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From Health Law Daily, July 28, 2015

Medicare contractor fails checkup, improperly paid $2.3M for dental services

By Mary Damitio, J.D.

Medicare contractors were found to have improperly paid almost $2.3 million in hospital outpatient dental service charges that were not covered by program, according to report issued by the HHS Office of Inspector General (OIG). Most of the overpayments were made for common dental services such as tooth extractions and socket repairs, which are not covered by Medicare (OIG Report, No. A-06-14-00022, July 23, 2015).

Jurisdiction K. The OIG determined that, from January 2011 through October of 2013, providers in certain states in “Jurisdiction K,” which includes Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont, received the highest reimbursement of all jurisdictions for hospital outpatient dental services.

Dental claims. Hospital outpatient dental services relating to the care and treatment of teeth are generally not covered by Medicare (Social Security Act Sec. 1862(a)(12)). In order to be covered, the dental services must be performed “incident to and as an integral part,” of a Medicare-covered service or procedure.

Review. The OIG reviewed 4,495 hospital outpatient dental services claims that totaled $3,005,245, and that were paid to providers by Medicare contractors in Jurisdiction K during the relevant audit period. The OIG then reviewed a random sample of 100 hospital outpatient dental service claims.

Findings. The OIG concluded that Medicare contractors paid providers in Jurisdiction K for hospital outpatient dental services that were not in compliance with Medicare payment requirements. Out of the 100 samples reviewed, 85 of them did not meet Medicare requirements. The most common source of overbilling was for tooth extractions and tooth socket repairs, which are not covered by Medicare. Additionally, the remaining 15 samples were not even reviewed because the claims were submitted to a different Medicare contractor. As a result, the OIG estimated that Medicare contractors overpaid providers in Jurisdiction K by at least $2,276,853 for hospital outpatient dental services that were not in compliance with Medicare requirements.

The providers that received the payments in the review agreed that they did not meet Medicare billing requirements, but explained that they billed Medicare first because most of the patients were eligible for both Medicare and Medicaid. Therefore, the providers were required to submit the bill first to Medicare. After it was denied, they could then bill Medicaid. However, the Medicare contractors improperly paid the claims.

Recommendations. The OIG recommended that the Medicare contractor who was primarily responsible for the payments, National Government Services, Inc. (NGS), recover the $2,276,853 in improper payments and use the results of the audit in educating providers. Also, NGS should implement a system to ensure that the payments are made to dental services that meet Medicare billing requirements. NGS agreed with the recommendations and stated that its Provider Outreach and Education team will make appropriate changes to its provider education materials and advised the OIG that it developed a system to deny payment for dental services based on specific diagnosis and procedure codes.

MainStory: TopStory PaymentNews PartBNews BillingNews CoPNews MedicareContractorNews

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