Children in the crossfire of Medicaid integrity issues

Health insurance issues affecting children of the poor made news last week, raising complex questions about Medicaid fraud, the risks of unnecessary services and limited access to care.

The Office of Inspector General, for example, released a report on questionable billing for Medicaid pediatric dental services in Louisiana. U.S. attorney's offices have prosecuted dentists for providing needless care endangering children's safety, as FierceHealthPayer: Anti-Fraud reported.  

The OIG identified 27 Louisiana dentists--roughly a third of whom worked for two dental chains--who collectively received $12.4 million from Medicaid for pediatric services in 2012. These providers filed high volumes of claims for extractions and "baby root canals," the report noted. This raised questions that claimed services may not have occurred, or that the chains urged providers to do unnecessary procedures to boost profits. Moreover, four dentists with flag-raising utilization had actions against them by the state board of dentistry, the OIG noted.

Meanwhile in California, "many thousands of children on Medi-Cal [the state's version of Medicaid] with severe health issues have been denied access to the fast-growing field of genetic testing that could improve their treatment, provide valuable information to their parents and reduce healthcare costs in the long run," according to the San Francisco Chronicle. These aren't experimental services, but tests considered part of mainstream medicine that are routinely covered by private payers and Medicaid plans elsewhere, the newspaper reported.  

This gap in coverage stems from Medi-Cal's 2001 decision to stop accepting new providers, including labs doing genetic testing. This measure was implemented to foil Medicaid fraud, the Chronicle noted.  

Finally in Florida, a class action lawsuit is pending against state health and child welfare officials to pay pediatricians and dentists higher rates to increase numbers of Medicaid children in their practices, the Miami Herald reported. When children don't get consistent care, "they become very much out of control with their chronic illnesses like asthma or diabetes," said pediatrician Lisa A. Cosgrove, M.D. at the trial, and this may raise healthcare costs.   

For more:
- read the OIG report (.pdf) 
- here's the San Francisco Chronicle article
- see the Miami Herald article