The Office of the Inspector General (OIG) has issued its latest report in its state-by-state series examining pediatric dental services provided under Medicaid.  This newest report examines such practices in California, and follows closely on the heels of previous reports examining pediatric dental billings in North Carolina, Indiana, Louisiana, Texas and New York.  As with previous reports, the OIG found what it believes are significant questionable billing practices. 

Key information from the report and what to take away from it include:

  • As with the previous reports, this latest report was based on an analysis of billing data and didn’t include a review of patient medical records.  Nonetheless, the OIG identified 329 dentists and six orthodontists with questionable billing. Together, they were paid $118 million for pediatric dental work in 2012.  Two-thirds of those dentists claimed an extremely large number of procedures per day, including one dentist who billed for more than 1,000 services per day on 97 different days.
  • The OIG continues to focus closely on what it terms “dental chains” - an entity with five or more locations within a state or around the country - stating that a majority of those providers that it identified as having aberrant billing patterns were on staff at five dental chains, two of which have previously faced government investigations into questionable billing practices. In recent years, a number of dental providers and chains have been prosecuted for providing unnecessary dental procedures to children with Medicaid and causing harm in the process.  It is clear that the OIG believes continued scrutiny is warranted.   
  • Just like the earlier reports, the OIG “designed” the report to “identify dental providers who warrant further scrutiny.”  This scrutiny will undoubtedly be forthcoming.  Indeed, California regulators have promised to undertake various reforms, such as enhanced detection of suspect billing patterns, by the end of 2015.  This, coupled with the fact that the OIG is undoubtedly sharing the identity of the providers it identified as outliers in these reports, practically  guarantee both Federal and State regulators and prosecutors taking a closer look at those identified in the report - and the broader DSO arena.

This latest drumbeat from the OIG makes it clear that they intend to bring increased scrutiny to Medicaid pediatric dental billings. The OIG has undertaken a robust data-driven review of claims on a statewide basis that is intended to serve as a roadmap for state and federal authorities to investigate these providers. Moreover, as with all the reports in these series, the OIG has focused the majority of its attention on what it terms “dental chains.” As such, pediatric dental providers who bill Medicaid would be well served to closely examine both the report, as well as their own billing patterns and compliance program.  This is doubly true for providers that are part of DSOs and other multi-practice structures.