Questionable Billing for Medicaid Pediatric Dental Services in New York

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 35 million children. In recent years, a number of dentists and dental chains have been prosecuted for providing unnecessary dental procedures to Medicaid children, as well as for causing harm to children while performing these procedures.

HOW WE DID THIS STUDY

We based our analysis on New York Medicaid fee-for-service paid claims for general dentists and orthodontists 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.

WHAT WE FOUND

We identified 23 general dentists and 6 orthodontists in New York with questionable billing. These providers are extreme outliers when compared to their peers. Medicaid paid these providers $13.2 million for pediatric dental services in 2012.

Notably, these 29 general dentists and orthodontists-representing 3 percent of dental providers we reviewed-received extremely high payments per child; provided an extremely large number of services per child; or provided certain selected services, such as pulpotomies or extractions, to an extremely high proportion of children. Additionally, almost a third of the general dentists were associated with a single dental chain that had settled lawsuits for providing services that were medically unnecessary or that failed to meet professionally recognized standards of care to children.

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 Medicaid children. Although some of their billing may be legitimate, providers who bill for extremely large amounts of services warrant further scrutiny.

WHAT WE RECOMMEND

We recommend that the New York State Department of Health (1) continue to monitor general dentists and orthodontists to identify patterns of questionable billing, (2) ensure that the State employs adequate safeguards to monitor general dentists and orthodontists under managed care, and (3) ensure appropriate followup on the general dentists and orthodontists identified as having questionable billing. The New York State Department of Health neither agreed nor disagreed with our recommendations. However, it identified actions it has taken or plans to take that support our first recommendation. It also outlined current requirements and processes that are in place that support our second recommendation. It did not indicate whether any steps were planned to address our third recommendation.