An audit of the Louisiana Medicaid Dental Program found that $6.4 million in payments made by the program from July 2012 through June 2016 violated the program's rules.
The investigation by Louisiana Legislative Auditor Daryl Purpera reported that these payments consisted of $5.7 million for 88,586 fee-for-service claims paid by the Louisiana Department of Health, and close to $700,000 for 18,456 claims paid by Managed Care of North America, which has administered Louisiana's dental Medicaid managed care program since it began in 2014. The audit was issued on March 22, 2017.
The payments that violated the dental Medicaid program's rules included $4.3 million for more than 44,000 restorative treatment claims, $1.4 million for more than 50,000 diagnostic services claims, and $450,000 for close to 5,000 adjunctive treatment claims.
Violations included using a procedure code for exams for patients ages 3 to 20 for those who were outside of this age range, and not obtaining the required prior authorization for applying resin-based composite to certain teeth.
The Louisiana Department of Health said the inappropriate fee-for-service payments could have occurred because provider manuals were not updated to account for changes to program rules. Managed Care of North America said that its payments violating program rules could be the result of claims being denied internally that were submitted to the Department of Health as approved.
The Medicaid program said it is taking action, including updating its provider manual, investigating rule violations, and recovering payments as appropriate.
