Office of Medicaid (MassHealth) Review of Controls over Dentist Billings for Detailed Oral Screenings and Other Dental Procedures
March 11, 2013 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published March 11, 2013 Audit covers January 1, 2008 – June 30, 2011 Under Suzanne M. Bump · 2011–2023
source
“As noted above, we question all of the 19,274 claims totaling $1,241,235 for detailed oral screenings submitted to MassHealth by the 10 dental providers in our sample during our audit period.”
Read the plain-English breakdown
This is a Massachusetts State Auditor report reviewing MassHealth dental billing controls for detailed oral screenings and several other dental procedures from January 1, 2008 through June 30, 2011.
“In accordance with Chapter 11, Section 12, of the Massachusetts General Laws, the Office of the State Auditor (OSA) conducted an audit of dental claims for detailed oral screenings and other dental procedures during the period January 1, 2008 through June 30, 2011.”
Auditors looked at these payments because earlier audits had found weaknesses in MassHealth dental claims processing, and Medicaid programs are considered vulnerable to fraud, waste, abuse, and mismanagement.
“This audit was conducted to determine whether the internal control and regulatory issues that the OSA identified during its previous audits of MassHealth’s Dental Program exist within its processing of claims for detailed oral screenings and several other selected dental procedures.”
The report says public trust depends on MassHealth paying only for medically necessary services and following the rules when processing claims.
“To maintain the public’s confidence in its Dental Program, MassHealth must have effective controls such as regulations that reflect best industry practices and policies and procedures in place to ensure that members receive only medically necessary services and that claims for such services are processed in accordance with all applicable state and federal laws and regulations.”
If you are a Massachusetts taxpayer or MassHealth member, this matters because weak controls can mean public healthcare money is spent on improper dental claims instead of necessary care.
“In fiscal year 2011, MassHealth paid a total of $266,987,637 in dental claims.”
The biggest issue was detailed oral screenings: auditors said 10 sampled providers were paid $1,241,235 for screenings that appeared to fall outside MassHealth’s rules.
“Consequently, the $1,241,235 in claims represents questionable costs to the Commonwealth.”
The auditor recommended that MassHealth review the questioned payments, recover money where appropriate, improve claim-system edits, and update rules and controls.
“MassHealth should also consider reviewing all payments made for this procedure by all of its providers during the past four fiscal years and recover any additional funds it deems appropriate.”
The audit points to a broader control problem: some improper claims were paid because MassHealth and its dental contractor did not have strong enough checks in place.
“Several previously issued OSA audit reports have disclosed significant weaknesses in the MassHealth Dental Program’s claims processing system, which resulted in millions of dollars in unallowable and potentially fraudulent claims.”
A “system edit” means an automatic claim-processing check that should catch and deny bills that break MassHealth rules before they are paid.
“Because DentaQuest’s claims processing system did not include edits to detect and deny claims for oral examinations that violated the limits for these services established by state regulations, the Commonwealth unnecessarily reimbursed these providers a total of $15,803 for the services in question during the audit period.”
5 figure(s) pending source verification - not shown
What the Auditor checked
- Partially Were dental claims filed by sampled participating dental providers accurate, properly supported, delivered, and in compliance with applicable laws, rules, and regulations?
What the Auditor found
Why it matters: MassHealth made as much as $1,241,235 in questionable payments to sampled providers.
Standard: 130 CMR 420.456(B)(1) and Subchapter 602 of the 2010 MassHealth Dental Program Office Reference Manual ( 130 CMR 420.456(B)(1); Subchapter 602 of the 2010 MassHealth Dental Program Office Reference Manual )
2 recommendations
- MassHealth should review the billings submitted by the 10 providers for detailed oral screenings and recover whatever amount of the $1,241,235 it deems appropriate.agency: agreed
- MassHealth should consider reviewing all payments made for this procedure by all providers during the past four fiscal years and recover any additional funds it deems appropriate.agency: agreed
Agency response & Auditor reply
Agency: "Based on the reported findings, MassHealth agrees that the sampled providers appear to be in violation of the regulation 130 CMR 420.456(B) in billing the service code D0160."
