Revisiting 2009 MassHealth Independent Audit Report; not much has changed.
- Audit report for period July 2005 – May 2009
- Dental Program claims processing system has resulted in millions of dollars in ineligible claims and potential fraudulent claims being paid.
- Only 15.7% of radiograph claims met requirements.
- 84.3% of radiographs (x-rays) by 10 providers (3 Small Smiles and 3 Kool Smiles) failed to meet requirements
- Radiographs (X-rays) claims paid to 3 Small Smiles clinics and 3 Kool Smiles clinics totaling $3,09,172 were unallowable.
- DentaQuest (f/k/a Doral Dental) Senior Dental Director stated providers “treat to the benefits allowed and not member’s need)
- 3 Kool Smiles and 3 Small Smiles clinics routinely gave members bitewing radiographs contrary to FDA recommendations.
- Small Smiles said in 2009 they implemented a new dental protocol that included the 2004 FDA recommendations.
- DentaQuest contract required them to identify standards of care based on published recommendation of nationally recognized authorities such as the AAPD.
- DentaQuest contract required it to monitor providers’ compliance with the AAPD guidelines.
- MassHealth failure to adequately control orthodontic services resulting in $321,553 overpayment to just one provider.
- DentaQuest failure to adequately monitor claims was widespread.
- Many cases of double billing and double payments
