Treatment and Billing Practices Among Dentists Providing Dental Care for Children in Publicly Funded Programs

by Kenneth G. Rawson, DMD; Marcia M. Ditmyer, PhD; Raymond D. Rawson, DDS, MA

ABSTRACT
Objective: The purpose of this paper was to review treatment and billing practices by Nevada dentists participating in Public Funded Programs (i.e., Medicaid, CHIP), which can lead to higher costs and unnecessary treatment of children needing dental care. Methods: Seventy-five thousand Medicaid/CHIP claim forms for dental care were reviewed by a licensed dentist representing the largest health care provider over a 12 month period (January to December 2012) for necessary and appropriate treatment in the state of Nevada. Results: Seventy-six percent of the cases reviewed received treatment for dental issues during the year and practitioner billings reached 220% of allowable charges, or 41 million dollars. While the majority of billings appeared to be appropriate, timely, and representing a high quality of care, several billing and treatment practices have been found that can lead to higher than budgeted utilization and cost. These include: a) up-coding, b) unbundling charges, c) overtreatment. Conclusion: The percentage of children receiving dental care with existing expenditures could be increased through careful control of approved coverage. Improvements in prevention among young children and wise implementation of policies regarding treatment can also lead to savings in Medicaid services.


The United States Surgeon General in May of 2000 reported that dental caries is the single most common chronic childhood disease being five times more common than asthma and seven times more common than hay fever.1 A major message derived from the Surgeon General’s report is that oral health is essential to the general health and well-being of all Americans and can be achieved by all Americans.1 However, not all Americans are achieving the same degree of oral health. Despite the advances in oral health services over the past half-century that have benefited the majority of Americans, many still experience needless pain and suffering, and complications that devastate overall health and well-being. Increased financial and social burdens have also diminished the quality of life for many Americans. What amounts to “a silent epidemic” of oral diseases is affecting our most vulnerable citizens — poor children, the elderly, and many members of racial and ethnic minority groups.1

Dental caries has been found to be unequally distributed among populations.2 Researchers have found that caries incidence, prevalence, and severity is greater in minority and economically disadvantaged children.2 Although dental caries prevalence in industrialized countries has declined significantly since the early 1970s, oral diseases, including caries, remain a major public health challenge.1,3 Dental care remains a significant economic burden for many countries, with five to 10 percent of public health expenditure being attributed to oral health.4 The reported prevalence of dental caries in the U.S. was approximately 60 percent in children ages 12 to 19, with a reported 20 percent having untreated tooth decay.5 While a great majority of US children report good oral health, subsets suffer a higher level of oral disease, primarily children living in poverty and some racial/ethnic minority populations.6 Children born into poverty suffer twice as much tooth decay as their more affluent peers and are more likely having no access to oral health care.7 It has been reported that children from families without insurance were 2.5 times less likely than insured children to receive preventive dental care and 3 times more likely to have unmet dental needs.6,7 Children, minorities, and the elderly have been found to experience negative oral health outcomes caused, in part, by a lack of dental insurance.7 It has been reported that black children have approximately 43 percent more untreated carious primary teeth than white children, and children at or below the federal poverty line have 138 percent more than children above the poverty line.2,8

In 1997, to provide necessary medical and dental coverage for children in families at or below 200 percent of the federal poverty line, the federal government passed legislation that established the State Children’s Health Insurance Program (SCHIP), now referred to as CHIP.9 The Children’s Health Insurance Program (CHIP) provides health coverage to nearly eight million children in families with incomes too high to qualify for Medicaid, but who can’t afford private coverage. Medicaid offers services to children of low income families that entitle them to comprehensive health care services known as Early, Periodic Screening, Diagnosis and Treatment (EPSDT).10 Medicaid and CHIP combined provide health coverage to more than 43 million children.10 States are required to provide dental benefits to children covered by Medicaid and CHIP. The federal government sets minimum guidelines for Medicaid eligibility. However, states may choose to expand that coverage beyond these minimum thresholds. All states have expanded coverage for children with an average CHIP income eligibility level for children of 241 percent of the Federal Poverty Level (FPL). While dental services are provided through Medicaid, in 2008, only 38 percent of Medicaid eligible children received services, which was below the Healthy People 2010 goal of 56 percent.11

The purpose of this paper was to review treatment and billing practices by Nevada dentists participating in Public Funded Programs (i.e., Medicaid, CHIP), which can lead to questionable or incomplete treatment of children needing dental care.

BACKGROUND
The challenge of providing services to children participating in Public Funded Programs has been attributed to enrolling sufficient providers and ensuring/creating dental homes for these children. While there is no specific evidence that increasing the fee structure or appropriating more dollars will increase the number of underserved receiving appropriate care, a number of States have increased provider rates as part of their strategies to increase children’s oral health access.12 However, fiscal conditions remain an obstacle to many States increasing rates. When payments are below usual and customary fees, there is always the concern that utilization will increase to maintain practitioner income. Therefore, it is critical for health care providers to look at treatment and billing practices among dentists providing dental care for children in these publically funded programs.

