Overview
Dr. Snehal Pingle, Dr. Yuan Fu Shek, and Dr. Ke Wang did not have adequate documentation to support 5 out of the 131 dental claims in our sample; these dental records did not contain all necessary information. Specifically, 5 dental records did not contain the names and titles of the individual service providers furnishing the services.
By submitting inaccurate billing information to MassHealth, Dental Arts Lawrence limits MassHealth’s ability to effectively monitor it.
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:
(1) the member’s name, date of birth, and sex;
(2) the member’s identification number;
(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;
(6) a description of any medications administered or prescribed and the dosage given or prescribed;
(7) a description of any anesthetic agent administered, the dosage given, and the anesthesia flowsheet;
(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; and
(10) copies of all approved prior authorization requests or the prior authorization number.
MassHealth also requires dentists who are part of a group practice to be clearly identified on the claims for their services, as stated in the following excerpt from 130 CMR 420.404(A):
A dentist or public health dental hygienist who is a member of a group practice can direct payment to the group practice under the provisions of the MassHealth regulations governing billing intermediaries. . . . The dentist or public health dental hygienist providing the services must be enrolled as an individual provider, and must be identified on claims for his or her services.
Reason for Issue
Dr. Snehal Pingle, Dr. Yuan Fu Shek, and Dr. Ke Wang of Dental Arts Lawrence did not have controls to ensure that all claims were properly documented according to MassHealth regulations.
Recommendation
Dr. Snehal Pingle, Dr. Yuan Fu Shek, and Dr. Ke Wang of Dental Arts Lawrence should implement monitoring controls to ensure that all claims are properly submitted to MassHealth.
Dental Arts Lawrence’s Response
In response to the five claims that did not have the names and titles of the provider furnishing the service, Dental Arts Lawrence stated,
The [Office of the State Auditor (OSA)] excel sheet only lists 6 dental records/claims out of which 1 claim . . . is already addressed. . . . The 5 claims were billed under a different provider (doctor record for the patient but evaluated from another dentist in absence of their colleague) due to a software error. . . .
After all, all patients in question actually received the dental services in our practice on the dates listed from one of our three dentists, Dr. Pingle, Shek, Wang that are MassHealth providers. This is documented adequately and includes labeled and dated radiographs, notes, consents etc. We are more than happy to provide any further additional documentation upon OSA’s request for verification. Using the same analogy, when MassHealth experiences system errors from time to time with eligibility updates, incorrect denials etc., we do not conclude this to be as lack of adequate service or not trustworthy.
MassHealth’s Response
MassHealth agrees with the OSA’s recommendation that the Dental Providers should implement monitoring controls to ensure that all claims are properly submitted to MassHealth in accordance with MassHealth regulations.
Auditor’s Reply
According to its response, Dental Arts Lawrence agrees with the issue related to billing under a different provider.
| Date published: | April 2, 2025 |
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