Review of Claims Submitted to MassHealth by the Office of Dr. Doreen Chong, DDS
May 10, 2011 · Office of Medicaid (MassHealth) · Read the full official report (PDF) ↗ · official site ↗
Published May 10, 2011 Audit covers July 1, 2005 – June 30, 2010 Under Suzanne M. Bump · 2011–2023
source
“Our audit identified unallowable payments to Dr. Chong for radiographs, orthodontic consultations, periodic orthodontic treatment visits, and orthodontic retention totaling $82,316.”
Read the plain-English breakdown
This is a Massachusetts State Auditor review of MassHealth payments to one Boston orthodontic provider over a five-year period.
“In accordance with Chapter 11, Section 12, of the Massachusetts General Laws, the Office of the State Auditor conducted an audit of dental claims submitted by Doreen Chong, DDS during the period July 1, 2005 to June 30, 2010.”
The audit was part of the State Auditor’s ongoing oversight of the state Medicaid program, after broader concerns had been found in MassHealth dental claims processing.
“This audit was conducted as part of the Office of the State Auditor’s (OSA) ongoing independent statutory oversight of the Massachusetts Medicaid program.”
The report says weaknesses in the dental claims system let improper payments get through instead of being flagged before payment.
“Due to deficiencies within the Dental Program’s claims processing system, these unallowable claims went undetected by MassHealth.”
If you are a taxpayer or MassHealth member, this matters because the audit is about whether public health care money was paid according to the rules.
“MassHealth, within the Massachusetts Executive Office of Health and Human Services (EOHHS), administers the state’s Medicaid program, which provides access to healthcare services, including dental services, to approximately one million eligible low- and moderate-income individuals, couples, and families.”
MassHealth and DentaQuest said they were adding reviews, edits, reports, and monitoring to catch or recover payments that do not meet the rules.
“DentaQuest will generate appropriate reports to identify all providers who have received more retention payments than regulations allow.”
The finding is not just about one office; the report ties it to broader weaknesses in MassHealth’s dental claims controls that had allowed ineligible and possibly fraudulent payments.
“This audit identified that deficiencies in the MassHealth dental claims processing system have resulted in millions of dollars in ineligible claims and, in some cases, potentially fraudulent claims being paid by MassHealth.”
“Edits” means automated checks in the claims system that should stop claims that do not meet MassHealth rules.
“Moreover, we found that the Dental Program’s claims processing system, which DentaQuest administers for MassHealth, does not contain adequate edits to identify and reject unallowable claims such as these for orthodontic services.”
What the Auditor checked
- Partially Determine whether certain dental claims submitted by Dr. Chong were accurate and properly supported by required documentation; services were delivered; and billings and payments were in compliance with applicable laws, rules, and regulations.
What the Auditor found
Why it matters: MassHealth paid $82,316 in unallowable claims, creating a risk that claims processing deficiencies would allow ineligible orthodontic service payments to go undetected.
Standard: 130 Code of Massachusetts Regulations 420.431 ( Chapter 11, Section 12, of the Massachusetts General Laws; 130 Code of Massachusetts Regulations 420.431 )
1 recommendation
- Dr. Chong should establish procedures to ensure claims submitted to MassHealth comply with state regulations.
Agency response & Auditor reply
Agency: "DentaQuest will generate appropriate reports to identify all providers who have received more retention payments than regulations allow."
Auditor: "Overall, based on its written comments, MassHealth is taking measures, including making improvements to its internal controls over these payments, to address our concerns relative to the issues we raise in this report."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
Prior findings revisited
"Our prior audit report, Independent State Auditor’s Report on MassHealth’s Administration of Dental Claims, No. 2009-8018-14C, dated November 16, 2010, identified that DentaQuest’s claims processing system did not include edits to detect and deny claims for orthodontic services that violated state regulations."
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