In a study performed in Ontario, Canada authors reported that like the U.S., sex, age, income, and race/ethnicity are important determinants of oral health status.12 In a group of adolescents examined, only 3.5 percent of those born in Canada required restorations, while 22.9 percent who immigrated to Canada in the previous two years needed restorations. Emergency care was needed by 0.5 percent and 10.4 percent of these groups, respectively. Children at low risk must also be identified to reduce unnecessary care and expenditures.12 Efforts must be directed to eliminate wasteful expenditures due to over treatment and/or fraudulent/inaccurate billing of patients already in the system.

In 2012, an estimated $19 billion (seven percent) of federal Medicaid funds was adsorbed by improper payments that included fraud and abuse, as well as unintentional mistakes such as paperwork errors. Improper payments totaled another estimated $11 billion — or nine percent — of states matching Medicaid budgets in 2010, the most recent data available.13 The Medicaid program for both medical and dental coverage is very expensive. Annual U.S. Medicaid spending
now exceeds Wal-Mart’s worldwide annual revenue.14 The program has grown so large and so complex that it is unmanageable at the federal level and is highly vulnerable to waste, error, and abuse. No one knows how much of Medicaid’s budget consists of waste, error, and abuse, but it may exceed $100 billion a year.

There are reports of abuse of Medicaid funds by dental providers. In Massachusetts, State Auditor Joe DeNucci reported that excessive, unnecessary and even potentially fraudulent claims for dental services are costing the Massachusetts Medicaid program millions of dollars annually. “Test results from an audit sample of dental providers participating in the Medicaid program uncovered nearly $5.7 million in overcharges and other unnecessary costs, mostly from excessive X-ray services over a period of four years. DeNucci’s report reviewed over 360,000 claims submitted to MassHealth, the agency that administers the Medicaid program.”16

In Texas the Department of Health and Human Services found widespread overpayment occurring in the state’s Medicaid dental and orthodontics programs. In an audit conducted by the Texas Office of the Inspector General it was determined that 95 percent of approved authorizations for orthodontic treatment should have been denied. In 2010, Texas’ Medicaid program was spending more on braces than the other 49 states combined.17

The Pew Charitable Trust has recently produced a research report on combating Medicaid fraud and abuse as a part of the online database of the State Health Care Spending Project.18 Improper payments totaled an estimated $11 billion or nine percent of states matching Medicaid budgets in 2010, the most recent data available.18

States are targeting Medicaid fraud and abuse with an array of policies and tools. To help policy makers learn from one another, the State Health Care Spending Project combed through federal data to gather hundreds of practices found to be promising by state and federal Medicaid agencies. The Pew Charitable Trust presents a summary of the promising practices provided as CMS Noteworthy Picks which are practices CMS identified in its comprehensive reviews of states that it recommends other states consider emulating.14 Nevada has adopted many of the recommended practices found to be effective and this paper looks at the effects of those practices.

METHODS
Medicaid and Nevada Check Up (NCU) are the State of Nevada’s Children’s Health Insurance Programs.18 NCU provides low-cost, comprehensive health care coverage to low income, uninsured children through 18 years of age who are not otherwise covered by private insurance or Medicaid. The Department of Health and Human Services maintains responsibility for the oral health status of all eligible enrollees of Medicaid and CHIP. In 2012, over 75,000 children state-wide were served at an annual expenditure of over $32 million.20

Seventy-five thousand Medicaid/CHIP claim forms for dental care for necessary and appropriate treatment were reviewed by a licensed dentist from January 2102 through December 2012 from one approved healthcare insurance carrier in Nevada. The patients were all recipients of publically funded dental care governed by the Nevada Department Health and Human Services.18 Descriptive demographics were computed for all eligible enrollees. The reviews also included screening for three areas of billing practices including:

Up-coding
Up-coding is selecting a dental procedure with a higher reimbursement rate when not necessary. Up-coding is a common finding with examples of such things as: 1) using stainless steel crowns in place of two surface restorations in cases of modest to low caries risk for children older than four years of age; 2) pulpotomies and stainless steel crowns in place of extractions or simple restorations; 3) full bony third molar impaction oral surgery claimed in place of partial bony or soft tissue impactions; 4) surgical extractions in place of simple extractions; and 5) root canal treatment and crown placement in place of extraction or simple restorations.

Unbundling
Unbundling charges is a method of separating out from a customary bundled treatment code to the individual procedures in order to obtain the higher reimbursement rates. Examples are: 1) charging for local anesthesia; 2) charging for liners and bases in addition to the restoration; 3) charging for gross debridement and four quadrants of scaling and root planning in place of a prophylaxis in young patients or patients under orthodontic care; 4) charging for individual restoration surfaces instead of normal surface restorations (e.g., mesial, occlusal, and lingual (three separate restorations) in place of a single mesio-occluso-lingual restoration.

