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Dentist Indicted on Nearly 200 Counts of New Hampshire Medicaid Dental Fraud

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New Hampshore Medicaid officials are investigating dental fraud.

(January 3, 2014):  A 57-year-old Queen City, New Hampshire dentist has recently been charged with 189 counts of Medicaid dental fraud. As a result, he could face many years in prison. The New Hampshire Medicaid program is a joint federal and state-funded health care program that serves individuals and families in that state who meet certain eligibility requirements.  It is run by the State’s Department of Health and Human Services (DHHS) and reimburses providers who deliver health care services for numerous covered medical services. Under a program called “New Hampshire Smiles,” the New Hampshire Medicaid program offers comprehensive dental treatment to eligible children. Adults enrolled in Medicaid may also receive emergency dental treatments. To receive payment for dental services rendered, an individual or group must be enrolled with New Hampshire Medicaid as a dental billing provider. Dental services must be performed by a dentist, or under the supervision of a dentist, who is enrolled as an individual provider and is currently licensed by the state. The dentist must, if required, request and obtain service authorization from Xerox, the DHHS’s fiscal agent.  Importantly, providers must agree to bill for procedure(s) using Code on Dental Procedures and Nomenclature (CDT) codes that most accurately describe the services provided.

I.  Allegations of State Medicaid Dental Fraud are Increasing Around the Country:

Unfortunately, states across the country are seeing an increase in instances of dentists abusing the system. One of the most common instances of Medicaid dental fraud is billing for services not performed. Under this scheme, a dentist will bill Medicaid for a treatment, procedure, or service that was not actually performed. For example, a dentist may bill the program for a dental filling that never was rendered.

Dentists may also try to “double bill” Medicaid.  Here, the provider attempted to bill both Medicaid and either a private insurance company or the patient himself, for the same treatment. Dentists may also attempt to get for services provided to a patient that have already been rendered.

Another fraudulent arrangement is billing for medically “unnecessary services.”  A dentist may attempt to misrepresent a diagnosis and accompanying symptoms on a patient’s dental record, and then bill Medicaid to obtain payment for unnecessary lab exams.

Other common Medicaid dental fraud schemes include obtaining kickbacks for services, misrepresenting cost reports, upcoding CDT codes, and unbundling.

To combat Medicaid dental fraud, the federal and state governments have joined in State Medicaid Fraud Control Units (MFCUs).  In 2012, the combined task forces received a total of $217.3 million in funds. Collectively, in FY 2012, the MFCUs conducted 15,531 investigations, of which 11,660 were related to Medicaid fraud. These investigations resulted in 1,359 individuals being indicted or criminally charged. Nearly 1,000 of these indictments were for fraud, with a conviction rate was nearly perfect: 982.

III.  Dentist Defrauds the New Hampshire Medicaid System and Falsifies Evidence:

In this recent New Hampshire Medicaid case, the dentist is alleged to have made false claims to the New Hampshire Medicaid program for services performed over the past five years. These procedures included oral exams, X-rays, tooth extractions and orthopedic treatment. The indictments contend that the provider’s claims were either not medically necessary based on member treatment records or had already been paid for through the program (double billing). Each charge in the indictment carries a possible 3½ to 7-year prison sentence.

The defendant dentist has been practicing since he received his dental license in 1985. According to his attorney, none of the charges against the dentist have anything to do with the level of care provided on behalf of his patients. Since the indictment was only recently released, the attorney could not specify the exact details that the State’s attorney general’s office was basing its accusations on.  However, he did note that Medicaid regulations are extremely complicated and change regularly.  He contends that the whole issue could simply come down to a basic misunderstanding.

IV.  Closing Thoughts:

It is essential that dentists participating in any state Medicaid dental program review both their operational and documentation practices to ensure that entities processing and examining their patient treatment records can readily ascertain why certain care and treatment decisions were made. Moreover, dentists must ensure that the services billed to the Medicaid program are not just medically reasonable and necessary, but that they also qualify for coverage and payment.

By participating in your state’s Medicaid program, dentists must recognize that your practice and documentation procedures must be scrutinized with a fine toothed comb.  Many Medicaid dentists have yet to implement an effective Compliance Plan within their practice. While it is not too late, dental practices without an operative compliance program will see an increase in audits by Medicaid contractors and face greater targeting by MFCUs.  Federal and state enforcement investigations of possible incidents of dental fraud will continue to increase in the coming years.  Therefore, it is imperative that all dental practices (especially those participating in Medicaid), carefully examine its documentation practices. Dentists must ask themselves,

Is the medical necessity of each dental service fully reflected in the patient’s medical record?

Have each of the care and treatment services provided been documented in the patient’s medical record?

Do the dental services meet the state Medicaid’s regulatory requirements for coverage and payment?

Have the dental services been properly coded?

Have the dental services been properly billed?

Can you answer positively to each of these questions? If not, you and your practice may be in trouble.  Need help drafting a Compliance Plan for your practice? We would be more than happy to assist you. Call us to discuss how we can help you with your compliance efforts.

