Medicaid Pediatric Dental Services Abuse Found in Indiana
In 2012, 94 general dentists and one oral surgeon in Indiana used incorrect Medicaid billing for $30.5 million in services.
- Recently, the Office of Inspector General of the Department of Health and Human Services, released a report that examined the billing and Medicaid practices of pediatric dental services in Indiana. It was discovered that in 2012, 94 general dentists and one oral surgeon had questionable practices and Medicaid paid $30.5 million of services.
Medicaid is the main source of dental coverage for children in low-income families. It provides an estimated 37 million children with access to dental care. However, according to the OIG, in recent years, a number of dental providers and chains have been prosecuted for providing unnecessary dental procedures to children covered by Medicaid and cause harm in the process.
The OIG examined Indiana Medicaid fee-for-service paid claims for general dentists and oral surgeons who provided services to 50 or more children in 2012. Using several metrics, including average payment per child, average number of service per day, average number of services provided per child per visit and the proportion of children with Medicaid who received fillings, extractions, stainless steel crowns, pulpotomies and behavior management.
It was discovered that 95 dental providers-representing 11 percent of the providers examined received extremely high payments per child; provided an extremely large number of services per day; provided an extremely large number of services per child visit. and/or provided certain selected services to an extremely high proportion of children.
Notably, 66 percent of the general dentists with questionable billing practices worked for four dental chains in Indiana, three of which have already been subject to Federal and State investigations. Because of this high number, there is concern that providers in these chains may be pressured by the chain to increase revenue by performing unnecessary procedures.
“Further, our findings raise concerns that certain providers may be billing for services that are not medically necessary or were never provided,” the report reads. “They also raise concerns about the quality of care provided to children with Medicaid. Although our findings do not prove that providers either billed fraudulently or provided medically unnecessary services, providers who bill for extremely large numbers of services warrant further scrutiny.”
The OIG recommends that the Indiana Family & Social Services Administration in several ways, all of which were agreed upon by the organization. This includes:
•Enhance its monitoring of dental providers to identify patterns of questionable billing
•Closely monitor billing by providers in dental chains
•Ensure dental providers appropriately bill for behavior management and educate providers on the use of this tactic
•Take appropriate action on the dental providers identified as having questionable billing.
The administration also noted in the report that it has taken steps to improve its systems including enhanced monitoring, linking providers in the same chain and changing its payment system.