Overtreatment/ Unnecessary Treatment
Overtreatment is providing care that is not necessary, such as: 1) restoration of incipient caries; 2) extraction of normal exfoliating primary teeth and asymptomatic third molars; 3) routine extensive periodontal procedures; and 4) overuse of radiographs, diagnostics, sealants, analgesia, surgical center or hospital admission, root canal treatment and crowns.

RESULTS
Of all eligible enrollees, 72.8 percent in 2010, 75.7 percent in 2011, and 78.5 percent in 2012 had at least one dental visit during the year (Table 1).

Table 2 details the various findings found when reviewing the three billing practices, 1) Up-coding, 2) Unbundling, and 3) Overtreatment/Unnecessary Treatment. While the majority of billings were appropriate, timely, and represented a high quality of care, these three billing and treatment practices were found to lead to higher than budgeted utilization and cost if they would have been paid without review or preauthorization. The examination of proposed extractions also exposed a significant rate of root canal failure in this population. While root canal treatment and crowns represented 6.9 percent of the total number of procedures, they represent 34.5 percent of the total dollars billed. There is no definitive study of the failure rate, because the Medicaid dental home is rarely a long term relationship, but it appears that a significant number of the root canals in this young population ultimately fail.

The failure rate of root canal therapy appears to be approximately eight percent in the first year after treatment and probably reflects the young age of many of the patients, poor choice of teeth for treatment, the high caries rate, incomplete follow through with restorative care and poor oral health maintenance found in this population. A definitive study is clearly indicated to gather reliable information for decision making.

DISCUSSION
Careful policy review with regards to decisions made on which teeth should be eligible for more costly procedures could yield a better cost-benefit. For example, third molars rarely warrant expensive root canal treatment and crown coverage. As a minimum all root canal and crown decisions should be predetermined and possibly be limited to those teeth anterior to second molars. Another example is the use of stainless steel crowns (SSCs) for treatment of two surface restorations. In young children with high caries risk, treatment with SSCs has been found to be better over time than multi-surface intra-coronal restorations.21 SSCs have a higher success rate in multi-surface restorations in primary teeth than multi-surface intra-coronal restorations in children under age four.21 The use of SSCs should also be considered in patients with increased caries risk whose cooperation is affected by age, behavior, or medica
l history because these patients are more likely to receive sedation/general anesthesia.21 The results from this study found that the proposed use of SSCs in children represented $6,210 per 1000 procedures in added production which represented the lowest added cost of all up-coding charges (Table 2). When considering the guidelines of the AAPD,21 the use of SSCs in patients with high caries risk and those that require treatment under sedation/general anesthesia may represent a more efficient utilization of funds instead of a primary tooth receiving multiple restorations during its short lifespan.

Due to the problems identified, there are a number of practices that are being used by many states to combat abuse.17 These practices include: 1) introducing regulations to make providers accountable for their actions and excluding problem providers; 2) prepayment review which includes service verification, prior authorization and claims review, and recipient lock-in; 3) post payment recovery which includes data mining, detection and investigation, penalties and recovery, and Medicaid Fraud Control Unit Coordination; and 4) cross-cutting which involves stakeholder coordination, provider outreach and education, managed care oversight, and targeting high-risk providers. Developing education efforts directed at review of the ethical standards regarding billing and treatment practices could additionally help reduce unintended consequences. These practices coupled with sound oral health prevention programs can help improve the oral health of the community while reducing excess costs. The percentage of children receiving dental care with existing expenditures could also be extended through careful control of the work approved for coverage using these ‘promising practices.’ While there is potential for overpayment due to submitted billings, there is no evidence of significant widespread overpayment because of the proactive predetermination and claims examination. OH


Kenneth G Rawson, DMD is an Assistant Professor and section head of pediatric dentistry at Southern Illinois University School of Dental Medicine. Dr. Rawson received the doctor of dental medicine from Southern Illinois University School of Dental Medicine in 2005 and received his pediatric dentistry certificate from the University of Nevada School of Medicine in 2007. He is a diplomat of the American Board of Pediatric Dentistry and he treats pediatric dental patients at Touchette Regional Hospital.

Marcie M. Ditmyer, PhD, MCHES, is an Assistant Professor and Director of Outcomes Assessment at the University of Nevada Las Vegas (UNLV), School of Dental Medicine. She is a master certified health education specialist. Ditmyer Has authored multiple articles about dental education and dental caries in adults and children.

Raymond D. Rawson, DDS, MA, DABFO, is a past president of the American Board of Forensic Odontology, forensic odontologist for the Clark County Coroner’s Office, Emeritus Professor in the Nevada System of Higher Education, and a member of the Nevada State Senate Hall of Fame following 20 years of service as a State Senator. He served as the dental director of a Nevada Quality Review Organization for dentistry since 1994.

Oral Health welcomes this original article.

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