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. Nicholas Franco is a dentist; a certified MassHealth dental service provider; and the owner of East Boston Dental Associates, which employs other dental service providers. Dr. Franco received a total of $3,464,028 for dental services provided to MassHealth members during the audit period:
|
Fiscal Year |
Number of Members Served |
Number of Claims |
MassHealth Payments |
|
2016 |
939 |
13,049 |
$ 745,717 |
|
2017 |
881 |
13,262 |
737,210 |
|
2018 |
828 |
11,723 |
655,226 |
|
2019 |
767 |
10,715 |
587,567 |
|
2020 |
625 |
9,174 |
495,062 |
|
2021* |
460 |
4,503 |
243,246 |
|
Total |
4,500† |
62,426 |
$ 3,464,028 |
* 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 1,866.
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 radiographic, diagnostic, preventive, restorative, endodontic, periodontal, and prosthodontic services. During the audit period, Dr. Franco provided the following types of dental service to MassHealth members.
- Diagnostic: 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.
- Preventive: These services include cleaning teeth, applying fluoride or sealants, and inserting space maintainers when a premature tooth loss may lead to loss of arch integrity.
- Restorative: These services include tooth restorations, crowns, posts, and cores.
- Endodontic: These services include pulpotomies (surgical removal of a portion of the innermost layer of the tooth) and root canals.
- Prosthodontic: These services include dentures and partial plates.
- Radiographic: 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;
4. the name and title of the individual servicing provider furnishing 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 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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