Now here’s a blog post you can really sink your teeth into, or you may be gnashing them together after reading this. An audit released last week by the Louisiana Legislative Auditor found about $6.4 million in payments from July 2012 to June 2016 that violated Medicaid Dental Program rules. This story easily emphasizes the importance of ensuring that when seeking cost reimbursement for a procedure, those cost must be eligible and allowable.
The state auditor reviewed payments made by the Louisiana Department of Health (LDH) or Managed Care of North America (MCNA) in the state’s Medicaid Dental Program. LDH administers the program to provide dental benefits and services for eligible individuals. Medicaid dental benefits vary based on the recipient’s age, as those under 21-years-old are in the Early and Periodic, Screening, Diagnostic and Treatment program, while those 21 and over are covered in the Adult Denture Program.
The state auditor found that about $153,237 was improperly paid for periodic oral examinations to individuals under 3 years old or over 20 years old, when these type services are only allowable for those eligible members between 3 and 20 years old. In another case, about $1.737 million in improper payments were made for 15,678 claims for a restorative service that requires prior authorization if the service is performed on certain teeth, yet such prior authorization was not received.
LDH told the state auditor that these payments may have been made because provider manuals were not updated to account for changes to program rules. MCNA officials added that violations could be the result of claims being denied internally, yet being submitted to LDH as approved. “This inconsistency means that LDH cannot effectively oversee the Dental Program, as it cannot identify in its own data if any of the violating claims were denied by MCNA,” the state auditor warns. Ouch!
The state auditor has recommended that LDH ensure that the provider manuals are updated and work with MCNA to identify claims that MCNA considers denied yet still appear as approved in LDH data. LDH responded that it seeks to complete action on these recommendations this summer.
Traditional health care improper payments may get the lion’s share of the press coverage in terms of Medicaid misspending, but let’s not forget that erroneous payments on the dental field can add up pretty quickly as well.
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