Overview
MassHealth will only cover one restoration per tooth per surface in a 12-month period, as outlined in Section 420.425(B)(3) of Title 130 of the Code of Massachusetts Regulations (CMR):
The MassHealth agency pays for only one resin-based composite restoration per member per tooth surface per 12 months per provider or provider location.
We found that Dental Arts Lawrence has a very high billing and re-billing rate for restorations on the same member, same tooth, and same surface, with many re-restorations occurring shortly after the expiration of the 12-month period. In the table below, we outlined the number of days between the same member, same tooth, and same surface for restorations during the audit period.
| Total Number of Restoration Claims | |
|---|---|
| Restorations replaced one year and 10 days after original restoration | 2,315 |
| Restorations replaced one year and between 20 and 30 days after original restoration | 3,409 |
| Restorations replaced one year and between 30 days and six months after original restoration | 9,544 |
While there is no regulation stating that Dental Arts Lawrence cannot bill restorations this way, according to an audit performed on Dental Arts Lawrence by MassHealth’s contracted dental program administrator, DentaQuest,
The Dental Director, [in this case, DentaQuest] questions why the volume of replacements on a per member basis and across all members treated is so high. It is understandable that in isolated instances a restoration may need to be replaced due to decay and/or trauma in a year timeframe. But if proper techniques are utilized in the placement of these restorations the medical necessity for their replacement should be an infrequent and isolated occurrence.
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.
The high rate of restorations on the same member, same tooth, and same surface makes the medical necessity of the procedure questionable and creates a concern for the quality of care provided to MassHealth members, especially considering the fact that 92% of all MassHealth claims over a four-year period occurred on days when the treating dentists reported that they worked at least 12 hours. We recommend that Dental Arts Lawrence work with MassHealth to determine whether these restorations were medically necessary.
Dental Arts Lawrence’s Response
As the [Office of the State Auditor] "Overview", Page #3, states that MassHealth provides access to healthcare services for approximately two million eligible children, families, people over 65 and people with disabilities all of whom have low or moderate incomes.
Many patients in our community have a very poor oral hygiene, high risk of decay, specifically young children and senior patients and affected mostly due to high caries risk; fractures (elderly) that happen due to bad habits. Further, very often, we treat a lot of immigrants and newer members of the community that are in need of extensive treatment as a result of severe lack of maintaining their oral hygiene, lack of access to healthcare providers, specifically, not seeing dentists for many years or not at all so as to prevent extensive treatment in a timely manner. They do not have healthy mouths and healthy habits which are very hard and sometimes impossible to break and turn around even after a series of educational attempts from our providers. We treat children that do not live with their immediate family; some are foster children; some are on head start programs and most of these patients—almost 40–50% have either poor oral hygiene or are periodontally compromised and or are bruxers. For instance, patients that are treated for deep cleaning . . . after MassHealth approval for coverage; they significantly lack consistency in maintaining a good oral care, inciding entering into periodontal maintenance program every 3–4 months versus 6–9 months. Many of these patients are in need of deep cleaning again in a years’ time. As we all know, that patient home care is #1 factor in maintaining the longevity of restorations provided.
As a practice that accepts both Medicaid and Private dental plans, our experience unfortunately shows that, most patients that are on Medicaid program who have no out-of-pocket expenses for dental work, tend to take the government support programs for granted and make very little or no improvement with their hygiene, do not follow the doctors’ recommendation, instructions etc. As a result these are high maintenance patients and unlike patients that have to cover at their expense any dental work needed.
It is our responsibility as healthcare providers, to act in the best possible interest of the patients’ health, provide the best possible care and treatment solely based on the actual medical need which sometimes consists of working in not so ideal healthy mouths, irrespective of their previous restoration(s). Otherwise, clinically any failure to detect, recommend and treat in a timely manner would be considered as negligence. . . .
All our doctors strongly feel that using statistical sampling leads to the risk of not detecting material misstatements in the population, thus not as accurate as auditing the entire samples and therefore leading to incorrect conclusions.
Each and every treatment rendered was medically necessary as well as was justified and we have provided to your team all the details, including the clinical review of all supporting documentation, including radiographs, clinical narratives, intra-oral pictures where areas of concern were marked for each and every restoration. . . .
In summary, this audit started on May 19, 2023, this is more than one year and ten months ago and we cooperated fully by providing you with all the detailed documents in a timely manner without dragging and yet your so-called findings are based on subjective, probabilities only and NOT evidence based. Why? Is it to maximize the fines and justify your investigation of almost two (2) years?
Auditor’s Reply
We understand the population that MassHealth serves and agree that some people have worse dental health than others. We do not agree with the conclusion that “most patients that are on Medicaid program who have no out-of-pocket expenses for dental work, tend to take the government support programs for granted and make very little or no improvement with their hygiene.” We believe it is well-established that issues related to underlying health, ability to modify health outcomes, ability to execute doctors’ instructions, etc. are related to other life events and are not caused by someone’s status as a MassHealth member.
All providers who accept MassHealth sign a contract to follow MassHealth regulations to get paid for services. According to 130 CMR 450.205(A),
The MassHealth agency will not pay a provider for services if the provider does not have adequate documentation to substantiate the provision of services payable under MassHealth. All providers must keep such records, including medical records, as are necessary to disclose fully the extent and medical necessity of services provided to, or prescribed for, members and must provide to the MassHealth agency and the Attorney General’s Medicaid Fraud Division, the State Auditor and the United States Department of Health and Human Services on request such information and any other information about payments claimed by the provider for providing services or otherwise described in 130 CMR 450.205.
Additionally, in its response, Dental Arts Lawrence stated that all services it provides are medically necessary. As auditors, we cannot determine the medical necessity of a service; nevertheless, for this issue, we pointed out an unusual trend we noticed in the data, about which DentaQuest also agrees is unusual. For this reason, we recommend that MassHealth work with Dental Arts Lawrence to determine whether all these services were, in fact, medically necessary.
Dental Arts Lawrence also questioned the use of statistical sampling; however, we did not select a statistical sample for this issue. Instead, we analyzed the entire population of restorations during the audit period, as Dental Arts Lawrence suggested we should.
Dental Arts Lawrence stated that our findings are not evidence-based. However, based on the documentation Dental Arts Lawrence provided, as evidence, the documentation does not align with MassHealth regulations and therefore has been reported accurately. We are not maximizing fines, as Dental Arts Lawrence stated; in fact, there is no dollar amount associated with Finding 1 or the Other Matters issues. A dollar amount was referenced in Finding 2, which Dental Arts Lawrence agreed with, as the regulation is clear that restorations made within one year are unallowable. However, we do not institute fines on any providers, and it is the responsibility of MassHealth to determine whether these are truly overpaid.
| Date published: | April 2, 2025 |
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