Healthcare LawyerRobert W. Liles, Esq., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law.   Liles Parker attorneys represent dentists and other health care providers around the country in licensure disputes, audits by government agencies and in contract disputes with private payors.  For a free consultation, call: 1 (800) 475-1906.

Hospital Outpatient Dental Services are Being Audited

December 4, 2013 by  
Filed under Dental Audits & Compliance

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Hospital Outpatient Dental Services Billed to Medicare are Being Audited.(December 4, 2013): Generally, Medicare does not cover hospital outpatient dental services. Under the general exclusion provisions of the Social Security Act, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures or removal of diseased teeth in an infected jaw) are not covered.  It is important to keep in mind that the issue of whether a specific dental service is “covered” by Medicare is not determined by the value of the needed procedure or by whether the service is medically necessary.  Rather, it is determined by the type of dental service to be provided and the anatomical structure on which the procedure is performed.

I.  Are any Dental Services Covered Under Medicare?

The short answer is “Yes.”   There are a handful of dental services that Medicare will cover.  Examples of these limited exceptions include:

  • Dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury).
  • Extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw.
  • Payments for oral examinations, but not treatments, preceding kidney transplantation or heart valve replacement (under certain circumstances). These oral examinations would be covered under Part A if they are performed by a dentist on a hospital’s staff or under Part B if they are performed by a physician.

While a small group of dental services do, in fact, qualify for coverage and payment under Medicare, it would be prudent for any health care provider billing the government for such services to carefully review the nature of each claim and ensure that the supporting documentation fully supports the claims prior to submitting them to the government for payment.  Providers should expect for these claims to be carefully scrutinized prior to being paid.

II.  One Recent Audit of Hospital Outpatient Dental Services:  

The Department of Health and Human Services, Office of Inspector General (OIG) recently audited a large Texas hospital with respect to Medicare reimbursement claimed by the hospital for hospital outpatient dental services. The OIG looked at a sample of one hundred claims and found that the hospital properly claimed Medicare reimbursement for only one (1) claim. The remaining ninety-nine (99) claims did not meet Medicare’s coverage and payment  requirements.

The OIG believes that these errors occurred, at least in part, due to the fact that the hospital did not have written policies and procedures in place during the audit period related to the billing of Medicare for hospital outpatient dental services. Additionally, the hospital did not have system billing edits in place to ensure that it billed only for services that met Medicare requirements.

In this particular case, it was alleged that the hospital billed Medicare for tooth extractions that were typically performed as a result of tooth decay, which is not a covered service. In addition, the hospital billed Medicare for unallowable partial or full mouth x-rays of the teeth. In most cases, the hospital performed the x-rays during a general dental examination and evaluation, which also are excluded from Medicare coverage.  These unallowable extractions and x-rays accounted for the majority of all unallowable claims. Other types of unallowable dental services varied and included, for example, the repair of a tooth socket in preparation for dentures.

III.  Final Considerations:

Providers of medical (as opposed to dental) services have been under the proverbial microscope for many years. Their claims are routinely scrutinized by both governmental and private payors before payment is authorized. Dental service providers can take advantage of the many hard (and often painful) lessons already learned by their medical counterparts.  Now, more than ever, it is essential that dentists, orthodontists, and other dental service providers take the time to know what is expected of them.  Moreover, it is equally important that you fully and accurately document the dental examination you have conducted, any findings that you have reached and any dental services that you ultimately provided.  Points to be considered include:

  • Generally, “medical necessity” is the threshold standard used by Medicaid (and Medicare for that matter) to decide whether a specific dental service will be covered.  While the specific language may vary somewhat from jurisdiction to jurisdiction, the test is typically whether a prudent dentist would provide a service or product to a patient to diagnose, prevent or treat dental pain, infection, disease, dysfunction, or disfiguration in accordance with generally accepted procedures of the professional dental community.
  •  Have you researched the “medical necessity” standard for your state?  Are you complying with those requirements?
  •  Several years from now, would a disinterested third-party who is asked to review your patient’s medical records find that medical necessity is supported solely through a read of the cold record?
  • Are your medical records legible, properly dated and structured in an easy-to-understand   fashion?
  • Is your documentation of the examination conducted, the findings reached and the corrective actions taken complete and accurate? 

Should you not consider or fail to meet one or more of the above requirements, there is a significant likelihood that you will face significant liability, including, but not limited to an overpayment assessment, suspension, being placed on “payment hold,” or referred to your law enforcement for possible investigation and prosecution. Compliance is not optional.  Research each payor’s requirements and do your best to meet those contractual mandates.

Healthcare LawyerRobert W. Liles serves as Managing Partner at the boutique health law firm of Liles Parker.  The firm has offices in Washington DC, Houston TX, McAllen TX and Baton Rouge LA.  Liles Parker attorneys represent dentists and other health care providers around the country in State Dental Board proceedings, Medicaid Audits and in Private Payor Audits.  Liles Parker also advises dental practices on documentation, compliance, OSHA and HIPAA issues.  For a free consultation, call:  1 (800) 475-1906.