Mass Auditor: Framingham Dental Provider Not Billing in Accordance with MassHealth Regulations

BOSTON – Massachusetts Auditor Suzanne M. Bump released a series of four audits of dental providers, three of whom incorrectly billed MassHealth for dental periapical radiograph claims, including one from Framingham.

The three audits for which incorrect billing was identified examined claims submitted by Sawan & Sawan, DMD of Framingham, Dr. Najmeh Rashidfarokhi, DMD  of Lawrence, and Webster Square Dental Care of Worcester. The audits reviewed claims submitted from July 1, 2010 through June 30, 2015.

Each of the three audits found that these providers billed for dental periapical radiographs, a type of x-ray, in a manner that was contrary to MassHealth regulations.

MassHealth regulations allow these x-rays to be taken only when medically necessary or as part of a series of x-rays taken every 3 years to monitor members’ dental health. However, the audits found that these providers often conducted these x-rays as part of routine examinations, citing the specific dental needs of MassHealth members.  Periapical radiographs are a type of x-ray that shows an entire tooth from the top of the jaw, and are used to identify problems with a tooth and surrounding area.

“In each of these audits, we heard from providers that what they deemed as medically appropriate was not in-line with MassHealth regulations,” Bump said, said in a press release. “If dentists believe the regulations are not supportive of positive patient outcomes, they should work with MassHealth to seek changes. That said, providers are responsible for following MassHealth’s regulations, and MassHealth has an obligation to ensure that its claims-processing system can identify when providers are not billing correctly so that it can rectify the situation.”

The audits found that the providers improperly billed MassHealth for the following amounts:

  • Sawan & Sawan – $79,190
  • Dr. Najmeh Rashidfarokhi – $267,251
  • Webster Square Dental Care – $246,497

Sawan & Sawan, DMD submitted claims, and was paid approximately $79,190, for unallowable dental periapical radiographs. Specifically, it billed for dental periapical radiographs as part of routine dental examinations. Also, in some cases the dental records were incomplete, so we could not determine the reasons periapical radiographs were taken.

We tested a statistically random sample of 60 out of 31,745 claims made by Sawan & Sawan, DMD for dental periapical radiographs during the audit period. Because the sample was statistical, we were able to project the potential error to the population.

Of these 60 claims, 15 were unallowable. These 15 claims were for dental periapical radiographs performed as part of routine dental exams and were not part of a triennial full-mouth series of radiographs.

The associated dental records did not indicate dental pain; anticipated extractions; or any suspected infection, periapical change, or anomaly.

We projected our results to the population of claims for dental periapical radiographs using a confidence level of 90% and a tolerable error rate of 10.61 percent.

The result was a projected overpayment of $79,190 during the audit period.

Sawan & Sawan, DMD believed it prescribed periapical radiographs in accordance with state regulations and the coverage limits imposed by the MassHealth Dental Program.

The state’s audiotor recommended the Framingham dentist office:

  • Sawan & Sawan, DMD should collaborate with MassHealth to repay the approximately $79,190 in improper payments it received for periapical radiographs.
  • Sawan & Sawan, DMD should ensure that in the future, it does not bill MassHealth for periapical radiographs that are unallowable under MassHealth regulations (e.g., those performed as part of routine dental examinations).
  • Sawan & Sawan, DMD should ensure that dental records reflect the need for periapical radiographs for members.

MassHealth agrees with [OSA’s] finding that Sawan & Sawan, DMD should develop internal controls to prevent improper billing for periapical radiographs in the future. MassHealth will work with its Dental third party administrator, DentaQuest, and Sawan & Sawan, DMD [and] their employees to provide education on MassHealth policies and recordkeeping requirements.

In order to ensure Sawan & Sawan, DMD adheres to MassHealth rules and implements proper billing procedures going forward, MassHealth will monitor their claims utilizing data analytics to detect possible overutilization of radiographs.

Based on the monitoring results, MassHealth may also request additional records or conduct unannounced on-site audits.

 

These audits were conducted as part of the Office of the State Auditor’s ongoing review of MassHealth. Several previous audit reports disclosed significant weaknesses in the claim-processing system, which has resulted in millions of dollars in unallowable claims payments.

The Office of the State Auditor also reviewed claims submitted by Our Dentist of Chicopee, which found insufficient supporting documentation of claims submitted for periapical radiographs totaling $3,720, but concluded that the radiographs were taken appropriately. MassHealth responded to the audit that it will work with Our Dentist to ensure proper documentation is maintained moving forward.

In fiscal year 2016, MassHealth paid healthcare providers more than $14 billion to provide services to approximately 1.9 million members. Massachusetts receives a reimbursement from the federal government for 50 percent of most services provided to MassHealth members. MassHealth expenditures account for roughly 39 percent of the state’s total annual budget.

Framingham Source Editor

Susan Petroni Framingham Source Editor Email: editor@FraminghamSource.com Phone: 508-315-7176

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