SmileCenter
December 1, 2011 · Read the full official report (PDF) ↗
Published December 1, 2011 Audit covers July 1, 2007 – June 30, 2010 Under Suzanne M. Bump · 2011–2023
source
“Our audit identified that SmileCenter billed and received from MassHealth at least $253,519 in unallowable, unnecessary, undocumented, and inappropriate claims for dental and orthodontic services during the audit period.”
Read the plain-English breakdown
This is a state audit of a Plymouth dental provider, SmileCenter, covering MassHealth-paid dental and orthodontic services from July 1, 2007 through June 30, 2010.
“SmileCenter, a sole proprietorship located at 92 Sandwich Street in Plymouth, is one of approximately 2,000 dental providers enrolled in the MassHealth Dental Program.”
The Auditor reviewed SmileCenter as part of oversight of the state Medicaid program, after earlier work found serious problems in MassHealth dental claims processing.
“Our audit of SmileCenter was conducted as part of the OSA’s ongoing independent statutory oversight of the Massachusetts Medicaid program.”
MassHealth dental care is paid with public money and serves low- and moderate-income residents, so improper payments can waste funds and raise concerns about whether patients got appropriate care.
“MassHealth, within the Massachusetts Executive Office of Health and Human Services (EOHHS), administers the state’s Medicaid program that provides access to healthcare services, including dental services, to approximately one million eligible low- and moderate-income individuals, couples, and families.”
If you are a taxpayer or MassHealth member, this report is about whether public dental dollars were spent properly and whether members received services from qualified providers.
“Our objectives were to determine whether certain dental claims submitted by SmileCenter were accurate and properly supported by required documentation; services were delivered; and billings and payments were in compliance with applicable laws, rules, and regulations.”
The audit says the problems were broad, not isolated, and included improper orthodontic billing, unsupported treatments, duplicate payments, and conflicts in records.
“The following ten audit results reveal a pervasive pattern of noncompliance with Medicaid regulations and best practices.”
The Auditor recommended that MassHealth review SmileCenter’s claims more broadly, check DentaQuest system fixes, clarify dental program rules, and referred the report for further review.
“This report is being forwarded to the Massachusetts Office of the Attorney General and federal Health and Human Services – Office of the Inspector General for further review.”
The largest single finding was that SmileCenter’s owner was paid for orthodontic services even though MassHealth said he did not meet its orthodontic training requirement.
“MassHealth concurs that in this one instance, [name of dentist] did not meet the two-year training requirement for a specialty in orthodontics.”
MassHealth is Massachusetts’ Medicaid program; DentaQuest helped administer dental claims; CODA is the accreditation body for advanced dental education; and MMIS is the payment system MassHealth used for claims.
“We then obtained SmileCenter’s dental claims information contained in the Massachusetts Medicaid Management Information System (MMIS), the automated claims processing system used by MassHealth to pay dental providers.”
3 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Determine whether certain dental claims submitted by SmileCenter 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 could not be assured that members received proper orthodontic treatment and paid $201,509 for unallowable orthodontic services.
Standard: 130 CMR 420.405(A)(6) ( 130 CMR 420.405(A)(6) )
1 recommendation
- MassHealth should terminate this provider’s specialty, transfer MassHealth members to properly trained orthodontic providers, and seek restitution for $201,509.agency: disagreed
Agency response & Auditor reply
Agency: "Although SmileCenter's Proprietor is not a "Specialist in Orthodontics" under 130 CMR 420.405(A)(6), MassHealth regulations simply do not require a dentist to qualify as a "Specialist in Orthodontics" to offer (and be paid for) orthodontic treatment to MassHealth members."
Auditor: "However, contrary to the assertion made by SmileCenter’s attorney in the agency’s response, SmileCenter’s proprietor does not meet all the qualifications necessary to offer orthodontic treatment to MassHealth members."
Why it matters: MassHealth paid $452 for claims warranting further review.
Standard: 130 CMR 420.421(B), 130 CMR 420.431(B), and 130 CMR 450.205(A) ( 130 CMR 420.421(B); 130 CMR 420.431(B); 130 CMR 450.205(A) )
1 recommendation
- MassHealth and DentaQuest should further review whether SmileCenter actually performed the services claimed.agency: partially agreed
Agency response & Auditor reply
Auditor: "Because SmileCenter did not comply with this fundamental recordkeeping regulation, the payments it received in this case should be recovered by the Commonwealth."
Why it matters: MassHealth paid as much as $36,065 for evaluations that did not meet program requirements.
Standard: 130 CMR 420.456(B)(1) and the MassHealth Dental Program Office Reference Manual ( 130 CMR 420.456(B)(1) )
1 recommendation
- MassHealth should recover $3,083 and investigate all payments SmileCenter received for detailed oral screenings.agency: disagreed
Agency response & Auditor reply
Agency: "Given that SmileCenter's billing complied with the Code and all applicable regulations, there is no need for further investigation by MassHealth."
