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Janury 22, 2008

 

DiNapoli: Dentists Overcharged Medicaid

Comptroller Turns Findings Over to Law Enforcement

Five dentists based in New York City over-billed Medicaid by thousands and potentially millions of dollars for dental fillings, according to an audit released by State Comptroller Thomas P. DiNapoli. Auditors found 151 cases where these dentists claimed to have filled 25 or more cavities in a single visit. One dentist submitted claims and was reimbursed for doing 270 fillings in just one day. DiNapoli referred the findings of the report to the State Attorney General’s office and Office of the Medicaid Inspector General (OMIG).

“Medicaid is not a candy store for unscrupulous dentists,” said DiNapoli. “These dentists took advantage of the weaknesses in the system and must be held accountable for their actions. The State Department of Health must improve its financial controls to detect over-billing. A claim from a dentist claiming to have performed 270 fillings in a single day should probably have raised a few questions.”

Auditors examined claims totaling nearly $150,000 and found evidence that these claims were potentially fraudulent. In total, these dentists submitted 103,964 claims for more than $9.9 million to the state. Auditors recommended that all of these claims be examined closely to determine whether they are legitimate or not. Because these dentists – two of whom are based in the Bronx, and one each in Manhattan, Queens and Brooklyn – are being investigated by law enforcement, the Comptroller’s office has been asked not to disclose the names of the dentists at this time.

DiNapoli’s audit, which covered the period of April 2003 to March 2007, found one dentist claimed he could fill a cavity in 30 seconds and another dentist who could not produce records for 335 claims totaling $26,657. Although the state Health Department’s Medical Review Unit considers claims for more than 24 fillings for a single patient visit to be excessive, it has not established specific policies or controls to detect inappropriate billings. The audit also found that:

  • On 37 occasions, four of the dentists claimed to have administered 25 or more fillings to one patient in a single visit;
  • Two dentists billed for four or more fillings on a single tooth, or for two types of fillings on the same surface of the same tooth; and
  • One dentist submitted nearly identical claims for eight patients, billing for three or more surface restorations on the same 11 teeth during a single office visit for each recipient.

The Department of Health (DOH) generally agreed with the audit’s findings and indicated they would take corrective action. The full response from DOH is included in the audit.

DiNapoli recommended that DOH officials:

  • Investigate and recover the $148,341 in inappropriate claims;
  • Review the dentists’ remaining 103,964 claims totaling more than $9.9 million to determine whether the dental restorations were appropriate, and recover payments where warranted;
  • Reinstruct dentists on their Medicaid claim filing requirements; and
  • Establish a policy that will set a limit on the number of dental restorations that can possibly be performed on a single patient during one visit.

About the State Comptroller’s Medicaid Oversight
The Office of the State Comptroller conducts regular audits of the state’s $47 billion Medicaid program, identifying hundreds of millions of overpayments and fraud. Auditors review Medicaid claims that have been submitted by service providers and identify billing patterns and other circumstances that warrant an examination to determine whether claims are valid and appropriate. In 2007, the State Comptroller’s Office identified more than $62 million in potential overpayments or inappropriate claims paid by the state’s Medicaid program.

Click here for a copy of the audit.

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