Medicare Contractors' Payments to Providers for Hospital Outpatient Dental Services Generally Did Not Comply With Medicare Requirements

In our previous audits of six Medicare contractors, we found that payments made to providers for hospital outpatient dental services generally did not comply with Medicare requirements. Of the 600 dental services in our 6 stratified random samples, 542 did not comply with Medicare requirements. We did not determine Medicare compliance for 3 dental services because the payments were refunded before our audit work, and we did not determine Medicare compliance for 28 dental services because the providers of those services submitted claims to a different Medicare contractor. Medicare contractors properly paid providers for the remaining 27 dental services. On the basis of these results, we estimated that the six Medicare contractors in our audits improperly paid providers an estimated $9.8 million for hospital outpatient dental services that did not comply with Medicare requirements.

We recommended that the Centers for Medicare & Medicaid Services (CMS) implement national edits for hospital outpatient dental services and work with the Medicare contractors to develop or strengthen their local edits to ensure that payments made to providers for dental services comply with Medicare requirements. CMS did not concur with our recommendation to implement national edits, stating that it would be difficult to implement because dental coverage is based on the specific clinical needs of the beneficiary. However, CMS stated that it will work with its contractors to develop and strengthen local edits to help ensure that payments made to providers for dental services comply with Medicare requirements.