More than 300 California dentists were paid $117.5 million for "questionable" billing for pediatric Medicaid care in 2012, suggesting potential fraud and harm to children, according to a new report from the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services.
The May 15 report identified 329 general dentists and six orthodontists in California with questionable billing for pediatric dental services in 2012.
Those general dentists and orthodontists who served more than 50 children in 2012 from California's Medicaid program were analyzed by OIG. Dental providers with questionable billing who are considered "extreme outliers" compared with their peers in California were studied, according to the report.
These practitioners (8% of the California general dentists and orthodontists reviewed) "provided a large numbers of services or provided certain services to an extremely large number of children," the report noted. Half of these practitioners worked for dental chains; most worked for five chains, two of which have been the subject of state and federal investigations, according to the report, which did not name the chains.
The services included pulpotomies and extractions. The findings raise concerns that some providers may be billing for services that are not medically necessary or were never provided, while questioning the quality of care for the children, the report stated. Although the findings do not prove that providers either billed fraudulently or provided medically unnecessary services, the OIG said it will investigate providers with extreme billing patterns and take "appropriate action" against them.
The OIG recommended that the California Department of Health Care Services take the following steps:
- Increase monitoring of dental providers to identify patterns of questionable billing.
- Closely monitor billing by providers in dental chains.
- Review its payment processes for orthodontic services.
- Take appropriate action against dental providers with questionable billing.
The report also commented on what it called "questionable billing in a small number of dental chains." The OIG noted that a "concentration of providers with questionable billing in chains raises concerns that these chains may be encouraging their providers to perform unnecessary procedures to increase profits."
The report recommended that California more closely monitor claims that are submitted by providers in dental chains.
The OIG recommended the following steps:
- Identify the chains in California.
- Identify all Medicaid providers in each chain.
- Review claims from providers in each chain for patterns of questionable billing.
- Follow up regarding individual providers and chains as warranted.
The report mentioned that the California Department of Health Care Services agreed with the recommendations.