The latest Texas HHS-OIG Quarterly Report issued last month, again for some reason, under provider integrity, focussed on findings made on investigations of Medicaid dental providers when these investigations only account for a tithe of full-scale investigations conducted by OIG.
Trends relating to 94% of investigations into other providers ignored
OIG's statistics reported in the provider integrity section of the report show that dental providers only account for 6% of all full-scale investigations while physicians (individual/group/clinic) account for 22%, hospitals for 20%, home health agencies for 18%, and pharmacies for 8%.
Dental providers at 7% aren't in the top three for OIG preliminary investigations. Dentists are well behind home health attendants at 37%, physicians (individual/group/clinic) at 21%, and home health agencies at 10%.
Doesn't make sense
Again, why this fascination with Medicaid dentists when there are more egregious players? Sure, there are mentions further down in the case section of the report but why not report on the trends in hospital or medical doctor or home health agency investigations?
Report needs to have perspective
TDMR is not saying that Medicaid dental providers should not be investigated nor are we saying that the results or highlights of these investigations should not be publicly reported.
What we are saying is that dental providers seem to get an inordinate mention in these reports out of proportion to other categories of providers that are getting investigated much more often.
What OIG found in dental investigations
As it is highly unlikely that many dental providers read the OIG Quarterly Report, we republish this part of the provider integrity section. There is no mention made of how many providers were found with these problematic situations. We sincerely hope they were few.
Medicaid Provider Field Investigations (PFI) continues to examine dental providers whose billing patterns suggest possible fraud, waste or abuse. Issues include billing for a high number of restorations (fillings) in children coupled with lower billing for preventive procedures such as sealants and preventive resin restorations. In many cases, a records review indicates upcoding by the dentist to receive a higher reimbursement for a restoration when post-treatment x-rays reveal that only a sealant was placed.
Investigators also found instances of x-rays not supporting medical necessity for placement of stainless steel crowns (caps), unnecessary removal (extraction) of primary (baby) teeth and upcoding simple extractions by using a more expensive reimbursement code reserved for more difficult extractions.Additionally, investigations address dental providers billing for an equal number of pulpotomies (root canals) and stainless steel crowns on primary teeth. Often the dental x-rays do not show that a pulpotomy is medically necessary.
Another concern within the Medicaid dental program arises when providers bill for services different than the ones they provided or services they did not provide. Examples include billing for x-rays not taken and performing a composite (white) restoration while billing for a stainless steel crown.
The full report is available for download.