OIG Update & Quarterly Report – Dental Fraud Highlighted


TDMR received an email newsletter this week from HHS-OIG.  They promoted their quarterly report and also a special downloadable publication for dentists on illegal dental solicitation.  We have these below for you to download.

Here some other items of interest from the email.

OIG releases second part of audit series

The OIG is conducting a series of audits of service coordination for STAR+PLUS Level 1 members. Read the second report.

OIG inspects complaint process of MCOs

The report, the second in a series of three inspections, details if the complaint intake and resolution processes of managed care organizations (MCOs) are consistent with contract requirements. Read the report.

OIG Quarterly Report Highlights

We decided to dig in here a bit as it is the last quarter of the year.

For 2019, OIG recovered quite a bit of money, some $421 million.  Most of the money came from third party collections Here is where they got it from providers.

Medicaid Program Integrity

  1. Provider collections $16,412,148
  2. Acute care provider collections $9,494,436
  3. Hospital collections $19,332,961
  4. Nursing facility collections $818,084
  5. Total $46,057,629

They have further targeted for recovery:

  1. MCO identified overpayments $6,190,764
  2. Acute care providers $3,046,572
  3. Hospitals $1,619,944
  4. Nursing facility overpayments $501,336
  5. Total $11,358,616

The report had a lot in it referring to dentistry. But there is a lot for everyone else too.

Dentistry highlights (or lowlights)

MCNA got a special mention for claiming unsupported, overstated, or unallowable expenses..

Managed Care of North America Insurance Company – A Texas Medicaid and CHIP Dental Maintenance Organization.

The OIG completed an audit of MCNA Insurance Company (MCNA), a Texas Medicaid and CHIP Dental Maintenance Organization. The audit objective was to evaluate the effectiveness of MCNA’s performance in complying with selected contract requirements, achieving related contract outcomes, and reporting financial and performance results to HHSC. Audit results indicated that MCNA’s 2017 Administrative Expenses financial statistical report (FSR) included unsupported, overstated, or unallowable expenses. In addition, MCNA did not request prior written approval from HHSC for the July 2012 administrative services fee increase and affiliate reporting exception, as required by the Uniform Managed Care Manual. MCNA adjudicated paid dental claims selected for review in accordance with requirements, and reasonably processed and resolved selected provider complaints.

Auditors offered recommendations to MCS which, if implemented, will address unallowable, unsupported, or overstated expenses reported on MCNA’s Administrative Expenses FSR for 2017, and strengthen oversight and compliance related to MCNA affiliate subcontracts.

Also, one dental provider case was highlighted.

Settlement agreement reached with dental provider

The OIG entered into settlement agreement in June with a dental provider in Irving for $98,094. The investigation found that the provider submitted claims with a pattern of inappropriate coding or billing that resulted in excessive costs to the Medicaid. The investigation found numerous program violations, including billing for services or merchandise that were not provided to the client, failing to maintain required records and other documentation of services and providing medically unnecessary health care services. Investigators also found evidence that some of the dental care failed to meet professionally recognized standards of health care.

Medicaid dentists are definitely under scrutiny despite only comprising 4% of MPI investigations.

In Program Integrity Highlights, dental fraud was covered. We republish that section here.

Data Drives Fight Against Medicaid Fraud in Dental Services

The OIG has taken an increasingly data-driven approach to fighting fraud, waste and abuse in Medicaid delivery. Experienced staff at the OIG have developed algorithms and data analysis processes to pinpoint areas where fraud may be occurring. After focusing attention on a particular provider or geographic region, the OIG then can deploy investigators and experts to corroborate findings from the data. The OIG used a data-driven approach in a recent OIG Fraud Detection Operation and an analysis of statewide Medicaid dental claims to find providers who were at high risk of illegally soliciting clients.

Fraud detection operation: Dental providers

One approach to fighting fraud is through a fraud detection operation (FDO). An FDO is a data-driven investigation that reviews providers who appear as statistical outliers among their peers and assesses whether this outlier status is due to program violations, fraud, waste or abuse. The advanced analysis of issues in an FDO may or may not lead to a full-scale investigation; identification of outlier status is not an automatic indicator of wrongdoing. The FDO simply flags providers who may warrant a closer look.

The OIG’s Medicaid Program Integrity (MPI) division is currently analyzing results from a July FDO. After providers were flagged through data analysis, the OIG’s chief dental officer and dental team conducted onsite clinical examinations of patients from four Dallas-Fort Worth area providers. The OIG team set up a mobile clinic to conduct the examinations, which were intended to verify that what was billed to Medicaid was indeed done. The team also checked the quality of procedures to ensure that the clients received the best care. Investigators also interviewed parents and dental staff to gain further insight.

Initial clinical exams identified providers who received reimbursement for restorations when either sealants or no restorations were performed. Preliminary findings also indicated two of the four dental providers were engaging in illegal dental solicitation. Dental providers are prohibited from offering cash, gifts or other items to people who have Medicaid in order to influence their health care decisions. These cases will move to full-scale investigations.

Illegal dental solicitation

Data analytics played a significant role in the OIG’s exploration of illegal dental solicitation. Medicaid providers are prohibited from offering clients inducements to influence their health care decisions. The OIG conducted a statewide examination of Medicaid dental claims between September 1, 2017 and August 31, 2018. Nearly 5,400 non-specialist billing providers were included, along with 2.3 million patients who received a general dental service.

Switching providers is often a natural occurrence in the course of care, but it also highlights conditions where solicitation can exist. OIG analysis revealed that client movement from one provider to another involves a minority of patients but a majority of providers. Eleven percent (257,790) of the patients in the data review received their services from two or more providers. Although a relatively small portion of the client population, that 11 percent was billed by 86 percent (4,662) of the non-specialist billing provider population.

Because client movement itself does not equate to solicitation, several data points were used to flag suspicious characteristics of provider activity that, in high volumes, can suggest patterns associated with solicitation. Red flags in the data include an unusually large number of new clients in a short period of time, clients receiving services on the same tooth from multiple providers or excessive services performed following a switch in providers.

The data analysis integrated such factors and ranked the providers as low, medium or high risk of illegally soliciting patients. One percent of the providers analyzed were considered high risk. Eighteen percent fell in the medium risk range, and the majority — 81 percent — were considered low risk. The providers flagged by the data as high risk may be subject to closer scrutiny from the OIG via an audit, inspection or investigation.

The OIG presented this data to dental maintenance organizations, dental associations and other stakeholders in June to inform them about the scope of the problem across the state. The presentation helped foster productive conversations among the stakeholders on how the issue of illegal dental solicitation affects the integrity of state health and human service programs.


Leave a Reply

Your email address will not be published. Required fields are marked *