Overview
During our audit period, Dr. Nicholas Franco did not have adequate documentation to support at least $2,528,147 in dental claims. The documentation was illegible, was altered, did not contain necessary information, or was missing from patient records. The lack of documentation and altered documentation call into question whether all of the services were necessary or delivered.
We extrapolated the test results from our sample of patient records to the population of “impossible” days. Based on this testing, we are 90% confident that the minimum amount of the overpaid dental claims (the lower limit) was $2,528,147 and the maximum amount (the upper limit) was $2,586,525. Our review of patient records indicated that none of the 131 sampled claims had adequate documentation. Specifically, records did not contain details of treatment; pertinent findings about dental conditions; the name and title of the individual service provider; and dated digital or mounted radiographs, when applicable. Also, 3 sampled claims did not include dates of service for procedures, and one patient record could not be located. In addition, documentation for 59 of the 131 sampled claims had been altered using correction fluid; most of these alterations were to dates of service.
Authoritative Guidance
According to Section 420.414(B) of Title 130 of the Code of Massachusetts Regulations (CMR),
Payment by the MassHealth agency for dental services listed in 130 CMR 420.000 includes payment for preparation of the member’s dental record, including electronic dental records. Services for which payment is claimed must be substantiated by clear evidence of the nature, extent, and necessity of care provided to the member. For all claims under review, the member’s medical and dental records determine the appropriateness of services provided to members. The written dental record corresponding to the services claimed must include, but is not limited to . . .
3. the date of each service;
4. the name and title of the individual servicing provider furnishing each service, if the dental provider claiming payment is not a solo practitioner;
5. pertinent findings on examination and in medical history . . .
8. a complete identification of treatment, including, when applicable, the arch, quadrant, tooth number, and tooth surface;
9. dated digital or mounted radiographs, if applicable.
MassHealth also requires providers to fulfill the recordkeeping and disclosure requirements in 130 CMR 450.205(D):
All records including, but not limited to, those containing signatures of medical professionals authorizing services, such as prescriptions, must, at a minimum, be legible and comply with generally accepted standards for recordkeeping within the applicable provider type as they may be found in laws, rules, and regulations of the relevant board of registration, professional treatises, and guidelines and other information published, adopted, or promulgated by state or national professional organizations and societies.
In 2010, the American Dental Association’s (ADA’s) Council on Dental Practice and Division of Legal Affairs published Dental Records, which was intended to provide useful information about such records. The “How to Write in the Record” section of the document states,
There are times when it is necessary to make a correction. There is nothing wrong with a correction if handled properly. Some state laws may allow you to simply cross out the wrong entry with a thin line, and make the appropriate change. Date and initial . . . each change or addition. Never obliterate an entry. Do not use markers or white-out. The important factor is that you must be able to read the wrong entry.
Reason for Issue
Dr. Franco did not have policies and procedures to ensure that all claims were properly documented according to MassHealth regulations and ADA guidelines.
Recommendations
- Dr. Franco should collaborate with MassHealth to determine how much of the $2,528,147 in unallowable dental claims should be repaid.
- Dr. Franco should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations and ADA guidelines.
Auditee’s Response
- As stated in your draft . . . dentists are required to retain documentation for each member for a minimum of four years after the last date of service. But you audited me back to July 1, 2015; almost seven years ago. Surely, a great number of the patients, in the early part of the audit, have not been seen for at least four years since their last visit. I would imagine a lot of them haven't been seen since their last appointment in the first two and a half to three years of the audit. Also, some of them may have only been seen once or twice in that two and a half to three year gap and are no longer patients of our office or even passed away.
- Looking at the graph . . . under “Overview of Audited Entity” you can see that the “Number of Members Served”, the “Number of Claims” and the “MassHealth Payments” has gone down dramatically since 2015 (Almost seven years ago). So by going back almost seven years in claims has made what you have determined what our overpayment was to be a lot larger than it would have been going back only the four years as you initially stated that I was required to maintain the records for.
- After reading Sections 420.414(B) and 450.205(D) of Title 130 of the Code of Massachusetts Regulations and “How to Write in the Record” section of the American Dental Association's publication Dental Records. I was surprised to learn all that was required to comply with those standards of information that needed to be included when filling out a record. We were never taught about this forty-five years ago. Forty-five years ago we were mainly concerned with treatment and quality of dental care we afforded our patients and, sorry to say, not all the now needed record documentation after the treatment was performed. At that time, we were instructed to address only services that were performed on the date of treatment and not such a complete narrative of everything done at the visit. Also, when we were involved in an audit by DentaQuest in the summer of 2012 concerning the dental services provided to MassHealth members there was no concern or problem with our record keeping at that time so what has changed since that time? When did the regulations or need of further notations change?
