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New York May Have Improperly Claimed Medicaid Reimbursement for Certain Dental Services

New York may have improperly claimed reimbursement for 7,650 dental services totaling $1.3�million ($670,000 Federal share). Of these, 712 claims, totaling $66,000 ($34,000 Federal share), were for Medicaid fee-for-service dental services and 6,938 claims, totaling $1.3 million ($635,000 Federal share), were for clinic dental services.

This occurred because New York's Medicaid claims reimbursement system did not always prevent the reimbursement of certain fee-for-service dental claims for beneficiaries residing at nursing facilities and residential treatment centers. In addition, while New York's regulations require these facilities to provide, as part of the basic service agreement, dental services to all patients, its regulations do not require clinic dental providers to seek reimbursement from the facility where the beneficiary resided, even though services provided to the beneficiary may be the same as those included in the facility's rate.

We recommended that New York investigate each potentially improper dental fee-for-service claim and refund up to $34,000 to the Federal Government, as appropriate, and revise its Medicaid claims reimbursement system edit to ensure that fee-for-service dental claims are not reimbursed for beneficiaries residing at nursing facilities and residential treatment centers. We also recommended that New York amend its regulations and program guidelines to prohibit the Medicaid reimbursement of clinic dental claims, which may have saved as much as $635,000 during our audit period, for services provided to beneficiaries who reside in nursing facilities and residential treatment centers.

Filed under: Centers for Medicare and Medicaid Services