Purpose

To determine the implementation status of the four recommendations made in our initial audit report, Questionable Payments for Practitioner Services and Pharmacy Claims Pertaining to a Selected Physician (2012-S-35).

Background

Our initial audit report, which was issued on September 18, 2015, found significant issues with medical records provided by a physician, Dr. Riaz Ahmad, to support his Medicaid claims. Our review of a sample of Dr. Ahmad’s medical records found they contained inadequate and sparse detail. The Department’s review of this sample found the records lacked sufficient details to ensure adequate treatment of complex diseases, contained no treatment plans, and were illegible. Department 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 the 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 and $327,154 for 5,664 encounter claims paid to Dr. Ahmad. We also questioned whether medications Dr. Ahmad prescribed in connection with these services, which accounted for 137,637 pharmacy claims totaling approximately $15 million, were all necessary.

In our initial audit, we made four recommendations to the Department to review Dr. Ahmad’s claims and recover overpayments as appropriate; determine whether Dr. Ahmad’s prescriptions were supported by his medical records; and determine if medical sanctions against Dr. Ahmad were warranted.

Key Finding

• At the time of our follow up review, the Office of the Medicaid Inspector General (OMIG) was actively investigating Dr. Ahmad. According to OMIG officials, steps will be taken to implement each of the four recommendations made in our initial audit pending the results of the investigation. Of the initial report’s four audit recommendations, all four were partially implemented.

Key Recommendation

• Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.

Other Related Audit/Report of Interest

Department of Health: Medicaid Program - Questionable Payments for Practitioner Services and Pharmacy Claims Pertaining to a Selected Physician (2012-S-35)