- I need to question what is considered an “impossible” day. [An audit team member] sent me a source of “the duration associated with certain dental procedure codes” provided by Cigna Dental Care from 2016. In my opinion, most of the times stated to perform certain procedures is very over generous with maybe a few of the estimates being vastly overstated. I also have a problem with the fact that there were no parameters stated as to how the estimates were obtained. Were they estimated by work done as a solo dentist on his own or with a fully trained dental assistant by his/her side. Allowing 120 minutes for any type of a crown is in my opinion is an hour to an hour and fifteen minutes too long. Just to give you some insight into my pre pandemic dental operations I will offer you this:
I have a total of six dental operatories in my office.
Three of the operatories are fully stocked with instruments and supplies that enable me to perform any services that any General Dentist is able to perform with one Dental assistant assigned for each room.
All three of the assistants were able to go over medical histories, take radiographs, perform four-handed dentistry, suction, perform gingival retraction, take impressions, make temporaries, pour models, process and sterilize instruments etc. just to mention some of their daily duties to make my day easier and provide me with additional time to provide more patient treatment.
The other three chairs were used primarily for emergency appointments, follow up appointments and for an occasional Dental Hygienist to use every now and again.
In summing up, when using the duration associated with certain procedure codes provided I have calculated a few theoretical days. The number of patient procedures performed during what is considered an “impossible” day, twelve hours, equates to approximately twelve patients visits per day if we did not perform multiple procedures on any one of them. Divide twelve patients by three assistants it comes to four patients being seen by each assistant per day. So it's very feasible to perform more procedures per day and in no way “impossible” to do.
5. The statement that "1 patient record that could not be located" was incorrect, sorry to say, was due to a clerical error by your audit team. There was no missing record; the unlocated record in question did not even exist. One of our [patients’] names was listed twice on the one hundred records requested list by mistake . . . [and] was in fact the same person seen on the two dates of service in question. Thus basically driving us crazy looking for a record that didn't exist until we realized their mistake that in fact the patient had been listed twice under two different names. We also notified the audit team of this oversight in a letter dated November 1, 2021 [and] they concurred with our assessment of the situation and told us that they would take care of it. . . . We even offered to supply another patient record to replace it and they told us that it wasn't necessary and it wouldn't be a problem. . . .
7. We have just concluded a retrospective utilization and peer review audit performed by DentaQuest, LLC (Case Number: 05258417) that was initiated on March 16, 2021 . . . for the dates of service 08/01/2019 to 01/31/2021 which overlapped your audit period for five months (08/01/2019 to 12/31/20). They also concurred with your assessment of our record keeping and we have already taken steps to ensure that all claims are properly documented according to MassHealth regulations and American Dental Association guidelines which you also have addressed in your audit. Furthermore, MassHealth has already been paid back . . . in full the monies that they deemed appropriate that we owed after the audit of that time period, (08/01/2019 to 01/31/2021), in question.
Auditor’s Reply
Dr. Franco states that some of the claims we reviewed were more than four years old, which exceeds the record retention period cited in our report, and suggests that this may be the reason there is some missing documentation. However, Dr. Franco did not indicate that he had determined that any of the sampled claims the Office of the State Auditor (OSA) reviewed fell outside this record retention period. Although our report does cite one regulation that requires dentists to retain documentation for each member for a minimum of four years after the last date of service, another regulation, 130 CMR 450.205(G), establishes a longer (six-year) retention period:
Notwithstanding any regulatory or contractual provisions that may provide for a shorter retention period, all records described in 130 CMR 450.204 and 450.205 must be kept for at least six years after the date of medical services for which claims are made or the date services were prescribed, or for such length of time as may be dictated by the generally accepted standards for recordkeeping within the applicable provider type, whichever period is longer.
Further, these regulations establish the minimum record retention period for MassHealth providers and are not meant to relieve a provider of the responsibility of maintaining adequate documentation to support all billing to MassHealth, which MassHealth regulations require regardless of the length of time involved. In addition, as noted above, Dr. Franco was able to provide OSA with all but one of the patient records requested. The claim associated with the missing patient record had a date of service in 2018, well within the cited record retention period, and therefore should have been available for OSA’s review. Also as noted above, the patient records Dr. Franco did provide were missing information, such as details of treatment; pertinent findings about dental conditions; the name and title of the individual service provider; and dated digital or mounted radiographs, when applicable. Given that Dr. Franco retained all the patient files and that the missing documentation varied from file to file, it was obvious to us that this was not an issue related to record retention, but rather an issue with Dr. Franco and his staff not properly documenting various types of required information in each patient’s record.
