(August 23, 2016): During 2014, the Texas Health Human Services Commission’s (THHSC), Office of Inspector General (IG) found itself at the center of a number of controversial investigations and probes associated with its review of Medicaid dental claims. In response, Governor Greg Abbott appointed Stuart W. Bowen, the former Inspector General for Iraq Reconstruction to serve as the new Inspector General for the THHSC. A graduate of the University of the South (Sewanee), Mr. Bowen set out in 2015 to set the IG’s Office back on course. Characterizing 2015 as a year of “restructuring and reform,” the IG’s Office entered 2016 ready to reinstitute an aggressive review of problematic Medicaid claims. As Texas Medicaid dental audits move forward, you need to ensure that your practices are compliant with all applicable statutory and regulatory requirements.
I. Implementation of a New Texas Medicaid “IG Pediatric Dentistry Action Team":
After learning from its previous missteps, the IG’s Office appears to now be taking a more systematic approach in its audit and investigation of Medicaid pediatric care cases. As discussed in the IG’s June 2016 Quarterly Report, the IG’s Office continues to be concerned about the pediatric sedation and anesthetization practices being used on some Medicaid patients. In response, the IG’s Office has established a new “Pediatric Dentistry Action Team” (PDAT). According to the Quarterly Report, the IG’s Office:
“Launched the IG Pediatric Dentistry Action Team to identify root causes of recent egregious incidents involving Medicaid pediatric dental patients and recommend improvements to Medicaid policy and contracts to prevent further loss.”
In addition to working with other state and federal law enforcement agencies, the PDAT is also expected to be working closely with the Texas Dental Board. Notably, the PDAT is slated to examine the following two critical issues:
- Are Medicaid dental providers meeting the required medical necessity criteria for performing procedures that use anesthetization and sedation?
- Do the anesthetization/sedation services performed on children meet Medicaid standards?
The PDAT finalized its survey work in July 2016. It has been conducting fieldwork this month and is expected to continue to do so in September 2016. A final report, with the PDAT’s recommendations and “lessons learned” is not expected until later this year.
II. What Will Texas Medicaid Dental Audits Mean for My Dental Practice?
Assuming the PDAT’s Final Report is issued in November or December 2016, we anticipate that audits and investigations flowing from their review may begin as soon as Spring 2017. It is therefore imperative that you take steps today to better ensure that your Medicaid dental practice fully complies with all applicable laws and regulations.
As a starting point, it is essential to keep in mind that as a participating provider in the Medicaid Program, you are required to have an effective Compliance Plan in place.
As set out to the Texas Medicaid Provider Enrollment Application, prospective Texas Medicaid providers must attest to its Compliance Program Requirement. Under this condition, a provider must verify that in accordance with requirement TAC 352.5(b)(11), the Provider has a Compliance Program containing the core elements as established by the Secretary of Health and Human Services referenced in §1866(j)(8) of the Social Security Act (42 U.S.C. §1395cc(j)(8)), as applicable.
Does this section look familiar to you? A Texas Medicaid provider must affirmatively attest that he or she has a compliance plan in place prior to submitting his or application for enrollment. However, you may have simply checked the box “yes” without even realizing what a compliance program is or what is required under this section. This may be a serious mistake. An effective Compliance Plan can better assist you in meeting your statutory, regulatory and contractual obligations as a Medicaid provider.
III. Areas of Risk Facing Medicaid Dental Providers:
Potential risk areas include, but are not limited to:
- Failure to meet the medical necessity criteria for performing procedures that use anesthetization and sedation on Medicaid beneficiaries.
- Failure to meet Medicaid’s standards for the anesthetization and / or sedation services performed on children.
- Billing Medicaid for unnecessary procedures.
- Billing Medicaid for procedures that were never performed.
- Billing Medicaid for substandard work. Submitting claims for reimbursement under another dentist’s Medicaid provider number.
- Billing Medicaid for multiple cleanings within a six-month period.
- Too many or too few X-rays. In some cases, the x-rays have been taken incorrectly, taken by employees not licensed to operate the x-ray machine, and/or unreadable or even blank.
- Inappropriate Medicaid billings for dental restorations.
- Inappropriate use of protective stabilization devices. For instance, using a “papoose board” to immobilize the children, regardless of whether or not restraint was necessary.
- Unnecessary pulpotomies.
- Altering dates or entering false information on patient charts.
- Paying kickbacks for referrals of Medicaid patients.
- Billing for services performed by unlicensed or uncertified employees.
IV. Conclusion:
Our attorneys currently represent a number of Medicaid dentists in Texas (and in other areas of the country) in connection with Medicaid and private payor audits of dental claims. We are also experienced in handling False Claims Act cases and in working with a dental practice to draft and implement an effective Compliance Plan. Texas Medicaid dental providers can’t afford to wait for the next round of dental audits and investigations. Now is the time to review the documentation, medical necessity, coverage and billing practices to ensure that your office is fully compliant with applicable state and federal Medicaid requirements.
