Questionable Billing for Medicaid Pediatric Dental Services in Indiana

WHY WE DID THIS STUDY

Medicaid is the primary source of dental coverage for children in low-income families and provides access to dental care for approximately 37 million children. In recent years, a number of dental providers and chains have been prosecuted for providing unnecessary dental procedures to children with Medicaid and causing harm in the process.

HOW WE DID THIS STUDY

We based our analysis on Indiana Medicaid fee-for-service paid claims for general dentists and oral surgeons who provided services to 50 or more children in 2012. Using several measures, we identified dental providers with questionable billing who are extreme outliers when compared to their peers in Indiana.

WHAT WE FOUND

We identified 94 general dentists and 1 oral surgeon in Indiana with questionable billing. These providers are extreme outliers when compared to their peers. Medicaid paid these providers $30.5 million for pediatric dental services in 2012.

These 95 dental providers-representing 11 percent of the providers we reviewed-received extremely high payments per child; provided an extremely large number of services per day; provided an extremely large number of services per child per visit; and/or provided certain selected services to an extremely high proportion of children. These services included pulpotomies, which are often referred to as "baby root canals," and behavior management, which includes techniques to calm or restrain a child. Notably, two-thirds of the general dentists with questionable billing worked for four dental chains in Indiana. Three of these chains have been the subject of Federal and State investigations. A concentration of such providers in chains raises concerns that these chains may be encouraging their providers to perform unnecessary procedures to increase profits.

Further, our findings raise concerns that certain providers may be billing for services that are not medically necessary or were never provided. They also raise concerns about the quality of care provided to children with Medicaid. Although our findings do not prove that providers either billed fraudulently or provided medically unnecessary services, providers who bill for extremely large numbers of services warrant further scrutiny.

WHAT WE RECOMMEND

We recommend that the Indiana Family & Social Services Administration (1) enhance its monitoring of dental providers to identify patterns of questionable billing; (2) closely monitor billing by providers in dental chains; (3) ensure that dental providers appropriately bill for behavior management and educate providers on the use of behavior management; and (4) take appropriate action on the dental providers identified as having questionable billing. The Indiana Family & Social Services Administration concurred with all four of our recommendations.