Auditor: "Consequently, the proprietor received unallowable payments totaling $36,065 for detailed and extensive oral evaluations during the audit period."
Why it matters: MassHealth paid $14,601 for consultations that were medically unnecessary or not separately reimbursable.
Standard: 130 CMR 420.410(A)(1), 130 CMR 420.431(B), and 130 CMR 420.431(E) ( 130 CMR 420.410(A)(1); 130 CMR 420.431(B) and 130 CMR 420.431(E) )
1 recommendation
- MassHealth should recover $14,601 in unallowable and unnecessary orthodontic consultation payments.agency: disagreed
Agency response & Auditor reply
Agency: "SmileCenter respectfully disputes the notion that it is never appropriate to perform a pre-orthodontic screening on a child under the age of 6."
Auditor: "While we acknowledge that there may be instances where a pre-orthodontic consultation is medically necessary for someone under the age of 6, the sheer volume of claims submitted by SmileCenter suggests a potential misuse of this dental procedure."
Why it matters: MassHealth paid at least $4,008 for fluoride treatments that exceeded recommended levels or lacked adequate support.
Standard: 130 CMR 420.414(B) ( 130 CMR 420.414(B) )
1 recommendation
- MassHealth should recover $4,008, analyze all other fluoride claims, and consider investigating undocumented claims with the Attorney General.agency: disagreed
Agency response & Auditor reply
Agency: "SmileCenter provided all fluoride treatments questioned by the OSA."
Auditor: "Certainly, SmileCenter’s usage of fluoride treatment “as a matter of course” during member’s frequent dental visits conflicts with AAPD recommendations and appear to represent medically unnecessary treatment."
Why it matters: MassHealth paid $2,303 for claims that did not document emergency dental pain treatment or involved routine visits.
Standard: 130 CMR 420.456(D) and 130 CMR 450.205 ( 130 CMR 420.456(D); 130 CMR 450.205 )
1 recommendation
- MassHealth should recover $2,303 and investigate the remaining 483 claims for treatment of dental pain.agency: disagreed
Agency response & Auditor reply
Agency: "The OSA questions 34 instances in which SmileCenter offered palliative treatment."
Auditor: "Regarding the 34 noted claims, the SmileCenter proprietor neither documented the member’s emergency nor the treatment provided to alleviate the pain."
Why it matters: The conflicts raised questions about whether services were billed but not performed, or performed without properly recording revenue.
Standard: 130 CMR 420.404 and 130 CMR 420.414(B) ( 130 CMR 420.404 and 130 CMR 420.414(B) )
1 recommendation
- MassHealth should comprehensively investigate SmileCenter’s dental records and billing practices, recover inappropriate payments, and refer the matter to the Attorney General if warranted.agency: disagreed
Agency response & Auditor reply
Agency: "The Draft Audit's findings of "Conflicts between SmileCenter's Dental Records and its Billings for Services" appear to result from clerical errors."
Auditor: "Contrary to what SmileCenter asserts in its response, the conflicts between SmileCenter’s case notes and billing records, in our opinion, represent a systemic deficiency within SmileCenter’s billing process and possibly a more serious (potentially fraudulent) situation."
Why it matters: MassHealth overpaid SmileCenter $2,510 because duplicate payments were not identified and corrected.
Standard: 130 CMR 450.235 ( 130 CMR 450.235 )
1 recommendation
- DentaQuest and MassHealth should ensure claim edits identify and correct overpayments, and MassHealth should investigate and recover overpayments.agency: partially agreed
Agency response & Auditor reply
Agency: "The OSA's finding that in 35 instances, MassHealth paid twice for the same procedure, calls into question MassHealth's records and practices, just as much as SmileCenter's."
Auditor: "The duplicate payments found at SmileCenter indicate a potentially serious deficiency within MassHealth’s claims processing system."
Why it matters: MassHealth paid $3,619 for nonreimbursable photographic image claims.
Standard: 130 CMR 420.423(E)(2) ( 130 CMR 420.423(E)(2) )
1 recommendation
- MassHealth should recover $3,619 paid for oral/facial photographic images contrary to state regulations.agency: disagreed
Agency response & Auditor reply
Agency: "SmileCenter submitted bills for oral/facial photographic images (using code D0350) pursuant to the explicit instructions of DentaQuest's MassHealth contract director."
Auditor: "However, such informal advice, if it was given, has no legitimate bearing on this issue."
Why it matters: MassHealth unnecessarily reimbursed SmileCenter $1,885 for oral evaluation claims that should have been denied.
Standard: 130 CMR 420.422 ( 130 CMR 420.422 )
Agency response & Auditor reply
Agency: "Here, SmileCenter has endeavored to code for what it did."
Auditor: "Consequently, SmileCenter was improperly paid $1,885 for certain member’s oral evaluations, which the Commonwealth should now recover."
Verified dollar findings
Money paid out that the audit found should not have been - overpayments, unallowable and nonreimbursable charges, improper claims.
Identified dollar findings that do not fall in a named band.