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:
- Review top billers and request OMIG to investigate fraudulent billing, and recover lost moneys;
- Remind practitioners it's inappropriate to bill for a dental consultation when a patient is transferred to them for a routine dental service; and
- Review the reimbursement methodology for dental services.
Click here for a copy of the audit report .