Below are select excerpts from the transcript and powerpoint slides of a January 2015 CMS Learning Lab Weninar entitled “Advancing Program Integrity for Medicaid Dental Programs: Federal, State and Stakeholder Efforts”. The Webinar was held by Medicaid-Chip State Dental Association’s (a must check out website) Lynn Douglas Mouden, DDS, MPH, Chief Dental Officer with the Centers for Medicare and Medicaid Services (CMS), (also associated with a host of other organizations). Speakers included:
First, John Hagg, Director of Medicaid Audits, Office of Inspector General, US Department of Health and Human Services, John.Hagg@oig.hhs.gov. His presentation begins on page 3.
Second, Meridith Seife, MPA, Deputy Regional Inspector General, Office of Evaluations and Inspections, Meridith.Seife@oig.hhs.gov, 212-264-2000. Her presentation beings on page 5, about 2/3 the way down the page, and;
Third, Linda Altenhoff, DDS Chief Dental Officer with the Office of Inspector General, Texas Health and Human Services Commission (THHS). Linda.Altenhoff@hhsc.state.tx.us. Her part of the presentation at the bottom of page 7.
(Bios of each speaker can be found on page 2 of the transcript)
I found a few things troubling, that I’ll discuss later.
Below are the excerpts from Ms. Seife portion where she speaks about the latest (at the time) OIG Questionable Billing Dental Medicaid Reports:
Who we are:•The Office of Evaluation and Inspections (OEI) conducts national evaluations of HHS programs from a broad, issue-based perspective.
•We are working on a series of studies evaluating Medicaid pediatric dental services in selected States.
So why are we looking at Medicaid dental services? Well, as I'm sure many of you know, in recent years, there have been a number of high-profile cases where certain dentists and dental chains were found to have engaged in some extremely abusive dental practices. Although such cases represent an extremely small number of bad actors, they can have truly devastating effects on children. Dentists have been found guilty of routinely extracting healthy teeth, performing unnecessary pulpotomies, or putting stainless steel crowns on teeth that didn't need them. Obviously our primary concern is that no kid should ever have to endure unnecessary treatment, or that treatment that doesn't meet basic standards of care. But this can also have a significant impact on taxpayers as well.
The primary goal of our evaluations was to use Medicaid claims data in a way that could accurately identify dental providers who exhibited patterns of questionable billing. We're doing this currently in four states. In 2014 we issued reports on providers in New York, Louisiana, and Indiana. And our California report will be issued early this year. Although we were somewhat limited in doing these studies in only a few selected states, we hope that these reports will serve as a model for how other states can use their Medicaid data to identify potentially problematic providers in their Medicaid programs, and, hopefully, to target their resources more effectively in looking at those providers.
So I've already referenced, a few times, this idea of questionable billing, but I haven't really defined what it means. It's based on a type of analysis that the OID has done in other parts of Medicare and Medicaid, but this is the first time we've applied such an analysis to dental services. What is it? It's really just a method of determining certain billing patterns that are significantly different from one's peers.
We base these analyses on certain key measures that we developed in consultation with numerous experts. We spoke with law enforcement officials who specialized in working dental fraud cases. We also spoke with dental experts in state Medicaid agencies and CMS. We also received a tremendous amount of help from experts within the AAPD and that ADA.
Once we developed these measures, we then analyzed Medicaid's claim data in each state to identify extreme outliers or questionable billers, as we referred to them in our report. Specifically, we use these measures to identify providers who received extremely high payments per child, provided an extremely large number of services per day, provided an extremely large number of services per child per visit, and/or provided certain selected services, such as pulpotomies and extractions, to an extremely high proportion of children.
Process for Conducting AuditsOnce we developed these measures, we then analyzed Medicaid's claim data in each state to identify extreme outliers or questionable billers, as we referred to them in our report. Specifically, we use these measures to identify providers who received extremely high payments per child, provided an extremely large number of services per day, provided an extremely large number of services per child per visit, and/or provided certain selected services, such as pulpotomies and extractions, to an extremely high proportion of children.
Just to give you a sense of what those outliers look like, here is an example of a questionable billing analysis on average Medicaid payments per child by individual dentists. As you see, the vast majority of dentists are clustered around the median and mean amount, with an average payment of about $200 per visit. But, of course, way out towards the left, you start seeing outliers that are very different from that amount. For example, you can see that one outlier was paid over $1,100 per visit on average.
•Audit Notification Letter / Entrance Conference
•Define: Audit Objectives, Scope, and Methodology
•Data Collection and Analysis
•Exit Conference
•Draft Report
•Auditee Comments
•Final Report
So, before I get into what we found, I do want to make just a few brief points about our methodology. One of the biggest challenges in conducting this type of an analysis is to be sure that you're comparing similar peer groups. Obviously you don't want to compare a general dentist in private practice with an oral surgeon working in a hospital setting. So, first, we separated out general dentists from other selected specialties. And once we grouped each peer group appropriately, we then established key thresholds for each of the measures.
These thresholds were established using a statistical method that's known as the "Tukey method." For the more statistically inclined among you, it basically calculates values that are greater than the 75th percentile plus three time its interquartile range. For those of you that are not statistically inclined, it's simply a way of identifying really, really extreme outliers. It also does this in a way that takes in the overall distribution into account. It means that you will not just be taking the top ten billers on a particular measure, it has to be significantly different from the norm. As a result, in a number of case, we found no outliers at all for a specific measure.
I should emphasize that this analysis does not confirm that a particular provider is engaging in fraudulent or abusive practices. Some providers may be billing extremely large amounts for perfectly legitimate reasons. Our position is simply that these providers are significantly different enough from the norm that it warrants further scrutiny.
So, using those measures, we identified a number of dental providers with questionable billing in each of the states we looked at. In total, we identified 151 providers with questionable billing, and Medicaid paid these providers over $56 million for pediatric dental services in 2012.
Questionable Billing Examples:
New York :
•Dentist averaged 16 procedures per child, compared with a statewide average of five.
•Dentist extracted the teeth of 76 percent of children he treated, compared with a statewide average of 10 percent.
Louisiana:
•Three dentists each provided an average of 146 or more services per day, compared to an average of 27 services for other dentists in the state.
16.
We also found that a significant proportion of these questionable billers were concentrated in certain dental chains. As many of you know, systemic problems within specific chains is a concern to many policymakers. In the three states we've reviewed so far, between one-third to more than half of the questionable billers worked for certain dental chains. Many of these chains had been previous investigated for providing services that were medically unnecessary or that failed to meet professionally recognized standards of care.
