Records Requests in an OIG Investigation


The following article was supplied by Texas HHS-OIG.


Keeping accurate and complete patient records is part of providing quality patient care. Good record keeping can also help protect a practice against allegations of wrongdoing. The patient record is a legal document that may be used in court to defend against malpractice allegations, and it helps determine whether a dentist’s diagnosis and treatment conformed to the Texas State Board of Dental Examiners’ standard of care.

The Health and Human Services Office of Inspector General (OIG) relies on provider record reviews as one of its tools to address fraud, waste and abuse in Medicaid-supported dental services. The reviews typically focus on comparing provider clinical records, including x-rays and treatment notes, with Medicaid billing and payments to verify that treatments provided and billed to Medicaid were medically necessary and that the sequencing of the services was appropriate. They also look at whether more complicated treatment was delayed and that all dental records requirements were satisfied. Dental providers are required by their contracts to supply the OIG with a Medicaid client’s dental record if that client’s treatment by the provider is under review.

What’s required

Dentists must ensure that patient records are accurate and complete. Texas State Board of Dental Examiners rule 108.8  lists what documentation must be included when dental services are performed; the OIG relies on the same documentation during a dental record review, audit, inspection or investigation. The basics include but are not limited to:

  • Patient’s personal information, medical history
  • Patient complaints and symptoms
  • Diagnostic quality x-rays and photographs
  • Treatment plan and progress notes, including prescriptions
  • Signed informed consent for treatment

As part of an investigation, an OIG records request will include the documents listed above, as well as prior authorization, charting, referrals for specialty care, lab referrals, surgical procedure records, type of software used for dental records and imaging, and a variety of business records. Additional specific items may be requested, depending on the allegations.

OIG investigations

The OIG investigates a dental provider typically after receiving a complaint from a patient or dental maintenance organization. When a claims data  review raises concerns or questions, an investigator requests records from the provider. The OIG dental team examines the records to verify patient consent and that the dentist documented everything they did—whether it was an exam or a procedure—how the problem was detected, and whether the treatment was medically necessary; the OIG checks for the proper permits if sedation is involved. More than recouping improper Medicaid payments, the OIG also ensures proper patient care and safety.

Costly violations

The OIG may seek to recoup payments to dentists who bill Medicaid for treatments that lack documentation demonstrating medical necessity. For example, inadequate documentation and numerous billing errors led to a $100,000 settlement with a North Texas dental provider in October 2020.  An OIG investigation discovered multiple instances of billing for services not provided, billing a more expensive service code instead of the appropriate lower-cost service code, and inadequate documentation for services over a two-year period.

Two other dental practices in North Texas agreed in November 2020 to pay $90,000 to resolve the overpayment caused by identified violations.  An OIG review of client files discovered instances of missing or inadequate documentation, inappropriate billing, services not rendered, upcoded services, medically unnecessary services and failure to meet the professional standard of care.

The provider settlements listed above included required repayment of Medicaid overpayments. Other outcomes from OIG investigations may include provider education, prepayment review of claims, penalties, referral to a licensure board or the Texas Office of the Attorney General, and the potential for exclusion from the Medicaid program.

Additional resources

The dentist is ultimately responsible for the CDT codes selected and documented in the patient record and billing systems. No matter who enters the information, the dentist must make sure all of the information, including any procedure codes referenced, is correct.

The ADA and the American Academy of Pediatric Dentistry (AAPD) offer resources on documentation and record-keeping. The ADA publication Dental Records (2010) explains in detail what a dental record should contain. Dentists will find more information in the Texas Medicaid Provider Procedures Manual and the Texas Administrative Code.

Everyone can play a role in protecting patient care and taxpayer dollars. If you suspect fraud, waste, or abuse in health care delivery, call the OIG Fraud Hotline at 800-436-6184 or use the fraud reporting form on the OIG website, ReportTexasFraud.com.

 

Connect with the Office of Inspector General:

Facebook: www.facebook.com/TxOIG

Twitter: www.twitter.com/TexasOIG

LinkedIn: hhsc-office-of-inspector-general

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