Auditor Bump: Plymouth Dentist Greatly Overcharged MassHealth
Medicaid investigation uncovers $253,519 in unallowable billing
BOSTON, MA – State Auditor Suzanne M. Bump reported today that SmileCenter, a dental office located in Plymouth, received at least $253,519 in unallowable reimbursements from MassHealth.
The bulk of the identified money represents orthodontic services performed by a dentist who did not possess the required accreditation. According to MassHealth regulations, dentists who practice orthodontics must complete a minimum of two years’ training in a specialized program administered by the American Dental Association. SmileCenter’s sole dentist, who is also its sole proprietor, did not complete such a program but still billed and received $201,509 from MassHealth for orthodontic services.
“This is not just an accounting problem. This is a public health problem” said Auditor Bump. “MassHealth and its members who sought services from SmileCenter have little assurance that they received proper orthodontic treatment from this dentist.”
As a result of Auditor Bump’s investigation, MassHealth stated corrective action will include terminating SmileCenter’s specialty as an orthodontist, transferring its members for continued orthodontic treatment to other dentists, and seeking restitution as appropriate.
The review of the $1.2 million SmileCenter received from MassHealth for dental services between fiscal years 2007 and 2010, cited a pervasive pattern of excessive treatments, duplicative payments, and payments for services that were possibly never performed.
As highlighted in an earlier audit released by the Office of the State Auditor last year, MassHealth’s claims processing system, which is administered through the subcontractor DentaQuest, does not contain adequate controls to identify and reject unallowable claims for dental services. Because DentaQuest did not adequately monitor the Dental Program, it did not identify these system deficiencies.
“This is an egregious example of a health provider manipulating the MassHealth system to maximize their own bottom line at the cost of the taxpayer,” said Auditor Bump. “MassHealth needs to take immediate steps against this vendor, and DentaQuest must improve its ability to prevent improper payments that are costing the Commonwealth millions of dollars annually.”
Consequent to the lack of control, SmileCenter was able to bill MassHealth for over $40,000 in unallowable fluoride treatments, oral examinations, and pain treatments that were contrary to regulations.
In one specific example, SmileCenter performed 27 fluoride treatments in a 24-month period for a single member who was free of cavities and tooth decay. According to guidelines set by the American Academy of Pediatric Dentistry, SmileCenter should have provided no more than four fluoride treatments. Among a sample of 30 MassHealth members, 61% of the 272 claims for fluoride treatment were unallowable, totaling $4,008.
Today’s audit also noted billing discrepancies between the records of SmileCenter and MassHealth amounting to $4,787. Such conflicts raise questions about whether SmileCenter submitted claims for dental procedures that were not actually performed. Furthermore, the investigation revealed 35 instances of SmileCenter billing twice for the same procedure, totaling $2,510.
In her report, Auditor Bump recommended that MassHealth recover the identified monies and called on SmileCenter to reform their billing procedures relative to MassHealth.
Today’s audit is the latest in the Office of the State Auditor’s ongoing review of the Medicaid program, which now accounts for one third of the entire state budget. In fiscal year 2011, MassHealth paid a total of $266,987,637 in dental claims.
Audit Report: SmileCenter