Dr. Franco states that after reading 130 CMR 420.414(B) and 450.205(D), “I was surprised to learn all that was required to comply with those standards of information that needed to be included when filling out a record. We were never taught about this forty-five years ago.” We are concerned about this statement because it appears that this may be the first time Dr. Franco has read this regulation; every MassHealth service provider is required to be aware of, and comply with, all current MassHealth regulations and other applicable authoritative guidance. Further, the requirement of maintaining complete and accurate patient documentation is a longstanding integral part of dental patient care. For example, the ADA publication Dental Records provides the following points about complete recordkeeping:
First, it can contribute to providing the best possible care for the patient. Patient records document the course of treatment and may provide data that can be used in evaluating the quality of care that is provided to the patient.
Records also provide a means of communication between the treating dentist and any other doctor who will care for that patient. Complete and accurate records contain enough information to allow another provider who has no prior knowledge of the patient to know the patient’s dental experience in your office.
Dr. Franco also asks in his response when MassHealth’s regulations changed to require this type of documentation. The regulations have remained essentially unchanged since 2010, well before the audit period; therefore, Dr. Franco should have been aware of, and complied with, all the documentation requirements therein.
Dr. Franco also states that his last audit, by DentaQuest in summer 2012, did not identify any problems with his recordkeeping. Since we were not provided with a copy of this audit, we cannot comment on the scope of the work DentaQuest conducted or any conclusions DentaQuest may have reached based on its audit work. Our concern is that, during our audit period, Dr. Franco and his staff did not maintain all the required documentation to support his bills to MassHealth; we have made recommendations to address this problem. Dr. Franco states that in 2021, DentaQuest completed an audit of his business that found similar recordkeeping problems to the ones OSA identified; this substantiates our findings.
Dr. Franco questions what is considered an “impossible” day. We did not use the definition of “impossible days” to determine whether the claims Dr. Franco submitted for such days were questionable. Rather, as stated in the “Audit Objectives, Scope and Methodology” section of this report, we deemed “impossible” days a high-risk area and therefore used them as the population of days from which to select our statistical sample. As noted above, for claims to be reimbursable, providers such as Dr. Franco must properly document the services provided in accordance with MassHealth regulations. This was the requirement we used to test the claims in our sample and find issues with all 131 claims tested. In addition, with regard to Dr. Franco’s discussion of dental assistants, the entire population of claims from which we drew our sample had Dr. Franco listed as the sole service provider.
Regarding one record, Dr. Franco states, “There was no missing record; the unlocated record in question did not even exist. One of our [patients’] names was listed twice on the one hundred records requested list by mistake.” This is incorrect. The patient with the missing record is separate from the patient who was listed twice. Dr. Franco was paid for dental services provided to the patient whose record was missing, and no supporting documentation was provided. There was another patient who was listed twice, under slightly different names and different member identification numbers, in our sample of 131 claims. OSA acknowledged in an email to Dr. Franco dated October 26, 2021 that the names belonged to the same person and the difference in names was a middle initial. However, this patient received dental services on two different dates of service and represented two different claims in our sample.
MassHealth Response
- MassHealth agrees with the OSA’s first recommendation that Dr. Franco should collaborate with MassHealth as it determines the amount of overpayments due. Specifically, MassHealth will review the 131-claim sample that the OSA reviewed for this audit. Assuming MassHealth agrees with the OSA that these claims constitute overpayments based on violations of MassHealth regulations, MassHealth will recoup the overpayments which resulted from these claims and will also impose appropriate sanctions. However, while MassHealth is very concerned by the findings of the [OSA’s] report, MassHealth does not believe it would be appropriate at this time to extrapolate an overpayment determination based on the OSA’s 131-claim sample to every claim submitted by the provider over a five-year period and therefore does not presently agree with the OSA’s finding that the provider had “inadequate documentation to support at least $2,528,147 in dental claims” or that such amount currently constitutes an overpayment. Therefore, MassHealth will complete a broader review of the provider’s claims. At that point, MassHealth will recoup additional overpayments, impose sanctions, and take other action against Dr. Franco as appropriate.
- MassHealth agrees with the OSA’s second recommendation that Dr. Franco should establish policies and procedures to ensure that all claims are properly documented according to MassHealth regulations and ADA guidelines.
| Date published: | May 26, 2022 |
|---|