Wash. centers to pay $3.35M for improper Medicaid billing

Washington State Attorney General Bob Ferguson announced last week that his office is recovering $3.35 million from Sea Mar Community Health Centers, stemming from allegations that Sea Mar improperly billed Medicaid for thousands of dental appointments.

The false claims unit of the attorney general's Medicaid Fraud Control Unit raised concerns that Sea Mar had overbilled Medicaid more than $3 million for dental services between 2010 and 2014 after a 2.5-year investigation.

According to a release from the attorney general's office, fluoride treatments that could have been performed by dental assistants as part of a patient's regular six-month checkup were instead billed as standalone appointments with a dentist or hygienist.

Fluoride treatments should be billed on a fee-for-service basis, usually between $13.25 (for 6- to 19-year-olds) and $23.41 (for younger children). Bills from Sea Mar instead were sent to Medicaid as "encounters," meaning patients were seen by a dentist or hygienist, with a typical fee of $180. Medicaid billing rules dictate that in order to bill for an encounter fee, the dental service provided must require a dentist or dental hygienist to warrant the higher cost.

The false claims unit alleged that Sea Mar's billing for these appointments also exceeded the number of dental exams allowed per patient under Medicaid, without any documentation of the findings of such exams or that the exams were actually done.

The agreement also resolves a pending case filed by Sea Mar in federal district court. Sea Mar cooperated fully in the investigation, according to the attorney general's office.

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