Audit of the Office of Medicaid (MassHealth) - Review of Claims by Reen & Reen, DMD, P.C.

This is a Massachusetts State Auditor performance audit of orthodontic claims that MassHealth paid to Reen & Reen, DMD, P.C. for services from July 1, 2012 through June 30, 2017.

“OSA has conducted an audit of orthodontic claims paid to Reen & Reen, DMD, P.C. (R&R), doing business as Reen & Willcutts Orthodontics, for the period July 1, 2012 through June 30, 2017.”

The auditor chose this provider after reviewing MassHealth orthodontic claims and finding high costs, frequent services, and billing patterns that could indicate problems.

“Based on the results of this analysis, we selected R&R for audit.”

MassHealth is a major public healthcare program, so billing errors can affect public money and public trust.

“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”

If you are a taxpayer or MassHealth member, this audit is about whether public healthcare dollars were billed correctly and whether oversight can catch mistakes.

“The purpose of the audit was to determine whether R&R properly billed MassHealth for orthodontic services and maintained documentation in members’ dental records to support these services.”

The auditor answered no to the main question of whether R&R properly billed MassHealth and kept enough supporting records.

“Did R&R properly bill MassHealth for orthodontic services and maintain documentation in member dental records to support these services?”

MassHealth said it would require training, monitor the provider, and use sanctions if the provider does not follow the rules.

“MassHealth intends to monitor this provider for compliance with these requirements, and will impose appropriate sanctions for noncompliance.”

The problems were not just paperwork: wrong provider numbers can make monitoring harder, and billing MassHealth before private insurance is settled creates a risk of MassHealth paying when it should not.

“As a result, there is a higher-than-acceptable risk that R&R could receive and retain payments from MassHealth to which it is not entitled.”

An explanation of benefits, or EOB, is the document from a private insurer showing whether it paid or denied a service; the audit says R&R should wait for that before billing MassHealth when a patient has private insurance.

“R&R should not bill MassHealth for any orthodontic services for a member until it has received an EOB from the member’s private insurance carrier.”