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Transcript for audio podcast: Questionable Billing for Medicaid Pediatric Dental Services in New York

From the Office of Inspector General of Department of Health and Human Services

[Meridith Seife] I'm Meridith Seife, the Deputy Regional Inspector General for the Office of Evaluation and Inspections in New York. With me is Lucia Fort. We are here to talk about a new report about questionable billing for Medicaid pediatric dental services. Lucia, can you tell us why you focused on this topic?

[Lucia Fort] For many children in low-income families, Medicaid is the only source of dental insurance available. Medicaid covers much-needed dental services for kids, such as dental cleanings, x-rays and treatments, like crowns and fillings.

[Meridith Seife] So in recent years, a number of dentists and dental chains have been investigated for some potentially abusive practices. Can you tell me more about that?

[Lucia Fort] Sure. Some dentists who treated children on Medicaid have extracted healthy teeth, performed unnecessary root canals, or put stainless steel crowns on teeth that didn't need them. So these kids endured unnecessary treatment, while those dentists billed Medicaid for the dental work.

[Meridith Seife] Wow. So can you just tell me a bit more about what you found in this report?

[Lucia Fort] For example, we looked at how much Medicaid paid each dental provider per child, the average number of daily services the dentist provided, and how many children were treated with specific services, like extractions.

[Meridith Seife] So did you find questionable billing patterns?

[Lucia Fort] We did. We found 29 dentists and orthodontists who received a combined total of nearly 13 million dollars from Medicaid in 2012. And our results are just for Medicaid patients and just for the State of New York.

[Meridith Seife] Could you give us some examples of what you found?

[Lucia Fort] Medicaid paid one dentist an average of almost $900 dollars per child in one year, and that's compared to the State average of $200 dollars. This dentist performed an average of 16 procedures on each child, compared to the State average of five procedures.

[Meridith Seife] So it sounds like a major quality of care issues for these children getting treatment as well as a major waste of taxpayer money.

[Lucia Fort] It certainly is. In another example, one dentist provided fillings on 42 tooth surfaces in one child's mouth during a single visit.

[Meridith Seife] Did you find other instances of potentially abusive treatments?

[Lucia Fort] We also looked at services like extractions and baby root canals. We found six dentists who performed these procedures on an extremely high number of children - like one dentist who performed extractions on 76 percent of the children he treated, and this is compared to the State average of 10 percent.

[Meridith Seife] And you mentioned orthodontists too. What did you find there?

[Lucia Fort] So, New York pays for orthodontic services only in very limited situations. We found one orthodontist who treated almost 5,000 children in a single year. That's about ten times higher than the State average for orthodontists. Treating that many kids raises concern about whether the orthodontist actually provided the services, or whether each child received appropriate treatment.

[Meridith Seife] Did you notice anything in common among the dentists with questionable billing?

[Lucia Fort] Yes, we did. Almost a third of the dentists were associated with a single dental chain.

[Meridith Seife] Interesting. So given what you found, what are you recommending to the State?

[Lucia Fort] We asked the State to follow up on the extreme billing patterns of the dental providers we identified. We also recommended that the State use the proactive data analysis outlined in our report to improve its existing systems for monitoring dental providers. Also, New York recently transitioned all pediatric dental services to managed care. We recommended that the State collect data from its managed care entities to continue identifying any questionable billing patterns that might emerge.

[Meridith Seife] And what other work are you doing in this area?

[Lucia Fort] Our investigators are following up on some of the potential fraud and abuse that we identified. Our auditors are looking into individual dental providers to determine if they inappropriately billed Medicaid for pediatric dental services. We are also going to do this study in several other States, and look for common trends. We also plan to look at Medicaid children's access to dental care. We know that there is a major problem with children's access to these services. Dentists who participate in the Medicaid program provide much-needed access to dental care for kids. But we need to ensure that children get regular checkups and high-quality care.

[Meridith Seife] Lucia, thank you so much for sharing this important work, it's such an important issue. And we look forward to your additional work in the future.

[Lucia Fort] Thanks Meridith.


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Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201