Office of Medicaid (MassHealth) - Review of Dental Periapical Radiograph Claims Submitted by Webster Square Dental Care
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
“Based on our audit, we have concluded that Webster Square Dental Care improperly billed MassHealth for dental periapical radiographs totaling approximately $246,497 during the audit period; 55% of the claims paid during this period were unallowable.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of MassHealth payments to Webster Square Dental Care for a type of dental X-ray over a five-year period.
“I am pleased to provide this performance audit of claims that Webster Square Dental Care submitted to the Office of Medicaid for dental periapical radiographs.”
The auditor looked at these claims because MassHealth had paid large amounts for this type of X-ray, and past 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.”
MassHealth is a major public program funded by taxpayers, so improper payments affect public money and trust in the system.
“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 taxpayer or MassHealth member, this audit is about whether public healthcare dollars were spent according to the rules and whether improper payments should be recovered.
“Webster Square Dental Care should collaborate with MassHealth to repay the approximately $246,497 in improper payments it received for periapical radiographs.”
The auditor concluded that Webster Square Dental Care was paid for X-rays that were not properly allowed under MassHealth rules, often because they were done as routine exam X-rays.
“Specifically, it billed for dental periapical radiographs as part of routine dental examinations.”
MassHealth said it would try to recover the overpayment, educate the provider on rules, and monitor future claims for possible overuse.
“MassHealth’s Provider Compliance Unit will seek to recover the overpayment from Webster Square Dental Care once the final report has been issued.”
The audit found a large error rate: more than half of the sampled claims were not allowable, leading to a projected overpayment of about $246,497.
“Of these 60 claims, 33 were unallowable.”
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 where the tooth is secured in the jaw.”
1 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did Webster Square Dental Care 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: MassHealth made approximately $246,497 in improper payments for unallowable radiographs, creating waste and recovery risk for the Medicaid program.
Standard: MassHealth regulations 130 CMR 420.423(B)(3) and 130 CMR 420.414(B). ( Section 420.423(B)(3) of Title 130 of the Code of Massachusetts Regulations; 130 CMR 420.414(B) )
2 recommendations
- Webster Square Dental Care should collaborate with MassHealth to repay the approximately $246,497 in improper payments it received for periapical radiographs.agency: disagreed
- Webster Square Dental Care should ensure that in the future, it does not bill MassHealth for periapical radiographs that are unallowable under MassHealth regulations, such as those performed as part of routine dental examinations.agency: disagreed
Agency response & Auditor reply
Agency: "We disagree with these findings for the following reasons:"
Verified dollar findings
Estimated or sample-projected amounts - shown separately because they are not a hard-identified dollar figure.
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