Office of Medicaid (MassHealth) Review of Dental Periapical Radiograph Claims Submitted by Hampshire Family Dental and Orchard Family Dental

This is a state audit of MassHealth payments to Hampshire Family Dental and Orchard Family Dental for a specific kind of dental X-ray over a five-year period.

“The Office of the State Auditor (OSA) has conducted an audit of dental periapical2 radiograph claims paid to Hampshire Family Dental and Orchard Family Dental for the period July 1, 2010 through June 30, 2015.”

The auditor looked at these claims because earlier audits had found problems with similar MassHealth dental X-ray payments, and these offices used this X-ray code more often than other providers.

“Because of the amount of these expenditures as well as prior OSA reports that have identified unallowable claims for periapical radiographs, OSA is conducting a series of audits focusing on providers of such radiographs.”

MassHealth is a major public program paid for with taxpayer money, so improper payments affect public trust and the state budget.

“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 Massachusetts resident or taxpayer, this audit is about whether public healthcare dollars were spent according to the rules and whether improper payments should be recovered.

“MassHealth provides access to healthcare services to approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities annually.”

The auditor says the offices should repay the improper payments and stop billing these X-rays as part of routine twice-yearly dental exams.

“Hampshire Family Dental and Orchard Family Dental should collaborate with MassHealth to repay the approximately $290,417 in improper payments they received for periapical radiographs.”

MassHealth said it would try to recover the overpayment and monitor the offices’ future claims, with possible record requests or on-site audits.

“MassHealth’s Provider Compliance Unit will seek to recover the overpayment from Hampshire Family Dental and Orchard Family Dental once the final report has been issued.”

The finding is significant because the auditor estimated that more than half of the sampled claims were not allowed, leading to a projected overpayment of about $290,417.

“Of these 120 claims, 72 were unallowable.”

A periapical radiograph is an X-ray that shows an entire tooth down to the jaw; MassHealth pays for it only in certain situations, such as part of a full-mouth series or when a specific dental problem is suspected.

“A periapical radiograph shows the whole tooth from the top to the jaw.”