HHS OIG Issues Report on Questionable Billing for Medicaid Pediatric Dental Services

What you need to know:

The Office of Inspector General for the US Department of Health & Human Services recently published the results of its study on Louisiana dentists who may be providing unnecessary dental procedures to children receiving Medicaid benefits.

What you need to do:

Dental service organizations and private equity firms with an ownership interest in a DSO should maintain proper oversight of Medicaid dental services to ensure that its dental providers are not engaging in any questionable billing practices.

The Office of Inspector General for the US Department of Health & Human Services recently published a report on a study it conducted on questionable billing for Medicaid pediatric dental services in Louisiana.  Recognizing that in recent years a number of dental providers and dental service organizations have been prosecuted for providing services that were medically unnecessary, or that failed to meet professionally recognized standards of care, the government has made identifying Medicaid fraud in the dental services industry a priority.  The OIG emphasized that its evaluation of dental billing practices in Louisiana is part of an ongoing review and that it intends to examine Medicaid dental providers in other states, with reviews already having been conducted in New York.   

Methodology

The study analyzed Louisiana fee-for-service paid claims for general dentists and oral surgeons who provided services to 50 or more pediatric Medicaid beneficiaries in 2012.  The study sought to identify providers who were extreme outliers when compared to their peers, using measures such as:

• the average Medicaid payment per child served;
• the average number of services provided per day; and
• the average number of services provided per child per visit.

Results

The OIG identified 26 general dentists and one oral surgeon who appeared to be engaging in questionable billing practices.  These providers made up 5% of those reviewed in the study.  In 2012, Medicaid paid these 27 providers $12.4 million for pediatric dental services.

The report specifically noted that 8 of the 27 identified providers worked for two DSOs, and that a concentration of dental providers with questionable billing in DSOs raises concerns that these DSOs (and the private equity firms with an ownership interest in them) may be encouraging unnecessary procedures to increase profits. 

The OIG’s Recommendations

The OIG recommended that the Louisiana Department of Health and Hospitals enhance its monitoring of dental providers to identify patterns of questionable billing, and to monitor dental providers and DSOs to determine whether providers with questionable billing practices are concentrated in certain DSOs.  The OIG intends to inform Louisiana of the identity of the specific dental providers the study found as having questionable billing practices, and encourages the State to review these providers’ billing patterns and patient records, and to perform unannounced site visits.  Based on these reviews, the OIG recommends that Louisiana take action, including:

• law enforcement action, if fraud is identified;
• referral to the State’s board of dentistry for licensure violations;
• recoupment of overpayments or payments made in error; and/or
• revocation of Medicaid billing privileges.

Conclusion

The OIG has made it clear that this review was part of an ongoing examination, so dentists and DSOs can expect that a similar study has been or will be conducted in your state.  The report appears to be aimed at identifying dental providers who are engaging in egregious and deceptive billing practices; however, all providers should review and update policies and procedures to ensure that proper oversight exists over dental operations, and that any questionable billing practices are investigated diligently.