Eight percent of dentists caring for children under Medi-Cal provided 34% of the services in 2012, and a lot of it is questionable work. The federal Medicaid program is called Medi-Cal in the state.
A new study (pdf) by the U.S. Department of Health and Human Services (DHHS) found 329 dentists and six orthodontists were paid $117.5 million under suspicious circumstances. Two-thirds of the suspect medical providers claimed an extreme number of procedures a day, including one who billed for 1,000 services a day on 97 separate days. The average is 24.
His personal record was 1,658 in one day. That's one service every 17.4 seconds, assuming an 8-hour workday. Two dentists averaged 500 services a day and 229 averaged 76 a day. One dentist averaged 862 services per day.
“An extraordinarily large number of services per day raises concerns that a dentist may be billing for services that were not medically necessary or were never provided, as well as raising concerns about the quality of care being provided,” the report said.
The study focused on 3,921 general dentists who provided Medi-Cal services to 50 or more children. The researchers developed several ways of measuring potential fraud, waste and abuse. They also looked at 170 orthodontists with similar patient rosters. The orthodontists served 63,728 Medi-Cal kids.
Half of the providers worked for dental chains and a dozen were already under investigation by the state's dental board. Most of those worked for one of just five chains. Two of the five chains have been the subject of state or federal investigations. Approximately 37 million children in low-income families are dependent on Medicaid nationally for dental care.
Medi-Cal dentists average five services per child visit, but one dentist averaged more than 12. She got there by providing more than 20 services per child for 30 different children, capped off with a 33-service visit for one 4-year-old. That visit included 13 stainless steel crowns and 11 pulpotomies. (The latter are called “baby root canals,” but as any child 21 or younger that is old enough to speak will tell you, they are not babies. And the procedure is not really a root canal.)
The suspect dentists were not only busy; they charged a lot. Nineteen of the dentists averaged $412 per child treated, compared to the statewide average of $166 for Medicaid kids. One dentist averaged $699 per kid and five averaged more than $3,000 for each of 10 kids they treated.
The six orthodontists stood out among the 170 in the report because of the “extremely large” number of children they serviced. The six serviced 584 or more children in 2012, one topped out at 1,079, compared to the average of 169.
Although the federal report raised a lot of red flags, it did not accuse anyone of fraud. But the feds thought “extreme billing patterns warrant further scrutiny.” They recommended the California Department of Health Care Services (DHCS) increase its monitoring of suspect dental billings, look especially close at dental chains, review its payment process for orthodontics and give extra-special attention to the list of 335 dental practitioners in the report.