Press Release  Auditor Calls on Dental Practices to Repay Over $290K to MassHealth

Boston — Auditor Suzanne M. Bump today released an audit of dental periapical radiograph claims submitted by Hampshire Family Dental of Northampton, and Orchard Family Dental of Indian Orchard (Springfield), both of which are owned by Dr. Samer Tahoun. The audit found that both practices improperly billed MassHealth for these radiographs, totaling approximately $290,417. Bump called on Dr. Tahoun to collaborate with MassHealth to repay these improper payments and take steps to prevent future improper billings.

“MassHealth providers must adhere to the regulations of the program and must document their claims,” Bump said. “MassHealth must now recover the improper payments made to these offices and decide whether further action should be taken against Dr. Tahoun. Additionally, MassHealth should take steps to identify these wrongful patterns of practice more quickly.”

Periapical radiographs are a type of x-ray that shows an entire tooth from the top of the jaw, and are used to identify problems with a tooth and surrounding area. Under state regulations, MassHealth will only pay for this procedure once every three years as part of a full-mouth series, or for specific areas when extraction is anticipated, or infection, or other anomaly is suspected and documented.

The audit found that these dental practices performed and billed MassHealth for these radiographs as part of routine dental exams without a full-mouth series, or documentation of pain, infections, or other issues. The audit examined these types of claims submitted by the practices to MassHealth from July 1, 2010 through June 30, 2015.

Bump’s office used advanced data analytics on dental x-ray claims billed to MassHealth to identify service trends and billing anomalies indicating potential fraud, waste, or abuse. These dental practices were selected for audit because claims for periapical radiographs represented 46 percent of total x-rays billed, significantly higher than the 28 percent average.

MassHealth agreed with Bump’s findings, and stated their intention to recover the overpayments and work with the practices to prevent future improper billings, and ensure appropriate record keeping.

Bump has previously found similar inappropriate payments by MassHealth for dental claims.

In fiscal year 2015, MassHealth paid healthcare providers $13.6 billion. Massachusetts receives a reimbursement from the federal government for 50 percent of most services provided to MassHealth members. MassHealth expenditures account for roughly 38 percent of the state’s total annual budget.

The Hampshire Family Dental and Orchard Family Dental audit is available here.

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