Kusserow’s Corner: Dental Fraud and Abuse

We don’t often hear news dental fraud and abuse cases. This is as result of more limited benefits provided by government programs. Occasionally, we are reminded that enforcement problems extend to this area. Recently, the HHS Office of Inspector General (OIG) has focused on this area. It noted that Medicaid is the primary source of dental for approximately 35 million children and that in recent years, a number of dentists and dental chains have been prosecuted for providing unnecessary dental procedures to Medicaid children, as well as for causing harm to children while performing these procedures.

The OIG conducted a review relating coverage for children in low-income families and provides access to dental care in New York and issued a report entitled “Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330).” It analyzed New York Medicaid program, specifically looking into the fee-for-service paid claims for general dentists and orthodontists who provided services to 50 or more children in 2012.

Using several measures, the OIG identified dental providers with questionable billing who are extreme outliers when compared to their peers. It identified 23 general dentists and six orthodontists in New York with questionable billing. Medicaid paid these providers $13.2 million for pediatric dental services in 2012 and received extremely high payments per child; provided an extremely large number of services per child; or provided certain selected services, such as pulpotomies or extractions, to an extremely high proportion of children. Additionally, almost a third of the general dentists were associated with a single dental chain that had settled lawsuits for providing services that were medically unnecessary or that failed to meet professionally recognized standards of care to children.

The OIG noted that its findings raise concerns that certain providers may be billing for services that are not medically necessary or were never provided. It also raises concerns about the quality of care provided to Medicaid children. Although some of the billing may be legitimate, providers who bill for extremely large amounts of services warrant further scrutiny. Based upon findings, the OIG recommended that the New York State Department of Health:

  1. Continue to monitor general dentists and orthodontists to identify patterns of questionable billing,
  2. Ensure that the State employs adequate safeguards to monitor general dentists and orthodontists under managed care, and
  3. Ensure appropriate follow-up on the general dentists and orthodontists identified as having questionable billing.

The New York State Department of Health neither agreed nor disagreed with the recommendations, but identified actions it has taken or plans to take that support the first recommendation. It also outlined current requirements and processes that are in place that support the second recommendation. It did not indicate whether any steps were planned to address the third recommendation.

Recent examples of dental fraud and abuse enforcement actions include the unlicensed owner of Indiana-based Anderson Dental Center, who was charged with Medicaid fraud, theft, money laundering, and forgery. Eight employees, including three dentists, are also facing various charges that include Medicaid fraud, money laundering, and forgery in connection with submitting fraudulent claims for un-provided dental services to the state Medicaid program and with falsifying documents.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.