Report Criticizes HHS' Fraud Detection Methodology

October 26, 2015
Jared Kaltwasser

A new report is raising questions about how the US Department of Health and Human Services' Office of the Inspector General uses clinical data to flag potential abuse.

A new report is raising questions about how the US Department of Health and Human Services’ Office of the Inspector General uses clinical data to flag potential abuse.

The study, produced by the consulting firm Sellers Dorsey and paid for by the Benevis Foundation, suggests that the methodology used by the OIG to identify potential fraud doesn’t properly account for some of the idiosyncrasies of caring for Medicaid patients. The Benevis Foundation is the research and education arm of Benevis Practice Services.

For instance, the OIG looks at the average number of services provided by each dentist on a given day. It notes that in Indiana, any dentist performing more than 51 procedures per day is flagged as an “outlier.” However, the report notes that there is a relatively small number of dentists who accept Medicaid for pediatric patients. Thus, a provider might need to see more patients per day in order to accommodate demand. By looking only at the number of procedures performed per day, the OIG might conclude that a dentist who sees 13 patients per day and performs 52 procedures is more of an outlier than a dentist who sees seven patients per day and performs 49 total procedures, even though the former dentist would have a lower procedure per patient rate.

The paper warns that the OIG could unintentionally create a “chilling effect” that could persuade other dentists to stop accepting Medicaid patients. That’s a problem, because, according to Scion Dental, only about 15% of all US dentists accept Medicaid.

“We look forward to working with government officials and other stakeholders in a collaborative and transparent way to ensure this patient population’s needs continue to be met while also ensuring the integrity of the Medicaid dental program,” said Geoffrey Freeman, a spokesman for the foundation. “Every child deserves a dental home. It is important that we work together to ensure that dentists continue to accept and take care of this underserved population.”

The white paper is available online here.

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