Minnesota Department of Human Services audit of medication therapy management programs

To inform medication therapy management (MTM) providers of findings of the Minnesota Department of Human Services review of claims submitted to Minnesota Health Care Programs (MHCP) for patients receiving MTM services and to discuss the impact of the audit on widespread MTM services and future audits.

A retrospective review was completed on MTM claims submitted to MHCP from 2008 to 2010. The auditor verified that the Current Procedural Terminology codes billed matched the actual number of medications, conditions, and drug therapy problems assessed during an encounter.

190 claims were reviewed for 57 distinct pharmacies that billed for MTM services from 2008 to 2010, representing 4.5% of all claims submitted. The auditor reported that generally, the documentation within the electronic medical record had the least "up-coding" of all documentation systems. A total of 18 claims were coded at a higher level than appropriate, but only 10 notices were sent out to recover money because the others did not meet the minimum $50 threshold.

The auditor expressed concerns that a number of claims billed at the highest complexity level were only 15 minutes long. Providers will need to be cautious of the conditions that they bill as complex and of how they define drug therapy problems. Everything for which is being billed must be clearly assessed or rationalized in the documentation note. The auditor expressed that overall, documentation was well done; however, many MTM providers are now asking how to internally prepare for future audits.