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MassHealth Dental Audit 2006-2009

MassHealth Dental Audit 2006-2009

Ratings: (0)|Views: 19,697|Likes:
Published by Dentist The Menace
Audit shows radio:
Radiographs of 10 providers totaling $5m violated regulations - 3 Small Smiles, 3 Kool Smiles
Orthodontic Overtreatment
DentaQuest failures
Claims increase of 97%
Payments increased 159%
Audit shows radio:
Radiographs of 10 providers totaling $5m violated regulations - 3 Small Smiles, 3 Kool Smiles
Orthodontic Overtreatment
DentaQuest failures
Claims increase of 97%
Payments increased 159%

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Published by: Dentist The Menace on Jun 08, 2014
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07/22/2014

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The Commonwealth of Massachusetts
AUDITOR OF THE COMMONWEALTH
ONE ASHBURTON PLACE, ROOM 1819 BOSTON, MASSACHUSETTS 02108
 
A. JOSEPH DeNUCCI
AUDITOR
TEL. (617) 727-6200
Created by Rita L. Taddeo on 11/10/2010 2:04:00 PM Template: Basic Template 2004-06-09 Last saved by Nick M. D'Alleva on 11/15/2010 2:58 PM Modified by Template Group on 6/9/2004 Report Printed on 11/15/2010 2:58 PM
 
NO. 2009-8018-14C INDEPENDENT STATE AUDITOR’S REPORT ON MASSHEALTH’S  ADMINISTRATION OF DENTAL CLAIMS  JULY 1, 2005 TO MAY 22, 2009
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2009-8018-14C TABLE OF CONTENTS/EXECUTIVE SUMMARY
i
Created by Rita L. Taddeo on 11/10/2010 2:04:00 PM Template: Basic Template 2004-06-09 Last saved by Nick M. D'Alleva on 11/15/2010 2:58 PM Modified by Template Group on 6/5/2003 Report Printed on 11/15/2010 2:58 PM
 
TABLE OF CONTENTS/EXECUTIVE SUMMARY
INTRODUCTION 1
MassHealth, within the Massachusetts Executive Office of Health and Human Services (EOHHS), administers the state’s Medicaid program, which provides access to healthcare services, including dental services, to approximately one million eligible low- and moderate-income individuals, couples, and families. In fiscal year 2009, the Massachusetts Medicaid program paid in excess of $6.8 billion on 66 million claims to health care providers, of which approximately 50%
1
 The goals of MassHealth’s Dental Program are to improve member access to quality dental care; improve oral health and wellness for MassHealth members; increase provider participation in the Dental Program network; streamline program administration to make it easier for providers to participate; and create a partnership between MassHealth and the dental community. MassHealth has approved over 5,000 dentists as participating providers in the Dental Program and according to MassHealth officials, as of June 2010, there were approximately 2,000 dentists who were actively participating in the program. In fiscal year 2009, MassHealth paid 4,668,657 dental claims totaling $300,961,788, or an average of 12,790 claims and $824,552 in payments daily.  was federally funded. Medicaid expenditures represent approximately 25% of the Commonwealth’s total annual budget. During the period covered by our audit, EOHHS awarded a contract to Dental Services of Massachusetts, Inc., (DSM) to administer the Dental Program. Initially, this contract had a three-year term of August 1, 2006 to July 31, 2009, but both parties have since agreed to extend the service contract through June 30, 2010. DSM performs its contractual responsibilities through a subcontractor currently known as DentaQuest, LLC (DentaQuest).
2
Our audit was conducted in accordance with applicable generally accepted government auditing standards. Our objectives were to determine (1) whether dental claims filed by the participating dental providers in our sample were properly supported by required documentation; services were delivered; and claims were complete, accurate, and in compliance with applicable laws, rules, and regulations; and (2) the extent and effectiveness of MassHealth’s internal controls over and oversight of its dental providers. Under the contract, DentaQuest has both programmatic and administrative responsibilities, including (a) dental provider network administration services, (b) customer services, (c) claims administration and processing, (d) contract administration and reporting, and (e) quality improvement/utilization management. MassHealth’s administrative responsibilities under the contract include reviewing DentaQuest’s performance to verify compliance with the terms of the contract and any applicable laws, rules, and regulations. Our audit was part of the Office of the State Auditor’s (OSA) ongoing independent statutory oversight of the Massachusetts Medicaid program. The heightened concern over the program’s integrity was evidenced in January 2003, when the U.S. Government  Accountability Office (GAO) placed the U.S. Medicaid Program on its list of government
1
 Under the American Recovery and Reinvestment Act, Massachusetts’s Federal Matching Assistance Percentage was temporality increased to 58.78% for fiscal year 2009 and 61.59% during fiscal year 2010.
2
 At the time EOHHS awarded the contract, DentaQuest was known as Doral Dental USA, LLC. On December 1, 2009, Doral Dental USA, LLC changed its name to DentaQuest, LLC.
 
