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NYS Comptroller

THOMAS P. DiNAPOLI

Taxpayers' Guide to State and Local Audits

Department of Health
Medicaid Program: Questionable Payments for Practitioner Services and Pharmacy Claims Pertaining to a Selected Physician


Issued: September 18, 2015
Link to full audit report 2012-S-35
Link to 90-day response

Purpose
To determine if Dr. Riaz Ahmad complied with Medicaid policies and whether Dr. Ahmad’s medical records support the services he billed and the prescriptions he wrote. The audit covered the period January 1, 2007 through December 31, 2011.

Background
Dr. Riaz Ahmad is a physician located in New York City who specializes in internal medicine. Dr. Ahmad has been enrolled in the Medicaid program since 1995. During the five years ended December 31, 2011, the Medicaid program (including Medicaid managed care plans) paid Dr. Ahmad $1,039,404 for 24,695 office visits. During this period, the Medicaid program also paid approximately $15 million for medications Dr. Ahmad prescribed in connection with those services.

Physicians participating in the Medicaid program are required to maintain complete, legible records for each Medicaid patient treated. The records must include information such as the pertinent medical history for each visit; notes regarding the patient’s progress and response to treatment; notation of all medications prescribed, including dosage and regimen; and a description of any diagnostic tests and the results of such tests. In addition, the patient record should include a statement regarding future visits or treatment as necessary. These records help ensure that an identifiable service was provided to the Medicaid recipient, and are required to support a physician’s Medicaid claim.

During the course of this audit, our fieldwork was temporarily suspended to avoid interfering with a review by other external oversight authorities.

Key Findings

  • Frequently, Dr. Ahmad’s medical records did not meet the minimum standards to support his Medicaid claims. Our review of a sample of Dr. Ahmad’s medical records found that they contained inadequate and sparse detail. Further, the Department of Health’s review of the records found that they lacked sufficient details to ensure adequate treatment of complex diseases, contained no treatment plans, and were illegible. Department of Health officials also determined the medical record details were not adequate to ensure continuity of care should another physician be required to treat Dr. Ahmad’s patients.
  • Due to deficiencies in Dr. Ahmad’s records, there was insufficient assurance that he provided appropriate medical care and that services totaling $1,039,404 warranted Medicaid payment. This included $712,250 for 19,031 fee-for-service claims paid directly by the Medicaid program to Dr. Ahmad and $327,154 for 5,664 claims paid by Medicaid managed care plans to Dr. Ahmad.
  • We question whether pharmacy claims totaling approximately $15 million for prescription drugs ordered by Dr. Ahmad were all necessary.
  • Subsequent to our audit, Dr. Ahmad’s claims to the Medicaid program for office visits significantly decreased – by about 55 percent. Similarly, payments for prescription drugs written by Dr. Ahmad also decreased – by nearly 60 percent.

Key Recommendations

  • Review the 19,031 Medicaid claims totaling $712,250 and recover overpayments as appropriate.
  • Review the 5,664 managed care claims totaling $327,154 and take appropriate corrective action.
  • Determine whether Dr. Ahmad’s medical records support the prescriptions he wrote and take appropriate corrective action.
  • Determine whether medical sanctions against Dr. Ahmad are warranted.

Other Related Audits/Reports of Interest

Department of Health: Improper Payments to a Physical Therapist (2013-S-15)
Department of Health: Improper Payments to a Dentist (2012-S-52)


State Government Accountability Contact Information:
Audit Director: Andrea Inman
Phone: (518) 474-3271; Email: StateGovernmentAccountability@osc.state.ny.us
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236