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Audit Audit of the Office of Medicaid (MassHealth)—Review of Claims by Reen & Reen, DMD, P.C.

This audit reviewed claims submitted to MassHealth by Reen & Reen, DMD, P.C. Auditors identified claims submitted using the wrong provider identification number and claims were submitted and paid by both MassHealth and private insurance carriers. The audit examines the period of July 1, 2012 through June 30, 2017.

Binder organization: Office of the State Auditor
Date published: June 8, 2018

Executive Summary

The Office of the State Auditor (OSA) receives an annual appropriation for the operation of a Medicaid Audit Unit to help prevent and identify fraud, waste, and abuse in the Commonwealth’s Medicaid program. This program, known as MassHealth, is administered under Chapter 118E of the Massachusetts General Laws by the Executive Office of Health and Human Services, through the Division of Medical Assistance. Medicaid is a joint federal-state program created by Congress in 1965 as Title XIX of the Social Security Act. At the federal level, the Centers for Medicare and Medicaid Services, within the US Department of Health and Human Services, administer the Medicare program and work with state governments to administer state Medicaid programs.

OSA has conducted an audit of orthodontic claims paid to Reen & Reen, DMD, P.C. (R&R), doing business as Reen & Willcutts Orthodontics, for the period July 1, 2012 through June 30, 2017. During this period, R&R was paid approximately $10,380,899 to provide orthodontic services to 6,887 MassHealth members. The purpose of the audit was to determine whether R&R properly billed MassHealth for orthodontic services and maintained documentation in members’ dental records to support these services.

The audit was conducted as part of OSA’s ongoing independent statutory oversight of the state’s Medicaid program. Several of our previously issued audit reports disclosed significant weaknesses in MassHealth’s claim-processing system that resulted in millions of dollars in potentially improper payments. As with any government program, public confidence is essential to the success and continued support of the state’s Medicaid program.

Below is a summary of our findings and recommendations, with links to each page listed.

Finding 1
 

R&R submitted bills using the wrong servicing provider identification number.

Recommendations
 

  1. R&R should always bill using the actual servicing provider identification number of the orthodontist who provided services.
  2. R&R should collaborate with MassHealth to clarify how to document and bill periodic orthodontic services when more than one person provides services to MassHealth members.

Finding 2
 

R&R improperly billed MassHealth when members had private insurance.

Recommendations
 

  1. R&R should not bill MassHealth for any orthodontic services for a member until it has received an explanation of benefits from the member’s private insurance carrier.
  2. R&R should collaborate with MassHealth and its subcontractor DentaQuest, LLC to ensure that it understands and follows MassHealth’s billing requirements under these circumstances.

A PDF copy of the audit of Reen & Reen, DMD, P.C. is available here.

Abbreviations

CMR

Code of Massachusetts Regulations

EOB

explanation of benefits

HLD

Handicapping Labio-Lingual Deviations

MMIS

Medicaid Management Information System

OSA

Office of the State Auditor

R&R

Reen & Reen, DMD, P.C.

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