Office of Medicaid (MassHealth) - Review of Evaluation and Management Claims Submitted by Dr. Hooshang D. Poor
August 21, 2017 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published August 21, 2017 Audit covers January 1, 2012 – September 30, 2015 Under Suzanne M. Bump · 2011–2023
Read the plain-English breakdown
This is a Massachusetts State Auditor review of MassHealth payments to Dr. Hooshang D. Poor for evaluation and management medical services from 2012 to 2015, with some expanded review periods for specific issues.
“The purpose of this audit was to determine whether Dr. Poor billed MassHealth for E/M services using appropriate procedure codes and modifier codes, met recordkeeping requirements, and provided supervision of NPs and a PA engaged in prescriptive practices in accordance with certain laws, rules, and regulations.”
The auditor chose this provider because data showed he submitted far more MassHealth E/M claims than most comparable doctors.
“We selected Dr. Poor for an audit because, using data analytics, we determined that the high number of claims that MassHealth paid him greatly exceeded the number of claims it paid most of his peers, as illustrated below.”
MassHealth is a major public program, so improper billing can affect public dollars and oversight of healthcare services for vulnerable residents.
“Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.”
If you are a Massachusetts taxpayer or MassHealth member, this report is about whether public healthcare money was spent properly and whether patient care was documented and billed correctly.
“MassHealth provided access to healthcare services to approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities in 2016.”
The auditor found multiple billing and documentation problems and recommended that Dr. Poor work with MassHealth to repay or determine amounts owed.
“MassHealth agrees with the OSA finding that Dr. Poor should repay MassHealth amounts due the Commonwealth.”
MassHealth said it would coordinate with the Attorney General’s Medicaid Fraud Division and act when appropriate.
“MassHealth will coordinate with MFD and will take action when appropriate.”
The report matters because it found problems across several areas: too many visits, wrong codes, missing modifiers, billing while out of the country, lack of prescribing guidelines, missing documentation, and illegible notes.
“Below is a summary of our findings and recommendations, with links to each page listed.”
E/M means evaluation and management services, basically medical visits and care-management work. Modifier codes tell MassHealth when a nurse practitioner or physician assistant did the work, which should usually pay less than a doctor visit.
“These modifier codes prompt MassHealth to pay 85% of the rate it would pay for a physician to provide these services.”
1 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did Dr. Poor perform visits to MassHealth members residing in nursing facilities only once a month, except in emergencies?
- Did not comply Did Dr. Poor properly bill for E/M services provided to MassHealth members using the required modifier codes for services performed by non-independent NPs or PAs?
- Did not comply Did Dr. Poor properly bill for E/M services provided to MassHealth members using procedure codes reflecting service locations?
- Did not comply Did Dr. Poor and his non-independent NPs and PA mutually develop written prescriptive guidelines?
- Did not comply Did Dr. Poor properly bill for E/M services while he was out of the United States?
- Did not comply Did Dr. Poor maintain proper documentation in members’ medical records to support E/M services provided?
What the Auditor found
Why it matters: MassHealth improperly paid $176,730 for services that exceeded coverage limits and were not documented as emergencies.
Standard: Section 433.416(B) of Title 130 of the Code of Massachusetts Regulations ( Section 433.416(B) of Title 130 of the Code of Massachusetts Regulations )
3 recommendations
- Dr. Poor should only provide one E/M service per month for MassHealth members unless emergency services are warranted.
- Dr. Poor should regularly review MassHealth regulations, bulletins, and updates to ensure future compliance with all coverage limitations.
- Dr. Poor should collaborate with MassHealth to repay the $176,730 that resulted from excessive E/M services.
Agency response & Auditor reply
Agency: "If there is concern that patients were being seen more than clinically appropriate, then I would like to review these specific cases with a clinical adviser and clarify the management."
Auditor: "Our conclusions are not based on clinical determinations, nor do we suggest that Dr. Poor should postpone medically necessary care to his patients."
Why it matters: MassHealth paid the standard physician rate instead of the lower NP and PA rate, resulting in at least $35,541 in overpayments.
Standard: 101 CMR 317.04(3), 101 CMR 317.03(4), 101 CMR 317.04(4), MassHealth All Provider Bulletin 230, and 130 CMR 450.301 ( 101 CMR 317.04(3); 130 CMR 450.301 )
3 recommendations
- Dr. Poor should ensure that his billing staff submits claims with the required modifier codes for services performed by his NPs or his PA.agency: no response
- Dr. Poor should develop an oversight process to ensure that claims are reviewed before submission and that they include proper modifier codes.agency: no response
- Dr. Poor should collaborate with MassHealth to determine amounts due the Commonwealth.agency: no response
Agency response & Auditor reply
Agency: "Dr. Poor did not provide comments on this finding."
