Dental cases review offers insight in avoiding billing and compliance issues
The OIG has worked on a variety of investigations involving dental providers. Many cases concerned illegal solicitation, recordkeeping, mishandling of anesthesia and sedation — which we previously covered — and quality of care concerns. This article breaks down two recent cases to examine the underlying regulations and how the problem could have been avoided.
Please note that this material is provided for general informational purposes only and is not intended to present an official position of the OIG or legal advice. The facts and circumstances of any particular question should be verified independently. Every case should be verified independently based on its unique facts and circumstances. It is vital that dentists and their staff stay abreast of any HHSC, TMHP and MCO updates to ensure proper delivery of services.
Case No. 1: Improper recordkeeping
The OIG reached a settlement with a Houston dentist to resolve four investigations involving insufficient or incomplete patient records and billing for services not provided. The provider failed to produce 86 out of the 120 records requested. Of the 34 records produced, the investigation revealed poor quality and non-diagnostic X-rays, missing or incomplete documentation, insufficient documentation of medical necessity, and errors or inconsistencies between the services documented and the corresponding billing for those services.
The provider settled with the OIG for $66,804, almost half of which consisted of penalties, and was excluded from Medicaid for two years.
Analysis:
Without adequate records, the OIG cannot establish whether the services allegedly provided were billed properly or ever performed. Additionally, without documentation of medical necessity or diagnostic quality X-rays, the OIG has no basis to determine whether the services provided were necessary or met the standard of care.
Prevention:
To avoid record-related issues, providers must thoroughly understand their responsibilities. The Texas State Board of Dental Examiners addresses these requirements in Texas Administrative Code, Title 22, Section 108.8. Providers may review grounds for OIG enforcement actions related to records and documentation in Texas Administrative Code, Title 1, Section 371.1667. Additionally, the August 2024 Texas Medicaid Provider Manual (TMPPM) covers such requirements in sections 1.10, 1.7.12, 3.2.3.5 and 3.3.
The Texas Medicaid Healthcare Partnership (TMHP) offers workshops and training sessions to stay up to date on program requirements. Dentists should also review TMHP provider notifications for recent changes.
Potential consequences:
Failure to keep adequate records may result in recoupment, including any overpayments determined through statistical sampling and extrapolation; interest and penalties; suspension or restriction of Medicaid payments; cancellation of the Medicaid provider agreement; exclusion for a specified period, permanently or indefinitely, which also includes all programs under Titles V and XX of the Social Security Act; or criminal or civil actions through the Office of Attorney General if the recordkeeping violations are an intentional act to defraud the State.
Case No. 2: Illegal dental solicitation
The OIG executed a settlement agreement with a Dallas-Fort Worth area dentist after an investigation found that the dentist employed a marketer to pay “educators” a per-person fee for each patient brought to the dentist’s practices for care. As a result of the settlement, the dentist voluntarily accepted a 10-year exclusion from participating in Texas Medicaid, CHIP and other HHS programs.
Analysis:
Texas Medicaid providers are prohibited from engaging in any marketing activity that is intended to influence a Medicaid client’s choice of provider or involves unsolicited personal contact with a Medicaid client or the client’s parent or is directed at them solely because they receive Medicaid benefits.
Medicaid providers cannot offer to pay another person in exchange for soliciting a patient for the provider. Further, providers are prohibited from offering cash, gifts or other items to Medicaid clients to influence their health care decisions. Providers may not offer, and clients may not accept:
Cash, cash equivalents or gift cards in any amount.
Transportation, unless it’s properly arranged through the Medicaid Transportation Program.
Free or discounted services for a family member to influence their health care decisions.
Providing goods or services of any value could be considered a violation, but that would typically not be true for non-cash, low-cost items customarily distributed at appointments, such as toothbrushes or dental floss valued at less than $15.
Prevention:
To avoid issues involving dental solicitation, providers must understand and adhere to the provisions of Texas Occupations Code, Chapter 102, as well as Texas Administrative Code Title 1, Sections 354.1452, 371.1669, and 371.27.
The Texas Health and Human Services Commission also provides marketing guidelines, which include information on an optional process where providers can submit marketing materials to the agency for review and approval.
Potential consequences:
A provider who solicits Medicaid clients may face a class A misdemeanor — or a third-degree felony if they were previously convicted of illegal dental solicitation or were employed by the federal, state or local government at the time. Further, the provider may be subject to disciplinary action by the Texas State Board of Dental Examiners, an injunction, civil penalties of up to $10,000 and possible exclusion from Medicaid.
Working with the OIG
Providers who discover their own discrepancies are encouraged to self-disclose the matter to the OIG by visiting ReportTexasFraud.com or calling the OIG Fraud Hotline at 800-436-6184.
By self-disclosing potential violations, dentists can potentially reduce their legal and financial exposure by avoiding prolonged investigations or litigation. Download the OIG’s Quick Guide to Self-Disclosing Errors or visit the OIG provider resources page to learn more.