Many of you read our bi-weekly emails for guidance on how to avoid potential liability. Well, today is one of those newsletters, with tips on how to avoid potential liability. While the subtopic is quite specific - Pediatric Dental Services on the OIG Hit List - the message is generic to all practitioners. OIG has a Hit List, and you can educate yourself on which services you may provide that are on the Hit List and why such services are on the Hit List to avoid becoming a target.
For general dentists and orthodontists, today's message is clear, the Office of the Inspector General (the arm of HHS responsible for protecting the integrity of federal Medicare and Medicaid funds) is eyeing with scrutiny pulpotomies—often referred to as “baby root canals”—and extractions, with the mindset that such services are areas of potential abuse by practitioners - some of whom are providing medically unnecessary services or fraudulently billing same without performance. See http://oig.hhs.gov/oei/reports/oei-02-14-00480.pdf.
The findings reported by OIG are as follows - We identified 329 general dentists and 6 orthodontists in California with questionable billing. Medicaid paid these providers $117.5 million for pediatric dental services in 2012. These 335 dental providers—representing 8 percent of the California general dentists and orthodontists whom we reviewed— provided large numbers of services or provided certain services to an extremely large number of children, among other practices. These services included pulpotomies—often referred to as “baby root canals”—and extractions. Notably, half of the dental providers with questionable billing in California worked for dental chains. The majority of these providers worked for five chains, two of which have been the subject of State and Federal investigations. A concentration of providers with questionable billing in chains raises concerns that these chains may be encouraging their providers to perform unnecessary procedures to increase profits. Further, our findings raise concerns that certain providers may be billing for services that are not medically necessary or were never provided. They also raise concerns about the quality of care provided to children with Medicaid. Although our findings do not prove that providers either billed fraudulently or provided medically unnecessary services, providers with extreme billing patterns warrant further scrutiny. We are engaged in further followup and OIG will take action against these providers, as appropriate.
The recommendations, while seemingly not too severe, may result in legal action against certain practitioners - We recommend that the California Department of Health Care Services (1) increase its monitoring of dental providers to identify patterns of questionable billing; (2) closely monitor billing by providers in dental chains; (3) review its payment processes for orthodontic services; and (4) take appropriate action against dental providers with questionable billing. The California Department of Health Care Services concurred with all four of our recommendations.
As is often the case, the OIG study on pulpotomies and extractions highlights that the few may be ruining the landscape and creating some concern of review for the many. The study references a good portion of those found to be abusive practitioners are in fact repeat offenders. So, suffice it to say if you operate your practice with concern for your patients, properly document and perform medically necessary services only, then let just serve as an additional reminder that Big Brother is watching his wallet and that it is not a bad idea every once in a while to take a step back and review our standard operating procedures.