Why it matters: MassHealth made $12,608 in improper payments and the auditor recommended repayment of $10,833 after excluding overlaps with other findings.
Standard: 101 CMR 317.02 and 101 CMR 317.04(4) ( 101 CMR 317.02; 101 CMR 317.04(4) )
2 recommendations
- Dr. Poor should use proper procedure codes when billing for services provided to members in rest homes.
- Dr. Poor should collaborate with MassHealth to repay the overpayment of $10,833 that resulted from the use of improper procedure codes for services provided to members in rest homes.
Agency response & Auditor reply
Agency: "According to the billing staff member, the MassHealth representative said “that the procedure codes were the same for place of services 31, and 32 [and] the reimbursement was the same for each place of service code.”"
Auditor: "The response Dr. Poor’s billing staff received from MassHealth did not address our concerns about using the wrong procedure codes for E/M are provided to members residing in rest homes."
Why it matters: MassHealth paid for services billed under Dr. Poor's provider number even though he was out of the country, resulting in $15,477 in questioned payments and a recommended repayment of $13,673 after exclusions.
Standard: 130 CMR 450.301(A), 130 CMR 450.235(A), and Section 3729(a)(1) of Title 31 of the United States Code ( 130 CMR 450.301(A); 130 CMR 450.235(A); Section 3729(a)(1) of Title 31 of the United States Code )
2 recommendations
- Dr. Poor should only bill MassHealth for E/M services he provides to members.
- Dr. Poor should collaborate with MassHealth to repay the overpayment of $13,673 that resulted from E/M services billed for dates when he was out of the country.
Agency response & Auditor reply
Agency: "Your report claims that there was billing under my name as the provider while I was out of the country, but there are discrepancies between my own passport and the report you received from the Department of Homeland Security."
Auditor: "We obtained information about Dr. Poor’s travel between May 14, 2010 and April 24, 2016 from the United States Department of Health and Human Services’ Office of Inspector General, the United States Department of Homeland Security, and OSA’s Bureau of Special Investigations, including passenger activity reports of travel dates and locations from each of his passport numbers."
Why it matters: The NPs and PA prescribed medications, including controlled substances, without required written guidance, which may have compromised members' health and wellbeing.
Standard: 244 CMR 4.07(2)(a), 244 CMR 4.07(2)(b)(8), and 263 CMR 5.07(4) ( 244 CMR 4.07(2)(a); 244 CMR 4.07(2)(b)(8); 263 CMR 5.07(4) )
3 recommendations
- Dr. Poor and his NPs and PA should immediately develop written prescriptive guidelines for his NPs and PA to follow when performing E/M services under his supervision.
- Dr. Poor’s NPs and PA should immediately cease all prescriptive practices until such guidelines have been developed.
- Dr. Poor and his NPs and PA should immediately notify the Department of Public Health and the federal Drug Enforcement Administration of the inaccurate information they provided to these agencies while seeking authorization for the NPs and PA to prescribe controlled substances.
Agency response & Auditor reply
Agency: "I will not be able to provide the form for [my] PA as she no longer works with me."
Auditor: "Although Dr. Poor indicated that he had filed an application for Massachusetts Controlled Substances Registration for Advanced Practice Registered Nurses and Physician Assistants for his NP, he did not indicate that he was taking any measures to address our recommendations on this matter."
Why it matters: MassHealth paid at least $79,388 for claims without evidence that the services were actually provided.
Standard: 130 CMR 450.205(A) ( 130 CMR 450.205(A) )
2 recommendations
- Dr. Poor should ensure that documentation is maintained to support services claimed.
- Dr. Poor should collaborate with MassHealth to determine amounts due the Commonwealth.
Agency response & Auditor reply
Agency: "I would like to see the specific reports from the clinical adviser that stated that notes . . . lacked supporting documents."
Auditor: "OSA did not need a clinical advisor to assess the adequacy of the clinical notes that Dr. Poor maintained."
Why it matters: Illegible medical records failed to support claims and resulted in at least $24,501 in questionable payments, with $7,619 recommended for repayment after exclusions.
Standard: 130 CMR 450.205(D) ( 130 CMR 450.205(D) )
2 recommendations
- Dr. Poor should ensure that his handwriting is legible when recording E/M services in members’ medical records.
- Dr. Poor should collaborate with MassHealth to repay the overpayment of $7,619 that was related to illegible service documentation.
Agency response & Auditor reply
Agency: "I would like to see the specific reports from the clinical adviser that stated that notes were deemed illegible."
Auditor: "OSA did not need a clinical advisor to assess the legibility of Dr. Poor’s medical notes."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
Funds recovered or repaid to the Commonwealth.
Estimated or sample-projected amounts - shown separately because they are not a hard-identified dollar figure.
Identified dollar findings that do not fall in a named band.
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