHealth likely paid too much because some services were billed as if the doctor performed them when the auditor said a nurse practitioner did.

“Based on our statistical sample of 88 E/M outpatient claims, we estimate that MassHealth made $24,357 of such overpayments during the audit period.”

A nurse practitioner is a licensed medical professional; a modifier code is a billing code that tells MassHealth a service was changed in some way, such as being performed by a non-independent nurse practitioner with a doctor.

“A modifier code is used when a medical procedure or service has been altered in some way.”