Feds audit La. Medicaid billings for pediatric dental services

A federal audit has concluded that 27 Louisiana dental providers treating children on Medicaid have excessive billing practices. These providers may be billing for services that were never performed, performing unnecessary procedures to increase profits, or providing questionable quality of care, according to a report released Wednesday by the Office of Inspector General (OIG) of the U.S. Department of Health and Services.

The analysis was based on Louisiana Medicaid fee-for-service paid claims for general dentists and oral surgeons who provided services to 50 or more children in 2012. The audit included 512 dentists and 41 oral surgeons, and found that 26 dentists and one surgeon had questionable billings, compared with their peers. These 27 providers were paid a total of $12.4 million in 2012, according to the report. These dentists served a total of 316,955 children with Medicaid.

According to the audit, the 27 dental providers -- representing 5% of the total reviewed -- received extremely high payments per child, provided an extremely large number of services per day, provided an extremely large number of services per child per visit, and/or provided certain selected services to an extremely high proportion of children.

General dentists in Louisiana receive an average payment of $264 for each child with Medicaid, but six dentists whose billing patterns were studied received more than twice this amount, or an average of more than $700 per child, according to the report. These dentists received more than $2,000 per child for a total of 237 children. One of these dentists received more than $8,000 for services provided to one child over the course of three visits.

Overall, general dentists in Louisiana provided an average of 27 services per day to children with Medicaid. Three dentists studied each averaged 146 or more services per day, and one dentist billed for 376 services in one day, the report noted.

"If this dentist spent only five minutes performing each service, it would have taken over 31 hours to complete all these services," the auditors noted.

General dentists in Louisiana provided an average of four services per Medicaid child during a single visit, according to the audit. Ten dentists, however, averaged six or more services per child per visit, with one dentist averaging 11 services per child per visit. Seven of these dentists provided more than 20 services in a single visit to a total of 170 children. One dentist provided more than 30 services to a child during a single visit.

Auditors found that six general dentists performed extractions on an "extremely high proportion" of the children with Medicaid who they served. Of the children served by these dentists, 40% or more of the children had one or more teeth extracted, compared with an average of 11% of children served by other general dentists performing extractions in the state. One dentist performed extractions on 70% of the children he treated.

Almost a third of the providers with questionable billing claims worked for two dental chains, which were not named, according to the report. Half of the eight providers worked for a chain that operates mobile school-based clinics around the U.S., which has been investigated for complaints that affiliated dentists treated children without their parents' permission and had provided medically unnecessary services. Four of the providers with questionable billing had previously been sanctioned by the Louisiana State Board of Dentistry.

Methodology

In conducting the audit, the OIG calculated the following three measures for each general dentist:

• Average Medicaid payment per child served
• Average number of services provided per day
• Average number of services provided per child per visit

Four additional measures for general dentists who provided selected services in 2012 also were developed. For each dentist who provided the following service, the proportion of children with Medicaid who received the following treatments was calculated:

• Fillings
• Extractions
• Stainless steel crowns
• Pulpotomies

For each measure, the averages and the distribution for all general dentists were measured.

Next, a threshold was set for each measure that, if exceeded, indicated that the dentist had billed an extremely high amount or number compared with other general dentists in Louisiana. A standard technique for identifying outliers, known as the Tukey method, was used. Under the Tukey method, OIG analysts considered dentists who exceeded one or more of certain thresholds to have questionable billing.

For the 41 Louisiana oral surgeons analyzed, the report calculated the same first three measures noted above for the general dentists. Overall, the oral surgeons served a total of 8,358 children with Medicaid.

After identifying the providers who were considered outliers, the auditors conducted Internet searches on each provider's background and analyzed his or her claims and payment history. The auditors then determined which providers worked for a dental chain in 2012, based on the billing names associated with their claims, and then researched public records to determine if the providers had ever been sanctioned.

Recommended actions

Auditors recommended that the Louisiana Department of Health and Hospitals (DHH) do the following:

1. Enhance its monitoring of dental providers to identify patterns of questionable billing.
2. Take appropriate action on the dental providers identified as having questionable billing.

The DHH concurred with the recommendations. Based on the audit's findings, Managed Care of North America was hired in July to manage Medicaid dental benefits in the state, according to a response written by state Medicaid Director J. Ruth Kennedy that was included in the report.

The DHH will conduct its own audit of the 27 dental providers identified by the OIG. The agency will perform a thorough review of the 27 providers' practice type against their billing history to validate the analysis, and determine whether the excessive billing practices are anomalies, an abuse of the billing system, or merely the result of a high-volume/low-margin business model, she wrote.

"Dependent upon DHH's independent findings, we will take appropriate actions based on the results, which may include, but are not limited, to termination/exclusion, recoupment/sanctions, and, if necessary, referral to the appropriate law enforcement agencies," Kennedy concluded.