Press Release  Audits Show Dental Providers Not Billing in Accordance with MassHealth Regulations

Boston — Auditor Suzanne M. Bump released a series of four audits of dental providers, three of whom incorrectly billed MassHealth for dental periapical radiograph claims. The three audits for which incorrect billing was identified examined claims submitted by Sawan & Sawan, DMD of Framingham, Dr. Najmeh Rashidfarokhi, DMD  of Lawrence, and Webster Square Dental Care of Worcester. The audits reviewed claims submitted from July 1, 2010 through June 30, 2015.

Each of the three audits found that these providers billed for dental periapical radiographs, a type of x-ray, in a manner that was contrary to MassHealth regulations. MassHealth regulations allow these x-rays to be taken only when medically necessary or as part of a series of x-rays taken every 3 years to monitor members’ dental health. However, the audits found that these providers often conducted these x-rays as part of routine examinations, citing the specific dental needs of MassHealth members.  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.                              

“In each of these audits, we heard from providers that what they deemed as medically appropriate was not in-line with MassHealth regulations,” Bump said. “If dentists believe the regulations are not supportive of positive patient outcomes, they should work with MassHealth to seek changes. That said, providers are responsible for following MassHealth’s regulations, and MassHealth has an obligation to ensure that its claims-processing system can identify when providers are not billing correctly so that it can rectify the situation.”

The audits found that the providers improperly billed MassHealth for the following amounts:

• Sawan & Sawan – $79,190
• Dr. Najmeh Rashidfarokhi - $267,251
• Webster Square Dental Care - $246,497

These audits were conducted as part of the Office of the State Auditor’s ongoing review of MassHealth. Several previous audit reports disclosed significant weaknesses in the claim-processing system, which has resulted in millions of dollars in unallowable claims payments.

The Office of the State Auditor also reviewed claims submitted by Our Dentist of Chicopee, which found insufficient supporting documentation of claims submitted for periapical radiographs totaling $3,720, but concluded that the radiographs were taken appropriately. MassHealth responded to the audit that it will work with Our Dentist to ensure proper documentation is maintained moving forward.

In fiscal year 2016, MassHealth paid healthcare providers more than $14 billion to provide services to approximately 1.9 million members. Massachusetts receives a reimbursement from the federal government for 50 percent of most services provided to MassHealth members. MassHealth expenditures account for roughly 39 percent of the state’s total annual budget.

The Sawan & Sawan audit is available here.
The Dr. Najmeh Rashidfarokhi audit is available here.
The Webster Square Dental Care audit is available here.
The Our Dentist audit is available here.

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