2009-8018-14C TABLE OF CONTENTS/EXECUTIVE SUMMARY
ii
Created by Rita L. Taddeo on 11/10/2010 2:04:00 PM Template: Basic Template 2004-06-09 Last saved by Nick M. D'Alleva on 11/15/2010 2:58 PM Modified by Template Group on 6/5/2003 Report Printed on 11/15/2010 2:58 PM
 
programs that are at “high risk” of fraud, waste, abuse, or mismanagement. GAO has estimated that between 3% and 10% of total healthcare costs are lost to fraudulent or abusive practices by unscrupulous healthcare providers. Further, several previously issued OSA audit reports have disclosed significant weaknesses in MassHealth’s ability and efforts to detect fraud, waste, abuse, or mismanagement in the Massachusetts Medicaid program. Our audit identified that deficiencies in the Dental Program’s claims processing system has resulted in millions of dollars in ineligible claims and, in some cases, potentially fraudulent claims being paid by MassHealth.
 AUDIT RESULTS 7
 
1.
 
MASSHEALTH HAS NOT ADEQUATELY CONTROLLED DENTAL RADIOGRAPH (X-RAY) SERVICES PERFORMED BY PROVIDERS, WHICH RESULTED IN COMMONWEALTH OVERCHARGES TOTALING AS MUCH AS $5,206,017, INCLUDING POTENTIALLY FRAUDULENT BILLINGS FOR SERVICES NEVER PROVIDED, AND ITS MEMBERS RECEIVING UNNECESSARY SERVICES INVOLVING RADIATION EXPOSURE 7 
Our audit found that MassHealth had not developed adequate internal controls over the use of dental radiographs (X-rays) performed by providers in its Dental Program. Specifically, MassHealth regulations state that the program will pay only for medically necessary dental radiographs taken as an integral part of diagnosis and treatment planning, with the intent of confining radiation exposure of members to the minimum necessary to achieve satisfactory diagnosis. However, we found that the 10 providers we  visited had taken dental radiographs totaling at least $5,206,017 on members that violated these regulations. Specifically, radiographs were taken for unallowable purposes, appeared to be unnecessary to achieve a satisfactory diagnosis, and conflicted with recommendations made by the U.S. Food and Drug Administration (FDA) on the proper use of dental radiographs. We also found that one of the providers we visited routinely billed and received payments from MassHealth for radiographic services that he had not performed for members. These unallowable, unnecessary, and potentially fraudulent payments occurred because DentaQuest and MassHealth had not collaborated to develop effective internal controls over these expenses, including developing edits  within the Dental Program’s claims processing system to detect and deny such unallowable claims.
2.
 
MASSHEALTH HAS NOT ADEQUATELY CONTROLLED ORTHODONTIC SERVICES, WHICH RESULTED IN COMMONWEALTH OVERCHARGES TOTALING AS MUCH AS $321,553 AT ONE PROVIDER, INCLUDING POTENTIALLY FRAUDULENT CHARGES FOR SERVICES NOT PERFORMED 29
MassHealth has established regulations governing orthodontic services for the Dental Program under 130 Code of Massachusetts Regulations (CMR) 420.423 and 420.431 that provide service descriptions and limitations for all covered orthodontic services. However, our audit found that MassHealth has not established adequate controls to ensure that dental providers submit claims for pre-orthodontic treatment visits and oral/facial photographic images in accordance with these regulations. Moreover, we found that DentaQuest’s claims processing system does not contain adequate edits to identify and reject unallowable claims for orthodontic services. Consequently, we found

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