Overview
Dr. Snehal Pingle, Dr. Yuan Fu Shek, and Dr. Ke Wang of Dental Arts Lawrence were paid for more than one tooth restoration on the same members’ teeth and teeth surfaces within a 12-month period in 3 of the 131 dental claims, totaling $215. The claims submitted for these restorations represent unallowable costs to the Commonwealth. This makes less funding available to pay for valid, allowable claims through the MassHealth program.
Authoritative Guidance
According to 130 CMR 420.425,
The MassHealth agency does not pay for composite or amalgam restorations replaced within one year of the date of completion of the original restoration when replaced by the same provider or dental group. The initial payment includes all restorations replaced due to defects or failure less than one year from the original placement. . . .
The MassHealth agency pays for only one resin-based composite restoration per member per tooth surface per 12 months per provider or provider location.
Reason for Issue
Dental Arts Lawrence stated the following in an email on January 23, 2025:
There are cases in which caries are detected during routine visit(s) more frequently for certain group of patients for various reasons such as poor oral hygiene, recurrent decays, etc. and we redo these restorations so as to mitigate further damages to the tooth, prevent or minimize more invasive as well as costly treatment.
Recommendations
- Dental Arts Lawrence should work with MassHealth to determine the number of claims that are unallowable and should enter into an appropriate program of financial recovery for the Commonwealth.
- MassHealth should update its system to ensure that dental restorations are paid for appropriately.
Dental Arts Lawrence’s Response
All treatments are done based on the clinical necessity. For proper and accurate record keeping, all rendered treatments are always documented and posted on patients’ chart, irrespective of insurance carrier, method of payment etc. That being said, our experience shows that MassHealth, automatically denies 99.9999% any restorative claims done within one calendar year for the same tooth. See attached Office Reference Manual (ORM). Here in this particular case, MassHealth system failed and obviously happens to be an exception, not the norm, certainly an error of 0.0001% and evidently an overpayment of $215.
MassHealth’s Response
MassHealth agrees with OSA’s recommendation that Dental Arts Lawrence should work with MassHealth in order for MassHealth to determine the number of claims that are unallowable. Specifically, MassHealth plans to review the 131-claim sample that the OSA reviewed for this audit. If MassHealth determines that any of these claims constitute overpayments based on violations of MassHealth regulations, MassHealth will recoup the overpayments which resulted from these claims. If, after the review of the 131-claim sample, MassHealth determines that a broader review of Dental Arts Lawrence claims is necessary, MassHealth will conduct such review.
MassHealth plans to review its systems to determine whether updates are needed to further ensure that dental restorations are paid for in accordance with MassHealth regulations. If MassHealth determines that updates are necessary, MassHealth anticipates updating the applicable systems.
Auditor’s Reply
According to its response, Dental Arts Lawrence agrees with our finding.
In addition, MassHealth is reviewing its system to determine whether any updates need to be made in order to ensure that restorations are paid for in accordance with its regulations and will work with Dental Arts Lawrence to determine how many restorations were overpaid.
| Date published: | April 2, 2025 |
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