Posted and filed under Fraud, Medical Record Auditing.

A 2017 audit fronted by Massachusetts State Senator Suzanne M. Bump revealed over $190 billion dollars in improper or ambiguous payments within MassHealth’s Behavioral Health program. The audit uncovered years of questionable billing practices, lack of administrative oversight, and conflicting understandings of requirements, regulations, and internal policies. The Senator went on the record explaining the disparities within MassHealth’s program by stating, “Some of the problems identified stem from MassHealth and its contractors’ different understandings of who is to pay what; other times MassHealth simply acts contrary to its own rules and standards.”

Many identifiable problems can be extracted from this audit and its results, including the breadth of ambiguous payments and errors in administration. Below is a short list of the most problematic, costly errors committed by MassHealth and their vendors:

  • MassHealth was found to be in a breach of contract with Massachusetts’s Behavioral Health Partnership (MBHP) for providing behavioral health and substance abuse care to members at a fixed monthly fee. From 2010-2015, MassHealth paid MBHP $2.6 billion dollars. The problem was that MassHealth was also paying doctors directly in the sum of $93 million for the exact same services.
  • MassHealth submitted nearly $100 million in payments for items such as family therapy session, behavioral health counseling, and psychological testing – none of which were definitively covered in their contract with MBHP.
  • MassHealth paid claims for behavioral health services that were rendered in the ER, instead of referring them to MBHP. This was a direct violation of their own

Each and every audit is inherently educational, which leaves us with one loaded question…

What Can This Teach Us?

The short answer is: a lot.

Consider for a moment the margin of error for internal discrepancies. The case of MassHealth demonstrates just how expensive these internal errors can be. When you factor in the exorbitant amount of errors that occur with a single avenue for failure and combine it with the myriad of external factors: CPT code changes, CMS regulations, state and federal guidelines, upcoding/downcoding…these mistakes become detrimental to an office, an organization, to an entire health system.

It’s important for any actor in the healthcare ecosystem to approach coding, billing, documentation, and reimbursements with a holistic point of view. A physician may think that undercoding only harms their bottom line – but with $1.1 billion in undercoded claims being reported, this presents a problem for the entire industry. Similar leniency on the payer side could also result in skewed reports and problematic audits – so please approach every claim and every audit with the utmost care.

Fortunately, where there’s room for error there is also room for correction. In the behavioral health specialty, specifically, there are typically three common and avoidable culprits for errors and denials. These include: insufficient or faulty documentation, policy violations (sound familiar?), and number of units billed (therapy).

Documentation may seem like an obvious answer, but there’s more to it than making sure the doctor signs off on the chart. Documentation errors occur because of missing notes, insufficient orders, lack of care plans, time sheets, and evidence that a procedure was performed. Before submitting any claims, it is imperative to ensure that you are meeting all requirements for documentation. Make sure that you’re avoiding using pre-populated EHR templates, verify chart legibility, and be ready to appeal any denials with legitimate proof.

Number of units billed is perplexing to many coders and auditors, so pay extra close attention to the details when it comes to coding for time spent on/in therapy. If the treatment lasted 15 minutes, under no circumstances should you be billing for a one-hour session.

You’ve already heard about the dangers of policy violations, but it’s worth another mention. Policies can include those instated by Medicare, by a commercial health plan, or by the state and federal government. These errors typically include failure to provide sufficient progress notes, the billing of non-covered services, and abandonment of prior-authorization ordinances. To prevent policy violations be sure to maintain a current and updates knowledge on all relevant sources, and ensure that your team has a uniform understanding of these guidelines.

Another recommendation would be to pay close attention to Evaluation and Management claims, especially when it comes to behavioral health. For tips on how to get started with coding and auditing E/M for psych and behavioral health, check out this module.