Report: NY paid $13.2M for questionable Medicaid services

Some 23 New York state general dentists and six orthodontists received $13.2 million in Medicaid payments in 2012 for services that appeared unnecessary or may not have been performed at all, according to a new report by federal health investigators.

The 29 providers 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," according to the 21-page report released March 26 by the U.S. Department of Health and Human Services Office of Inspector General.

The report is filled with questionable practices, including these egregious examples:

• One dentist, Dolly Rosen, DDS, billed Medicaid for 991 procedures in a single day. She was later convicted of grand larceny and her license was revoked in 2010, according to the New York State Board of Dentistry.
• One dentist claimed to have provided one child 42 restorations in a single visit.
• One orthodontist said he treated almost 5,000 children in a single year, about 10 times the state average.
• One dentist averaged 16 procedures per child in one year, charging almost $900 per child, compared with the state average of $200. For more than 20 children, the dentist was paid more than $1,500 per child.
• One dentist performed as many as six pulpotomies during the same visit on a 2-year-old child.
• One dentist provided 179 services in a single day.
• One dentist averaged 54 services per day.
• One dentist performed extractions on 76% of the children he treated, compared with a state average of 10%.

The dentists and orthodontists described in the report were not identified.

The report offered this scathing observation about the dentist who claimed he provided 179 services in one day:

"If this dentist spent only give minutes performing each service, it would have taken him over 15 hours to complete all of these services," the investigators wrote.

Lucia Fort, an analyst in the Office of Inspector General (OIG), also questioned whether it's possible to treat 5,000 children in a single year. "Treating that many kids raises concern about whether the orthodontist actually provided the services, or whether each child received appropriate treatment," she told Meridith Seife, deputy regional inspector general for the Office of Evaluation and Inspections in New York, according to a transcript of questionable billing for Medicaid pediatric dental services in New York.

Orthodontic services were offered through managed care in New York after October 2012.

In a recent audit, the OIG found that providers inappropriately billed for orthodontic services provided to 43 of 100 sampled beneficiaries in New York City, totaling an estimated $7.8 million in inappropriate reimbursement, the report stated.

Some of the treatment was done without the required approval, while other services were undocumented or never provided, according to the report. The oversights occurred because New York agencies did not ensure that cases were reviewed annually to determine the need for continuing care and did not ensure that services were adequately documented.

"OIG is also conducting a number of audits of individual dental providers to determine whether they inappropriately billed Medicaid for pediatric dental services," the report stated.

The investigation focused on 719 general dentists who provided services to 50 or more Medicaid children and 165 orthodontists who provided services to 50 or more Medicaid children during 2012. The dentists treated 119,102 Medicaid children; the orthodontists provided care to 83,894 Medicaid children.

New York state has strict criteria for orthodontic services, the report noted, and orthodontists may bill for only a limited number of services. Providers receive a one-time payment for "comprehensive orthodontic treatment," which usually includes the initial placement of braces. Orthodontists may also bill for periodic treatment services once per quarter -- regardless of the number of visits provided -- which covers ongoing maintenance. They can also bill for related diagnostic services, such as x-rays.

The report called providers with questionable billing patterns "extreme outliers" compared to their peers, which included 3% of the general dentists and orthodontists who were reviewed by investigators.

"Extremely high payments per child raise concerns about whether these dentists are billing for services that are unnecessary or that they did not provide," the report noted.

General dentists in New York provided an average of 10 services per day to Medicaid children. However, 13 dentists averaged more than 23 services per day, according to the report.

Four general dentists performed extractions on an extremely high proportion of Medicaid children. More than 38% of the children treated by these dentists had one or more teeth extracted, compared with an average of 10% of children served by all general dentists in New York state, the report stated. The four dentists provided an average of three extractions per child.

Two general dentists provided pulpotomies to an extremely high proportion of Medicaid children. At least 14% of the children treated by these dentists received pulpotomies, compared with only 4% of children served by all general dentists who provided pulpotomies, according to the report. These dentists frequently provided three or more pulpotomies during a single visit.

The state dental board initiated disciplinary action against one dentist for negligence, malpractice, or incompetence after receiving several complaints, the report noted. Two other dentists had malpractice lawsuits brought against them.

New York orthodontists provided services to an average of 531 Medicaid children in 2012, according to the report. Five orthodontists, however, each provided treatment to more than 2,100 children, and one of these orthodontists provided services to 4,870 children.

All five of these orthodontists most often provided periodic treatment visits, which are billed for on a quarterly basis, regardless of how many visits occurred during the quarter. Periodic treatment accounted for almost half of the services these orthodontists provided in 2012. The five orthodontists had a minimum of 43,564 visits with 17,365 children over the course of the year, the report stated.

One orthodontist who treated 4,870 children had at least 12,598 visits with the children in 2012.

"The high volume of children seen by each of these five orthodontists raises concern about whether they are able to ensure that each child receives treatment that meets professionally recognized quality-of-care standards," the investigators wrote, adding that it was doubtful they even did the procedures.

"Although some of their billing may be legitimate, providers who bill for extremely large amounts of services warrant further scrutiny," they wrote.

Small Smiles

Seven of the 23 general dentists who had submitted dubious charges in the investigation were associated with the Small Smiles dental chain, which paid $24 million in 2010 to settle allegations of Medicaid fraud with 22 states and the U.S. Department of Justice.

"Notably, almost a third of the general dentists with questionable billing 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 report stated.

Two Small Smiles clinics in New York stopped billing Medicaid in April 2012, after their management company decided to close the clinics and stop practicing in New York.

In July, 2012, Church Street Health Management, a private-equity-backed company that had managed 63 dental centers under various Smiles brands in 21 states, emerged from bankruptcy with new owners, CSHM.

CSHM emailed this comment to DrBicuspid.com:

CSHM LLC is not in a position to comment on the operational, administrative, or billing practices of Small Smiles dental centers prior to its purchase of substantially all of the assets of Church Street Health Management, LLC on June 1, 2012. All of the New York Small Smiles dental centers referenced in the OIG report dated March 2014 closed prior to June 2012.

The March 26 OIG about New York dentists report follows a February letter from a congressional oversight committee that expressed impatience that little has been done to rein in scofflaw dental management service companies.

A few weeks after the letter from Congress was sent, on March 7, the OIG excluded CSHM, which owns the Small Smiles chain, from federal healthcare programs such as Medicaid for multiple breaches to a compliance agreement.

Recommendations

"These findings demonstrate the need to improve the oversight of Medicaid pediatric dental services," the report authors concluded.

They stopped short of criticizing the New York State Department of Health, which oversees the state's Medicaid program, but they urged officials to develop adequate safeguards to prevent dentists from questionable billing and treatment practices. The health department did not dispute the findings but asserted it has been working to crack down on fraud.

The OIG report recommended the follow:

• Continue monitoring general dentists and orthodontists to identify patterns of questionable billing.
• Ensure that New York employs adequate safeguards to monitor general dentists and orthodontists under managed care.
• Ensure appropriate follow-up on the general dentists and orthodontists identified as having questionable billing.

The New York State Office of the Medicaid Inspector General is actively investigating and monitoring numerous orthodontists and general dentists.

The OIG now will investigate possible Medicaid fraud in other states, looking for common trends, according to Fort.

"We also plan to look at Medicaid children's access to dental care," Fort said. "We know that there is a major problem with children's access to these services. Dentists who participate in the Medicaid program provide much-needed access to dental care for kids. But we need to ensure that children get regular checkups and high-quality care."