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State inspectors discovered that 329 general dentists and six orthodontists in California charged $117 million in questionable billing for 2012 Medicaid pediatric dental services.
The Office of Inspector General (OIG) recommended these dentists undergo further scrutiny to determine whether they are committing fraud or if disciplinary action is warranted.
“Our findings raise concerns that certain providers may be billing for services that are not medically necessary or were never provided. They also raise concerns about the quality of care provided to children with Medicaid,” the report stated.
The OIG, whose mission is to protect the integrity of the Department of Health and Human Services, identified the dentists by auditing Medicaid billing for the year 2012. Using a series of measures to compare the billing for offices, the identified providers whose billing and services numbers were far higher than the average office. They determined these dentists, who represented about 8% of the dentists in the state, required further investigation.
The OIG report is part of a series of reports investigating dental providers that charge Medicaid for services either unnecessary or fictional. Similar investigations occurred in New York, Louisiana, and Indiana. These investigations began following the discovery that many dental providers and large dental chains nationwide provided unnecessary dental procedures to children with Medicaid.
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Unnecessary, harmful, and possibly fraudulent procedures
The three most common questionable procedures include pulpotomies, also known as “baby root canals,” stainless steel crowns, and extractions. The OIG expresses in their report concerns that they might not only be unnecessary, but also might have caused harm to the children.
The report details some of the severe examples of excessive procedures on young children they uncovered in their investigation. One examination regarding some dentist’s billing for stainless steel crowns showed nine dentists provided more than 15 stainless steel crowns per visit to ten children, aging in range from two- to five-years-old. In one case, a dentist claims to have provided 19 pulpotomies and 15 other services to a 3-year-old child. In another case, a dentist reported providing 19 pulpotomies and 21 other services on a 5-year-old child. The audit also revealed that seven dentists performed extractions on 80% of the children they treated, and one dentist’s billing history revealed he performed extractions on 98% of the children he treated.
The six orthodontists identified in the audit showed Medicaid treatment activities inconsistent with those of their peers. Medicaid covers orthodontic care only for children with severe dental problems, including those with cleft palates or suffering malocclusion. But these six dentists provided care to over 584 children, and one of them claimed to provide services to 1,079 children. The OIG wondered how these doctors could provide care adhering to the standards required by their profession.
In addition to large numbers of particular treatments, the audit also revealed that 229 general dentists provided large numbers of service per day. The average dentist performed 24 services per day to children with Medicaid. However, the 229 dentists identified by the OIG showed they performed 76 services a day. Two dentists in this group averaged 500 services per day. One particularly dentist claimed to have performed 1,658 services in one day.
Regarding this last example, the report goes on to explain, “If this dentist spent only five minutes performing each service, it would have taken over 138 hours to complete all of these services.” The report goes on to explain that numbers like these indicated the services never happened.
The OIG notes in their report that half of these providers (166 in total) worked for chains, which they suggest indicates the chains encourage their providers to participate in the practice of performing the unnecessary procedures to boost profits.
In their conclusion, the report stated the following: “Our findings raise concerns that certain dental providers may be billing for service that are no medically necessary or were never provided. They also raise concerns about quality of care and whether children treated by these providers were harmed by these procedures.”
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The OIG submitted the report to the California Department of Health Care Services (DHCS), which recommended four recommendations to fix the problems. The DHCS agreed and has begun implementation of each of the following:
· Increase its monitoring of dental providers to identify patterns of questionable billing. The DHCS will update their criteria for monitoring the billing to resemble that of the OIG’s audit by the end of 2015.
· Closely monitor billing by providers in dental chains. The DHCS will further monitor billing by the dental chains within its authority.
· Review its payment processes for orthodontic services. Using the OIG report as a basis, their intention is to revise the way claims are processed for orthodontia.
· Take appropriate action against dental providers with questionable billing. The DHCS will pursue appropriate disciplinary action against providers identified in the report that reside within their authority. They have set a deadline for these actions for December 2015.
To read the full report of the OIG to the California Department of Health Care Services, please click here.