During the second quarter of fiscal year 2023, the OIG’s Medicaid Provider Field Investigations (PFI) team reviewed dental providers exhibiting billing practices that could indicate fraud, waste or abuse. Recent investigations have identified billing trends that indicate some providers are focusing on higher-cost services to increase reimbursement from the Medicaid program while forgoing lower-cost preventative procedures like sealants and resin restorations.
Providers also upcoded their services, a billing technique where dentists claim expensive reimbursement codes when medical records indicate clients received less-costly procedures. Instances of upcoding included overbilling the state for simple tooth removal by claiming more expensive methods were required and billing for dental restoration procedures when post-treatment X-rays revealed less-costly sealants had been applied.
Investigators also found cases where unnecessary procedures were billed, including placing stainless steel crowns which investigators determined were unneeded. It was also found that some providers performed a root canal for every stainless-steel crown that was applied, even when X-rays did not support the procedure.
Medicaid dental providers are responsible for accurately documenting medically necessary services for clients. In addition, they must ensure that submitted claims for payment match the provided procedures. PFI team members monitor the records submitted with claims for service and use the expertise of medical professionals to determine when procedures are unnecessary or billed incorrectly.