Office of Medicaid (MassHealth) - Review of Dental Periapical Radiograph Claims Submitted by Our Dentist
February 10, 2017 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published February 10, 2017 Audit covers July 1, 2010 – June 30, 2015 Under Suzanne M. Bump · 2011–2023
source
“However, based on Our Dentist’s comments on the need for these periapical radiographs, substantiated by our review of the member dental records, we concluded that the radiographs, though not adequately documented, were appropriately taken.”
Read the plain-English breakdown
This is a state audit of MassHealth payments to a Chicopee dental provider, Our Dentist, for a specific kind of dental X-ray called a periapical radiograph.
“OSA has conducted an audit of dental periapical2 radiograph claims paid to Our Dentist for the period July 1, 2010 through June 30, 2015.”
The auditor reviewed these claims because MassHealth spends a lot on these dental X-rays and previous audits had found improper claims in this area.
“Because of the significant 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.”
Good records matter because they support proper billing and give future dentists a complete picture of a patient’s dental history.
“However, without proper documentation of the need for these periapical radiographs in members’ files, members will not have a complete dental history if they need to see a new dental provider.”
If you are a MassHealth member or taxpayer, this audit is about making sure public healthcare money is spent properly and that patient records are complete.
“As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.”
MassHealth said it would work with its dental administrator and Our Dentist on better documentation, education, and monitoring of claims.
“MassHealth will work with its Dental third party administrator, DentaQuest, and Our Dentist to develop processes to document the reasons for taking periapical radiographs, in addition to providing education on MassHealth policies and recordkeeping requirements.”
The audit covered $13,480 in payments to Our Dentist for these X-rays and identified about $3,720 in claims where the reason was not properly documented.
“During this period, MassHealth paid Our Dentist approximately $13,480 to provide periapical radiographs for 447 MassHealth members.”
A periapical radiograph is a dental X-ray that shows an entire tooth, from the top down to where it sits in the jaw.
“A periapical radiograph shows the whole tooth from the top to the jaw.”
1 figure(s) pending source verification - not shown
What the Auditor checked
- Partially Did Our Dentist bill appropriately for periapical radiographs provided to MassHealth members, and did it maintain documentation in member dental records to properly support these claims?
What the Auditor found
Why it matters: Members may not have a complete dental history if they need to see a new dental provider.
Standard: 130 CMR 420.423(B)(3) and 130 CMR 420.414(B) ( Section 12 of Chapter 11 of the Massachusetts General Laws; Chapter 118E of the Massachusetts General Laws; Section 420.423(B)(3) of Title 130 of the Code of Massachusetts Regulations; 130 CMR 420.414(B) )
1 recommendation
- Our Dentist should ensure that the reasons periapical radiographs are taken are properly documented in members’ dental records.agency: no response
Agency response & Auditor reply
Agency: "Our Dentist chose not to provide written comments to this report; however, we discussed the content of the report with the auditee, whose verbal comments we considered when preparing this final report."
Verified dollar findings
Estimated or sample-projected amounts - shown separately because they are not a hard-identified dollar figure.
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