Overview
Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services for approximately 1.8 million eligible low- and moderate-income children, families, seniors, and people with disabilities annually. In fiscal year 2020, MassHealth paid healthcare providers more than $17 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represented approximately 39% of the Commonwealth’s total fiscal year 2020 budget of approximately $43 billion.
According to Section 420.421 of Title 130 of the Code of Massachusetts Regulations (CMR), MassHealth pays for medically necessary dental services provided to its members. Dr. Melissa Hamilton, a certified MassHealth dental service provider, is a dentist and the owner of her practice in Taunton. Dr. Hamilton received a total of $5,998,275 for dental services provided to MassHealth members during the audit period, as detailed below.
|
Fiscal Year |
Number of Members Served |
Number of Claims |
MassHealth Payments |
|
2016 |
2,075 |
11,841 |
$ 1,364,154 |
|
2017 |
2,127 |
12,710 |
1,386,206 |
|
2018 |
1,730 |
10,129 |
1,102,197 |
|
2019 |
1,616 |
8,933 |
983,902 |
|
2020 |
1,190 |
6,058 |
686,723 |
|
2021* |
749 |
4,319 |
475,094 |
|
Total |
9,487† |
53,990 |
$ 5,998,275‡ |
* This row only includes the first six months of fiscal year 2021 (July 1, 2020 through December 30, 2020).
† The unduplicated number of members served is 8,174.
‡ Discrepancies in dollar amounts are due to rounding.
Dental Services
The services provided by dentists to eligible MassHealth members include diagnosing, treating, and managing tooth disorders. MassHealth instructs providers to use specific procedure codes to bill for dental services, such as diagnostic, preventive, restorative, endodontic, periodontal, and prosthodontic services, as well as radiographs. During the audit period, Dr. Hamilton provided the following types of dental service to MassHealth members:
- Diagnostic Services: These services include oral evaluations, which members may receive at least twice per calendar year. Members may also receive evaluations that are limited to specific oral health problems or complaints.
- Oral and Maxillofacial Surgery: These services include extractions and surgical removal of teeth.
- Radiographic Services: These services include radiographs and diagnostic imaging taken as an integral part of diagnosis and treatment planning.
MassHealth pays for dental services only when there is complete documentation in the member’s dental record, and dentists are required to retain documentation for each member for a minimum of four years after the last date of service. MassHealth has promulgated regulations regarding the documentation requirements for members’ dental records. Specifically, 130 CMR 420.414(B) requires the following to be documented:
3. the date of each service . . .
5. pertinent findings on examination and in medical history . . .
8. a complete identification of treatment . . .
9. dated digital or mounted radiographs, if applicable.
The required documentation of pertinent findings on examination and in medical history includes, but is not limited to, patient complaints and resolutions, progress and treatment notes, and diagnostic records.
| Date published: | May 26, 2022 |
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