New York Improperly Claimed Medicaid Reimbursement for Orthodontic Services to Beneficiaries in New York City

The New York State Department of Health (State agency) claimed Federal Medicaid reimbursement for orthodontic services provided to beneficiaries in New York City that did not always comply with Federal and State requirements. Of the 100 beneficiaries in our random sample, the State agency properly claimed Medicaid reimbursement for 57 beneficiaries. However, for the remaining 43 beneficiaries, the State agency claimed Medicaid reimbursement for 1 or more services that were unallowable.

On the basis of our sample results, we estimated that the State agency claimed at least $7.8 million in unallowable Federal reimbursement.

These deficiencies occurred because the State agency and providers did not ensure that cases were reviewed annually to determine the need for continuing care and that services were documented. Further, the State agency provided limited guidance to providers on State regulations requiring orthodontic care to be reviewed annually to determine the need for continuing care. Finally, the State agency did not (1) sufficiently educate providers regarding their responsibilities to ensure that their patients receive annual clinical reviews at screening centers and (2) maintain adequate documentation.

We recommended that the State agency (1) refund $7.8 million to the Federal Government and (2) strengthen guidance and provider education activities related to authorizing continuing treatment and maintaining adequate documentation. The State agency did not indicate concurrence or nonconcurrence with either of our recommendations.