Department of Health

Inappropriate Medicaid Billings for Dental Restorations

We audited a sample of $148,341 in Medicaid claims submitted by five dentists. We initiated our audit because our ongoing analysis of Medicaid records indicated that the dentists often submitted questionable claims. The claims were questionable because the dentists claimed to have provided Medicaid recipients with an unusually large number of dental services, either over a period of months or in a single office visit. For example, on 151 different occasions, the dentists claimed to have provided a Medicaid recipient with 25 or more fillings during a single office visit.

To determine whether the claims in our sample were valid and appropriate, we visited the dentists’ offices and reviewed the medical records relating to the claims. We found that all the claims in our sample were inappropriate and potentially fraudulent because they were either not supported by the dentists’ medical records or did not comply with the rules set forth in the Department of Health’s Medicaid Dental Manual. We disallowed all $148,341 in payments on these claims. In addition, because of the billing patterns identified by our audit, we recommended that the Department of Health review an additional $9.9 million in Medicaid payments to the five dentists and recover any further unsupported or inappropriate payments. We also recommended the Department implement controls that would prevent these kinds of overpayments in the future.

For a complete copy of Report 2007-S-71 click here.
For a copy of the 90-day response click here.