The Audit division of the Health and Human Services Office of Inspector General released a report at the end of October (although TDMR just received the email notification about it today) about an audit they conducted on the practice of a single New York City dentist. The dentist is not named and only referred to as “the New York City dentist.”
Single oral surgeon’s practice subject of audit although employed others
The dentist is described as “an oral surgeon who provided oral and maxillofacial surgery services to underserved urban populations in several locations throughout the boroughs of Manhattan and the Bronx. The New York City dentist employed or contracted with several dentists during our January 1, 2010, through June 30, 2012, audit period.”
The audit was occasioned because the dentist was “identified [as] a dentist at risk for billing a potentially excessive number of services during our audit period.”
Per the report, the dentist had “31,738 claims for dental services, totaling $2,584,485 ($1,291,111 Federal share), provided to 5,833 Medicaid beneficiaries” for diagnostic, oral and maxillofacial surgery, and related services during the 30 month audit.
Only deficiency – did not check whether or not other treating dentists were enrolled in Medicaid
The federal auditors conducted the audit by reviewing a random sample of 100 cases. They found that 12 of the 100 did not qualify for Medicaid because the dentists doing the treatment were not enrolled as a Medicaid provider. It turns out that the practice did not check whether or not every dentist who treated Medicaid patients was enrolled in Medicaid.
Those 100 cases cost the federal government a total of $3,944 or $39 a piece. The 12 unqualified cases cost a total of $427 (federal share) or $35.58 each.
Feds want back $64,000 from state, out of $1.2 million
When the auditors used the magic of extrapolation (“estimated the unallowable Federal Medicaid reimbursement in the sampling frame of 31,738 claims”), all they could seek back from NY state was $64,454 out of the $1,291,111 (federal share).
So 12% of the cases accounted for less than 5% of the monies paid.
No allegations of fraud, waste or abuse
There were no allegations of Medicaid fraud, waste or abuse although the finding of such was clearly the purpose of the audit (see the quote below).
Other than not checking on the eligibility of the treating dentists, “the New York City dentist” apparently did an admirable job.
Shades of Dr. Leonard Morse.
Congressional testimony on dental fraud provided rationale for audit
There is a Texas twist to this story because the background for checking up on dental services in NY and elsewhere came from a Congressional hearing which many in Texas might remember.
“In an April 2012 hearing on government efforts to address Medicaid fraud, Congress noted its concerns on waste, fraud, and abuse of certain Medicaid program services, including dental services. Based on Congress’ concerns, the results of a review we conducted on certain Medicaid orthodontic services provided to beneficiaries in New York City, and other Office of Inspector General (OIG) reviews throughout the country, we are conducting a series of reviews of claims submitted for Medicaid reimbursement by the New York State Department of Health (State agency) for dental services billed by dentists which we identified as being potentially at risk for noncompliance with certain Federal and State requirements. In this review, we identified a dentist at risk for billing a potentially excessive number of services during our audit period.”
This is the hearing at which orthodontist Dr. Christine Ellis testified and made claims, since debunked, that large numbers of dentists and orthodontists in Texas had conspired to commit massive “fraud” in Medicaid orthodontic billings.
It is a definite boost to the reputation of the dental profession that, four years down the road, a successful and productive “New York City dentist” that treats large numbers of Medicaid-eligible patients is audited and found to not be involved in fraud, waste or abuse.21301032