Questionable billing practices among California dentists who treat pediatric patients covered by Medicaid highlight the need for better oversight, according to a recent Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit.
Medicaid paid 329 dentists and six orthodontists $117.5 million for pediatric dental services in 2012. The providers represented 8 percent of all dentists and orthodontists in the state, but they provided a large number of services to an extremely large number of beneficiaries, raising concerns about the legitimacy of their billing practices and the potential that certain providers bill for services that are not medically necessary or were never provided.
For example, 229 dentists averaged 76 services each day, well above the statewide average of 24, and two dentists averaged more than 500 service each day. On one particular day of the year, one dentist provided 1,658 services, which, the OIG points out, would take 138 hours if each service lasted five minutes. Furthermore, while California dentists averaged $166 per Medicaid child, 19 averaged $412 per child and one reached $699 per child.
Additionally, the audit raised concerns about specific services including stainless steel crowns, pulpotomies (baby root canals) and extractions. More than 200 dental providers exceeded the threshold of questionable billing for those services.
The report stopped short of accusing providers of fraud but did recommend that the state increase monitoring of questionable billing practices by dental providers, review payment processes for orthodontic services, take appropriate action against dentists with questionable billing patterns, and closely monitor billing practices by dental chains. The majority of providers identified in the audit worked for five chains, two of which have faced state and federal investigations.
Last April, the OIG identified Medicaid billing problems tied to dental care in New York, amid criminal charges of dental fraud in Indiana. In February, FierceHealthPayer reported that despite Medicaid expansion in five states, including California, dentists are often unwilling to treat Medicaid beneficieries because of low reimbursement.
- here's the OIG audit (.pdf)