Questionable Billing for Medicaid Pediatric Dental Services in Louisiana

WHY WE DID THIS STUDY

Medicaid is the primary source of dental coverage for children in low-income families and provides access to dental care for approximately 37 million children. In recent years, a number of dental providers and chains have been prosecuted for providing unnecessary dental procedures to children with Medicaid and causing harm to them in the process.

HOW WE DID THIS STUDY

We based our analysis on Louisiana Medicaid fee-for-service paid claims for general dentists and oral surgeons who provided services to 50 or more children in 2012. Using several measures, we identified dental providers with questionable billing who are extreme outliers when compared to their peers.

WHAT WE FOUND

We identified 26 general dentists and 1 oral surgeon in Louisiana with questionable billing. These providers are extreme outliers when compared to their peers. Medicaid paid these providers $12.4 million for pediatric dental services in 2012.

These 27 dental providers-representing 5 percent of the providers we reviewed-received extremely high payments per child; provided an extremely large number of services per day; provided an extremely large number of services per child per visit; and/or provided certain selected services to an extremely high proportion of children. These services included pulpotomies-often referred to as "baby root canals"-and extractions. Notably, almost a third of the providers with questionable billing worked for two dental chains. A concentration of such providers in chains raises concerns that these chains may be encouraging their providers to perform unnecessary procedures to increase profits. In addition, four of the providers with questionable billing had actions taken against them by the State Board of Dentistry.

Further, our findings raise concerns that certain providers may be billing for services that are not medically necessary or were never provided. They also raise concerns about the quality of care provided to children with Medicaid. Although some of their billing may be legitimate, providers who bill for extremely large numbers of services warrant further scrutiny.

WHAT WE RECOMMEND

We recommend that the Louisiana Department of Health and Hospitals (1) enhance its monitoring of dental providers to identify patterns of questionable billing and (2) take appropriate action on the dental providers identified as having questionable billing. The Louisiana Department of Health and Hospitals concurred with both of our recommendations.