Audit Questions Medicaid Billing by 335 California Dentists

A California dentist who treats children under Medicaid billed for more than 1,000 services a day for almost 100 days in 2012. Another provided 33 procedures — including multiple stainless steel crowns and baby root canals — to a 4-year-old during a visit. Another received an extremely high payment per child — $699 compared with a statewide average payment of $166 per child.

About 8 percent of dentists in California treating children enrolled in Medicaid may be overcharging, raising questions about the quality of care, according to a federal report released to be Monday.

Auditors for the U.S. Department of Health and Human Services identified 329 dentists and six orthodontists with questionable billing. Together, they were paid $118 million for pediatric dental work in 2012.

Because investigators only analyzed claims data and did not review medical charts, the report did not determine whether the dentists engaged in fraudulent billing or provided services that were not medically necessary. But the billing patterns merit a closer look, auditors said.

“What we found in California’s Medicaid program is very concerning. There were a number of dentists with extremely unusual behavior, which points to some real vulnerabilities in the care being provided to children,” deputy regional inspector general Meridith Seife said in a statement.

It’s the latest scrutiny of dental care provided to children covered under Medicaid, the federal-state program for the poor and disabled. Federal health auditors in recent years found questionable billing among dental providers in North Carolina, Indiana, Louisiana, Texas and New York.

The California report focused on dentists and orthodontists serving at least 50 children who billed Medicaid in 2012 for work such as fillings, extractions, stainless steel crowns and baby root canals. While extreme outliers made up a small percentage of dentists studied, they provided care to about a third of the children served.

Among the findings: Two-thirds claimed an extremely large number of procedures per day, including one dentist who billed for more than 1,000 services per day on 97 different days. Nineteen dentists received unusually high payments per child. One dentist routinely gave patients multiple steel crowns and performed other procedures. Half worked for dental chains. A dozen were investigated by the state dental board.

Their identities were not released, but federal investigators planned to forward names to the state to follow up.

In an accompanying response to the report, the California Department of Health Care Services said it will step up monitoring to better identify providers with questionable billing and take action if needed.

The California Dental Association supports the federal effort and works with the state to “ensure that the billing process is clear to dentists in an effort to prevent billing errors,” spokeswoman Alicia Malaby said in a statement.

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