Office of Medicaid (MassHealth)-Review of Selected Outpatient Evaluation and Management Services Claims Submitted by Dr. Kunwar S. Singh
April 27, 2016 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published April 27, 2016 Audit covers January 1, 2010 – June 30, 2015 Under Suzanne M. Bump · 2011–2023
source
“Based on our audit, we have concluded that Dr. Singh improperly billed MassHealth for E/M services totaling approximately $55,390.”
Read the plain-English breakdown
This is a state audit of certain MassHealth office-visit claims submitted by Dr. Kunwar Singh for services from January 1, 2010 through June 30, 2015.
“The Office of the State Auditor (OSA) has conducted an audit of selected outpatient evaluation and management (E/M) claims paid to Dr. Kunwar Singh for the period January 1, 2010 through June 30, 2015.”
The auditor reviewed the claims because MassHealth has had past problems with improper payments, and this audit was part of ongoing oversight of the Medicaid program.
“The audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program.”
MassHealth is a very large public program serving many Massachusetts residents and using a major share of the state budget, so billing problems affect public money and trust.
“Medicaid expenditures represent approximately 38% of the Commonwealth’s total annual budget.”
For ordinary residents, the issue is whether taxpayer-supported healthcare dollars are being paid only for properly documented services.
“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”
The report says Dr. Singh used high-complexity billing codes for many visits that the auditor found were routine or less complex.
“Specifically, Dr. Singh billed routine, less-complex cases using codes that were designated for high-complexity cases.”
The report recommends that Dr. Singh repay the estimated improper payments and improve billing controls; MassHealth said it would work to recover the money and monitor future claims.
“MassHealth’s Program Integrity Unit will work with Dr. Singh to recover the overpayment once the final report has been issued.”
The audit found problems in 50 of 60 sampled claims, then used that sample to estimate the total overpayment for the high-level codes reviewed.
“Of these 60 claims, we identified 50 as billed using an incorrect procedure code.”
“Upcoding” means billing a visit as more complex, and therefore more expensive, than the care documented in the record supports.
“This billing practice is referred to as upcoding.”
What the Auditor checked
- Did not comply Did Dr. Singh bill for outpatient E/M services provided to MassHealth members using procedure codes that reflected the level of service provided?
What the Auditor found
Why it matters: MassHealth made approximately $55,390 in improper payments.
Standard: 130 CMR 450.223(C), 130 CMR 450.307, the CPT Codebook, and CMS Documentation Guidelines for Evaluation and Management Services. ( Section 450.223(C) of Title 130 of the Code of Massachusetts Regulations; 130 CMR 450.307; 130 CMR 433.409 )
2 recommendations
- Dr. Singh should collaborate with MassHealth to repay the approximately $55,390 in improper payments he received from the upcoding of claims.agency: disagreed
- Dr. Singh should develop internal controls to ensure that his claims are not upcoded for E/M services.agency: agreed
Agency response & Auditor reply
Agency: "For all of these reasons, these claims cannot be deemed to be “upcoded” to a 99205 or 99215 visit, and, more importantly based on this evidence, cannot amount to a determination as an overpayment pursuant to 130 CMR 450.237."
Auditor: "MassHealth’s Office of Clinical Affairs staff confirmed that Dr. Singh’s medical records were deficient and did not support the claims he submitted using procedure codes 99205 and 99215."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
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