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July 28, 2010

DiNapoli: State Dental Insurer Overcharged by $1.6 Million

Group Health Incorporated (GHI), the administrator for New York State’s dental benefits plan, paid about $1.6 million in questionable claims by dentists for scaling and root planing procedures, according to an audit released today by New York State Comptroller Thomas P. DiNapoli. This represented nearly one-third of the amount GHI paid dentists for this procedure over the four-year period audited.

“Scaling and root planning are painful enough for the patient; they shouldn’t cause even more pain for taxpayers,” DiNapoli said. “GHI should be more vigilant. When a dentist bills for doing the same procedure seven times in four years, a flag should go up somewhere. Health care costs are high enough without taxpayers being forced to pay for procedures that were not needed or never done.”

New York State Department of Health (DOH) guidelines recommend that dentists perform scaling and root planing procedures on no more than two quadrants of a patient’s mouth during a single visit. Dentists are also discouraged from scaling and root planing the same quadrant more than once every three years.

These procedures are more extensive than a routine dental cleaning and more costly.  DiNapoli’s audit, which looked at payments made by GHI between January 1, 2005 and December 31, 2008, found that they were frequently made outside of these guidelines. GHI never questioned the propriety of one dentist who billed GHI for performing scaling and root planing procedures on the same patient’s mouth seven times in a four year period.

Auditors visited two dentists that frequently billed outside the accepted parameters and found the dental records often did not support the billings.  Auditors also tested GHI’s compliance with its own internal processing procedures that required proper dental charts before payment. GHI paid many claims without proper supporting records.

DiNapoli recommends that GHI officials:

  • Review claim payments to the two dentists visited by auditors;
  • Investigate questionable billing patterns from other dentists; and
  • Recover funds from any dentists who have overbilled.

GHI generally agreed with the audit’s findings.

Click here for a copy of the audit.



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