State auditor: Carlisle optometrist owes MassHealth $310,000

Doctor submitted improper and incorrectly documented claims

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CARLISLE — A Carlisle-based optometrist is requested to repay over $310,000 to MassHealth for improper and incorrectly documented claims, State Auditor Suzanne Bump announced Tuesday.

Dr. Frederick Wagner Jr. owns an optometry business, but travels to nursing facilities statewide, according to Bump’s news release.

According to the audit — which examined the period from Jan. 1, 2014 to Dec. 31, 2017 — there were documentation issues with 113 out of 180 sampled MassHealth vision care claims paid to Wagner.

On 226 occasions, Wagner received payment from MassHealth for services, though no eyeglasses were ordered from the supplier, the audit found.

In addition, Wagner submitted bills with dates that did not match patients’ medical records, the state alleges.

“If the date of service is wrong, members might incorrectly be denied services for which they are eligible, or a provider might be paid for services that were not eligible for reimbursement; such overpayments could have been allocated to Medicaid or other state benefit programs,” the audit states.

“I have concerns that some of Dr. Wagner’s patients, many of whom are individuals with Alzheimer’s disease, dementia, and other similar conditions, may not have been able to properly consent to the procedures provided, resulting in these improper payments,” Bump said in the news release.

MassHealth identified similar problems with Wagner’s documentation prior to the state audit.

Bump recommends Wagner reimburse MassHealth for $310,112. In addition, she advised MassHealth to amend its policy on non-emergency transportation claims.

The current regulation allows providers to submit claims for transportation to each patient, even if multiple patients are seen at the same location. Under this policy, Wagner was paid for travel to 27 patients, but only visited two nursing facilities, the state auditor said.

“The current policies of MassHealth regarding transportation claims defy logic and are ripe for abuse,” Bump said in the news release. “MassHealth must revise this policy and implement protocols to ensure physicians cannot bill the program multiple times for a single trip.”

Over the course of the audit, Wagner submitted 35,385 claims and received $1,045,556 from MassHealth.

Wagner told auditors that he does record medical history, examinations and medical decisions. He also said that he begins filling out documentation before a patient’s exam. If the examination doesn’t take place as scheduled, Wagner said he returns another day to fulfill it, but doesn’t update the date on document, according to the audit.

“Although we did find some evidence of these components in members’ medical records, it was not adequate to support the level of E/M (evaluation and management) service billed,” the audit states.

Wagner did not respond to telephone message left at his Carlisle office.