Department of Civil Service
New York State Dental Program: Payments for Scaling and Root Planing Procedures New York State provides dental insurance benefits to certain State employees and their dependents. The Department of Civil Service contracts with Group Health Incorporated (GHI) to process dental claims on behalf of the State. During our four-year audit period, GHI paid 92,703 claims totaling about $4.7 million for certain dental services (scaling and root planing services for the treatment of periodontal disease). We reviewed these claims and found that about $1.6 million was paid for services that exceeded certain prescribed limits, as more than two quadrants of the patientsí mouths were scaled and root planed in one visit and/or the same quadrant was scaled and root planed multiple times within a short period of time.
Moreover, when we visited two of the dentists that routinely submitted claims for such excessive services and reviewed their medical records, we found that the excessive services claimed by the two dentists were often not supported the records. In addition, when we selected a sample of 134 of the claims for excessive services and reviewed the periodontal charts that had been submitted by the dentists to GHI demonstrating the need for the services, we found that the need for the services was supported by the charts in only 25 percent of the claims.
We concluded that there was a considerable risk that the providers submitting such claims were either performing the services more often than was medically necessary or were billing for more costly dental procedures than they were actually performing. We recommended that GHI improve its controls over such claims. We also recommended that certain questionable claims be investigated for possible improprieties.
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