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Dental Fraud in Medicaid

  • by Steve Nesnidal, MD, CPC, AHFI
  • May 9, 2023, 14:20 PM

The Department of Justice (DOJ) recently announced an indictment of a Washington DC dentist and dental hygienist that amounted to fraud estimated at $4 million dollars. The fraud involved billing false claims to DC Medicaid for services that were never provided. The fraudulent claim pattern included submitting multiple claims for two procedures - space maintainers and crown lengthenings. 

In some cases, the provider submitted claims for more than 30 crown lengthenings in a five-year span for a single patient. Although the DOJ press release does not provide specific details about the CDT codes involved, the crown lengthening CDT code is D4249. Per the DC Medicaid Dental Billing Manual, CDT code D4249 is allowed once per lifetime per tooth.  

As an example of how highly unusual it would be to perform 30 crown lengthenings on a single patient in a five-year span, we can use the DC Medicaid dental benefit likely age group of beneficiaries under the age of 21.  By three years of age, the average child has their full set of 20 deciduous teeth and not until 21 years of age, with the eruption of wisdom teeth, does the average adult have all 32 permanent teeth.  

Almost equally unusual is that this dental provider pair submitted 20 space maintainer procedures on some of these patients.  The space maintainer CDT codes involved would be codes D1510, D1516, D1517.  Dental space maintainers are devices used for kids who have lost some of their primary/deciduous (baby) teeth, but it is expected to be awhile before their permanent teeth grow in.  Per DC Medicaid Dental Billing Manual, these codes, their allowed frequencies, and limitations are as follows: 

D1510 – One (1) per lifetime per quadrant 

D1516 – One (1) per lifetime per arch 

D1517 – One (1) per lifetime per arch  

CDT codes D1510, D1516, and D1517 (Space Maintainers) will be reimbursed only to prevent tooth movement following premature loss of primary (baby) teeth so permanent teeth can erupt into proper position. CDT codes D1510, D1516, and D1517 are reimbursed for beneficiaries up to the age of 12 and will not be reimbursed for adults. 

Regardless of which space maintainer codes the dental provider pair submitted, 20 such procedures performed on one patient in a five-year period is medically unlikely.  For example, per DC Medicaid dental benefit, one unit of CDT code 1510 is allowed per lifetime per quadrant.  Assuming the per quadrant code was performed by this provider pair, that means they installed all quadrant space maintainers five times in a five-year period.  The support for such an extensive group of services was clearly not documented in the dental record.   

When this same provider pair submitted 20 space maintainer procedures and 30 crown lengthening procedures on some members of this Medicaid population in a five-year period, they raised two obvious red flags.  Dedicated FWA Analytic reports like those offered by Context4 Healthcare can readily detect these and other aberrant patterns in dental claims data.  Once detected, an appropriate sample of dental records would typically be selected and reviewed.  The patients, their caregivers, and perhaps the providers themselves would likely be interviewed regarding these encounters.  The details gained from this investigation need to provide sufficient supportive evidence to determine how to move forward.   

For more details on Context4 Healthcare’s Payment Integrity Solution, visit us at: [add link back to our website here] 

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