October 1, 2010
DiNapoli: Medicaid Over-Billed for So-Called Dental Consultations
Forty percent of Medicaid payments made to dental specialists who were supposed to provide consultant services were improper and many may be fraudulent, according to an audit released by State Comptroller Thomas P. DiNapoli. The audit found that dentists were reimbursed $87 per consultation, vs. the $29 they should have been paid for more routine service. The audit covered 2005 to 2010 when Medicaid spent more than $10 million for consultations. DiNapoli recommended the Office of the Medicaid Inspector General determine whether fraudulent billing took place.
“With New York’s Medicaid system, it’s the same old story but different day,” said DiNapoli. “We keep ringing the same bell, but DOH just doesn't hear it. DOH must ensure providers are receiving payment only for legitimate purposes.”
DiNapoli’s auditors analyzed claims paid to the 10 dental specialists with the highest reimbursements for consultations. Auditors estimated overpayments to be as high as $1.3 million. If these same results are true for all other dental consultation claims, Medicaid could have overpaid an additional $2.6 million.
While examining records for Medicaid recipients, DiNapoli’s auditors found many instances where there were no written communications between practitioners to support referrals for consultation services. Auditors also found numerous cases indicating the patient obtained actual dental services rather than consultation from the consulting practitioner. In these instances, the claims should not have been reimbursed the $87 fee established for consultation services. The appropriate fee would have been $29.
There is considerable risk that fraudulent up-coding for services is being used to maximize reimbursements. DiNapoli also noted that to guard against ignorance of the regulations, DOH needs to remind practitioners that the transfer of a recipient for actual, routine care does not constitute dental consultation. When a recipient is transferred to another dentist for specific procedures, consultation fees should not be charged.
DOH administers New York’s Medicaid program, relying on its eMedNY computer system to process and pay provider claims for Medicaid services. DiNapoli made the following recommendations:
Click here for a copy of the audit report.
MEDICAID & STATE HEALTH INSURANCE SAVINGS IDENTIFIED BY DiNAPOLI’S OFFICE SINCE 2007
NYSHIP DENTAL AUDIT SAVINGS
Report #: 2010-S-1 - New York State Dental Program: Accounting for Voided Dental Claims and Voided Checks. August 9, 2010.
Identified savings: $753,975
2009-S-95 New York State Dental Program: Payments for Scaling and Root Planing Procedures. July 28, 2010.
NYSHIP SAVINGS SUBTOTAL: $2.34 MILLION
MEDICAID AUDIT SAVINGS
Report #: 2007-S-3 Inappropriate Medicaid Billings for Dental Services. September 28, 2007 Identified savings: $896,000
2008-F-46 Follow Up-Inappropriate Medicaid Billings for Dental Services. (Dr. Mayell; 2007-S-3). July 2, 2009.
2007-S-58 Inappropriate Medicaid Billings for Dental Sealants. November 26, 2007. Savings: $469,300
2008-F-55 Follow Up-Inappropriate Medicaid Billings for Dental Sealants (2007-S-58) May 7, 2009.
2007-S-71 Inappropriate Medicaid Billings for Dental Restorations. December 28, 2007 Savings: $148,341
2008-F-56 Follow Up-Inappropriate Medicaid Billings for Dental Restorations. May 7, 2009.
2008-S-67 Inappropriate Medicaid Billings for Dental Services. July 9, 2008. Savings: $1,818,789
2009-F-34 Follow Up-Inappropriate Medicaid Billings for Dental Services. (2008-S-67) October 8, 2009.
2008-S-125 Inappropriate Medicaid Payments for Dental Services Provided to Patients with Dentures. March 25, 2009.
2008-S-70 Medicaid Claims Processing Activity April 1, 2008 through September 30, 2008. July 21, 2009.
2009-S-46 Medicaid Payments for Excessive Dental Services. August 16, 2010
MEDICAID SAVINGS SUBTOTAL: $48.6 MILLION
TOTAL IDENTIFIED SAVINGS: $51 MILLION