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Reen & Reen, DMD, P.C. Submitted Bills Using the Wrong Servicing Provider Identification Number.

The audit identified 82 claims that were billed to MassHealth using a provider identification number for an orthodontist that did not perform the service(s).

Table of Contents

Overview

Reen & Reen, DMD, P.C. (R&R) submitted claims to MassHealth using the wrong servicing provider identification number. We examined the dental records for a random statistical sample of 180 out of 35,725 paid claims for all orthodontic services. Of these 180 claims, we identified 82 (46%) that were billed to MassHealth using the servicing provider identification number of an orthodontist who was a member of R&R’s group practice but did not actually perform the service/s. We found that all orthodontists at R&R were properly certified by MassHealth, and therefore we are not questioning the qualifications of the orthodontists who performed the services. However, by submitting inaccurate billing information to MassHealth, R&R is limiting MassHealth’s ability to effectively monitor it.

Authoritative Guidance

According to Section 420.404(A) of Title 130 of the Code of Massachusetts Regulations (CMR), when billing MassHealth, dentists (including orthodontists) who are part of a group practice must be identified on the claims for their services:

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 in 130 CMR 450.000. . . . 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.

Additionally, according to 130 CMR 450.302(B), providers in a group practice must submit claims identifying the provider who provided the service:2

All claims submitted by a group practice must clearly identify by provider number the individual practitioner who actually provided the services being claimed.

Reasons for Improper Billing

R&R’s billing administrator stated that R&R typically used the provider number of the owner of the practice (Dr. Reen before January 2017 and Dr. Willcutts after that date) when submitting bills to MassHealth. According to Dr. Willcutts, this decision was originally made by Dr. Reen, and Dr. Willcutts continued the practice. He believes it is the best way for the group practice to bill because members could receive services from multiple providers within the group practice throughout the orthodontic process.

Recommendations

  1. R&R should always bill using the actual servicing provider identification number of the orthodontist who provided services.
  2. R&R should collaborate with MassHealth to clarify how to document and bill periodic orthodontic services when more than one person provides services to MassHealth members.

Auditee's Response

Our office understands that Masshealth would like to have the ability to monitor individual servicing providers. Per your suggestion we will collaborate with Masshealth so that there can be a better understanding of how they would like periodic orthodontic services billed when more than one doctor provides services over the course of treatment. It is important for Masshealth to understand that in a group orthodontic setting, where multiple doctors often work together on the same day, a patient may actually see two doctors at one visit. Doctors collaborating on cases can provide the best treatment for the patient. That being said, we will contact Masshealth for their guidance on how this situation should be managed in the future.

MassHealth's Response

  1. MassHealth agrees that the servicing provider identification number of the orthodontist who provided the services should be used when R&R submits claims to MassHealth.
  2. MassHealth will require R&R to complete mandatory training on MassHealth billing rules and ensure that R&R’s orthodontists that are providing the services are appropriately reflected on all claims submitted to MassHealth. MassHealth intends to monitor this provider for compliance with these requirements, and will impose appropriate sanctions for noncompliance.

2. This quotation is from the version of the law that was in effect January 2012–June 2017 and thus was in effect for the majority of our audit period.

Date published: June 8, 2018
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