MassHealth Providers Engage in Improper Telehealth Billing Practices

A recent report from the Commonwealth of Massachusetts Office of the State Auditor described the MassHealth expenses between January 1, 2020, and June 30, 2021, and the number of providers who engaged in improper telehealth billing practices.

Findings from the Office of the State Auditor (OSA) revealed $91,852,881 in provider payments for virtual behavioral health services that did not meet documentation requirements.

The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to investigate fraud, waste, and abuse in the Medicaid program of the Commonwealth, which is known as MassHealth. In this performance audit, OSA reviewed MassHealth payments for telehealth behavioral health services that occurred during an 18-month period. Between January 1, 2020, and June 30, 2022, MassHealth paid about $96,464,816 for $1,306,414 claims to its providers for virtual behavioral health.

The OSA noted that several previous audit reports detailed weaknesses in the claim processing system of MassHealth as well as improper billing practices from providers. To improve and ensure public confidence, the OSA provided a summary that included its findings and the recommendations that resulted from the research.

At the beginning of 2019, MassHealth announced that it would be covering telehealth behavioral health services from there on out, assuming that all participants would be willing to abide by various rules and regulations. On March 10, 2020, however, Governor Charlie Baker declared a state of emergency in the Commonwealth due to the surge in COVID-19 cases that took place at the time, which led to telehealth flexibilities.

Every six months between March 1, 2019, and June 30, 2021, a recap of MassHealth telehealth services took place, detailing expenses and claims. When comparing the periods of March 1, 2019, to August 31, 2019, and March 1, 2021, to June 30, 2021, it was evident that the monthly average number of claims for non-telehealth behavioral health service and expenses gradually dropped.

Following the detailing of this information, the report noted how Section 12 of Chapter 11 of the Massachusetts General Laws led the OSA to conduct a performance audit of MassHealth activities during the given period, in this case, January 1, 2020, to June 30, 2021.

Following this review, the OSA composed an audit objective that questioned whether MassHealth monitored telehealth practices for behavioral health services to confirm they comply with the “Requirements for Telehealth Encounters,” located in the appendix and supplemental materials.

This led the OSA to conduct inquiries with MassHealth officials to better understand the internal control environment. The information they gained related to telehealth claims for behavioral health services for the audit period, as well as insight into medical record documentation.

The office recommended that MassHealth should provide training for providers to confirm that the documentation of telehealth services coincides with All Provider Bulletins.