Sneak Preview: Mass. Auditor Requests Drug Service Modifications

May 17, 2018 | By Jerry Ashworth | Post a Comment

xsass_bookshot(The following was excerpted from a recent article in the Single Audit Information Service.) The Massachusetts Office of State Auditor (OSA) made numerous recommendations in a recent audit aimed at helping MassHealth, which oversees the state’s Medicaid program, address its long-standing weaknesses related to improperly paying claims for Medicaid drug testing and drug screening services.

MassHealth covers medically necessary laboratory services, including drug tests and screens, provided to its members. From 2013 to 2017, MassHealth paid about $39.3 million for more than two million drug testing and screening claims. State law requires MassHealth to pay laboratories for drug tests and drug screens as long as the laboratory has received “a written request to perform that specific service from an authorized prescriber who is treating the member and will use the tests for the purpose of diagnosis, treatment or any otherwise medically necessary reason.” MassHealth further instructs laboratories to use specific procedure codes when billing for each qualitative drug screen and quantitative drug test performed on its members.

A “qualitative/presumptive drug screen” is used to detect the presence of a drug in the body. A test that can estimate the amount of drug in a specimen is called a “quantitative drug test.”

After auditing MassHealth’s payment of drug tests and screens from March 1, 2013, through June 30, 2017, OSA found that MassHealth overpaid claims for these services by as much as $4.38 million. “This audit shows that measures taken by MassHealth have not fully addressed problems related to drug screening and testing,” said Massachusetts State Auditor Suzanne Bump, referring to a similar OSA audit in 2013 that also found that MassHealth’s Medicaid Management Information System (MMIS) claims processing system improperly paid millions of dollars for drug tests and screening. “More work is needed to stop additional money from being wasted. MassHealth needs to take stronger measures to stop drug labs from ripping off taxpayers.”

In response to the 2013 audit, MassHealth in January 2013 developed and implemented an edit to MMIS to prevent and deny payment for certain drug test procedure codes when billed for the same member on the same day. MassHealth installed this system update to prevent laboratories from “unbundling” (i.e., a process in which providers bill MassHealth for multiple procedures individually) certain quantitative drug test procedure codes when also billing for qualitative drug screens provided to a MassHealth member on the same day.

(The full version of this story has now been made available to all for a limited time on Thompson’s Grants Compliance Expert site.)

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