Auditor: "The responses we received from eight of the 10 sampled dental providers indicate that they bill for all dental procedures in accordance with the Current Dental Terminology (CDT) Reference Manual published by the American Dental Association."
Why it matters: MassHealth paid $37,687 for photographic image claims that should have been denied.
Standard: 130 CMR 420.423(E)(3) ( 130 CMR 420.423(E)(3) )
2 recommendations
- MassHealth should recover the $37,687 paid to the two providers for oral/facial photographic images contrary to MassHealth regulations.
- MassHealth should maintain the claims processing edit to deny oral/facial photographic image claims unless MassHealth requested the service.agency: already implemented
Agency response & Auditor reply
Agency: "Regarding the unallowable oral/facial photographic images, you state in your audit that MassHealth regulations allow for payment for oral/facial photographic images when MassHealth specifically requests a provider to take these images only."
Auditor: "However, MassHealth did not request the oral/facial images taken by Dr. Keefe and Dr. Sansouci."
Why it matters: MassHealth paid $15,803 for oral evaluation claims that were not allowable under frequency and same-day billing limits.
Standard: 130 CMR 420.422 ( 130 CMR 420.422 )
2 recommendations
- DentaQuest and MassHealth should modify system edits to identify and deny claims that violate oral evaluation limits.
- MassHealth should recover $15,803 in unallowable oral evaluation payments made during the audit period.
Agency response & Auditor reply
Agency: "DentaQuest currently has edits in the system that do not allow oral evaluations to be paid for more than the established limit as stated in the regulation."
Auditor: "As previously discussed, MassHealth has established 130 CMR 420.422 and 420.456, which limit the frequency and circumstances under which it will pay claims for member oral evaluations and emergency treatment visits, respectively."
Why it matters: MassHealth paid claims that represented unallowable costs because the participating dentist did not perform the services.
Standard: 130 CMR 420.404, 130 CMR 450.222, and 130 CMR 450.231 ( 130 CMR 420.404; 130 CMR 450.222; 130 CMR 450.231 )
2 recommendations
- MassHealth should instruct the provider to stop billing MassHealth for services performed by his spouse.agency: agreed
- MassHealth should determine and recover the total amount paid for services performed by the provider's spouse.agency: agreed
Agency response & Auditor reply
Agency: "In the interest and concern of the patient she may assist, however, I provide all services billed in my name."
Auditor: "These notations indicate that his spouse performed examinations and other dental procedures on certain MassHealth members."
Why it matters: MassHealth paid $14,280 for duplicate or excessive fluoride treatments.
Standard: 130 CMR 420.424(B)(1) and American Academy of Pediatric Dentistry recommendations ( 130 CMR 420.424(B)(1); American Academy of Pediatric Dentistry recommendations )
3 recommendations
- MassHealth should recover $14,280 paid to the two providers for unnecessary fluoride treatments.
- MassHealth and DentaQuest should develop an edit to identify and deny multiple fluoride treatment claims for the same member on the same day.agency: already implemented
- MassHealth should establish a regulation limiting annual fluoride treatments consistent with AAPD recommendations.agency: already implemented
Agency response & Auditor reply
Agency: "There was no frequency limitation on the service code D1203 for the dates of service the fluoride treatments were provided."
Auditor: "At Brockton Family Dental, we questioned the multiple applications of topical fluoride on the same member on the same day."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
Prior findings revisited
"Several previously issued OSA audit reports have disclosed significant weaknesses in the MassHealth Dental Program’s claims processing system, which resulted in millions of dollars in unallowable and potentially fraudulent claims."
"During previous audits, we identified other dental providers who had received payments for oral/facial photographic images contrary to state regulations."
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