Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
Q B  
UESTIONABLE  ILLING 
 
 
M P
FOR  EDICAID  EDIATRIC 
 
 
D S  
ENTAL  ERVICES 
 
N  Y  
IN  EW ORK 
 
Brian P. Ritchie  
Acting Deputy Inspector General 
for Evaluation and Inspections  
 
March 2014  
OEI-02-12-00330   
   
EXECUTIVE SUMMARY:  QUESTIONABLE BILLING FOR MEDICAID 
PEDIATRIC DENTAL SERVICES IN NEW YORK 
OEI-02-12-00330 
 
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 35 million children.  In recent years, a 
number of dentists and dental chains have been prosecuted for providing unnecessary dental 
procedures to Medicaid children, as well as for causing harm to children while performing 
these procedures.   
 
HOW WE DID THIS STUDY  
We based our analysis on New York Medicaid fee-for-service paid claims for general 
dentists and orthodontists 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 23 general dentists and 6 orthodontists in New York with questionable billing.  
These providers are extreme outliers when compared to their peers.  Medicaid paid these 
providers $13.2 million for pediatric dental services in 2012.   
 
Notably, these 29 general dentists and orthodontistsrepresenting 3 percent of dental 
providers we reviewedreceived extremely high payments per child; provided an extremely 
large number of services per child; or provided certain selected services, such as 
pulpotomies or extractions, to an extremely high proportion of children.  Additionally, 
almost a third of the general dentists were associated with a single dental chain that had 
settled lawsuits for providing services that were medically unnecessary or that failed to meet 
professionally recognized standards of care to children.  
 
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 Medicaid children.  Although some of their billing may be legitimate, 
providers who bill for extremely large amounts of services warrant further scrutiny.  
 
WHAT WE RECOMMEND  
We recommend that the New York State Department of Health (1) continue to monitor 
general dentists and orthodontists to identify patterns of questionable billing, (2) ensure that 
the State employs adequate safeguards to monitor general dentists and orthodontists under 
managed care, and (3) ensure appropriate followup on the general dentists and orthodontists 
identified as having questionable billing. The New York State Department of Health neither 
agreed nor disagreed with our recommendations.  However, it identified actions it has taken 
or plans to take that support our first recommendation.  It also outlined current requirements 
and processes that are in place that support our second recommendation.  It did not indicate 
whether  any steps were planned to address our third recommendation. 
     
   
 
TABLE OF CONTENTS 
 
Objectives.................................................................................................... 1 

Background ................................................................................................. 1 

Methodology ............................................................................................... 3 

Findings....................................................................................................... 6 

Twenty-nine general dentists and orthodontists in New York  

had questionable billing in 2012 ..................................................... 6 

Conclusion and Recommendations ........................................................... 11 
 
Agency Comments and Office of Inspector General Response .... 13 

Appendix ................................................................................................... 14 

Agency Comments ........................................................................ 14 

Acknowledgments ..................................................................................... 17 

 
     
   
OBJECTIVE 
To identify general dentists and orthodontists with questionable billing for 
Medicaid pediatric dental services in New York. 
BACKGROUND 
Medicaid is the primary source of dental coverage for children in 
low-income families and provides access to dental care for approximately  
35 million children.1,2  Medicaids Early and Periodic Screening, 
Diagnostic and Treatment (EPSDT) benefit requires States to cover all 
medically necessary dental services for children 18 years of age and 
under.3  Medicaid dental services must include diagnostic and preventative 
services, as well as needed treatment and follow-up care.  Diagnostic 
services may include x-rays of the mouth; preventative services may 
include cleanings, topical fluoride applications, and dental sealants.  
Dental treatment covers a wide range of services such as fillings; tooth 
extractions; and pulpotomies, which are often referred to as baby root 
canals.   
New Yorks Medicaid program also provides limited services for 
orthodontia. The State does not allow orthodontic treatment for purely 
cosmetic purposes; however, it will allow such treatment in instances of a 
severe handicapping malocclusion.4  This type of malocclusion occurs 
when a childs teeth are so far out of position that he or she cannot engage 
in normal activitiessuch as eating and talkingwithout difficulty. 5 It is 
commonly associated with other medical conditions such as Down 
syndrome, muscular dystrophy, or craniofacial anomalies such as a cleft 
lip or palate. A provider must receive prior approval from the State before 
providing orthodontic treatment to a child.  
 
1 Thomas P. Wall, Dental Medicaid  2012, American Dental Association (ADA),  2012. 
2 Centers for Medicare & Medicaid Services (CMS), Annual EPSDT  Participation  
Report, Form  CMS-416 (National), Fiscal Year  2011, December 20, 2012. 
3 Social Security Act (SSA)  1905(r)(3);  42  CFR  441.56.  Dental services are covered 
up to age 18, but States may choose to extend eligibility through age 21.  New York is 
among the States that have done so. 

4 New York State Medicaid Program,  Dental  Policy and Procedure Manual, 

May 15, 2011. 

5 Christine Ellis, University of Texas Southwestern  Medical Center, Division of  Oral and 
 
Maxillofacial Surgery, written  Congressional testimony, Is Government Adequately 

Protecting Taxpayers from Medicaid Fraud?, April 25, 2012.  Accessed at 
 
http://oversight.house.gov/wp-content/uploads/2012/04/4-25-12-Ellis-Testimony.pdf on 
 
October 30, 2013. 

Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   1   
   
In recent years, a number of individual dentists and chains have been 
prosecuted for providing services that were medically unnecessary or that 
failed to meet professionally recognized standards of care.  These 
providers have often been found to have suspect Medicaid billing patterns 
when compared to their peers.  For example, a dental provider in New 
York billed Medicaid for 991 procedures on a single day; she was later 
convicted of grand larceny and her license was revoked.6 In addition, 
FORBA Holdings LLC, a dental management company that manages 
clinics nationwide known as Small Smiles Centers, settled with the 
United States in 2010 for $24 million to resolve allegations of providing 
services that were either medically unnecessary or performed in a manner 
that failed to meet professionally recognized standards of care to Medicaid 
children.7   As part of the settlement, FORBA agreed to enter into a 5-year 
corporate integrity agreement with OIG.   
In 2012, New York State transitioned Medicaid pediatric dental services 
from fee-for-service to managed care.  Prior to this transition, New York 
offered Medicaid pediatric dental services both on a fee-for-service and 
managed care basis; however, after July 2012, most dental services were 
offered through managed care.  Orthodontic services were offered through 
managed care after October 2012. 
This report is part of a series. Other reports will examine Medicaid 
dentists in a number of other States.  An additional report will determine 
the extent to which children enrolled in Medicaid received dental services 
in these States.    
Related Work 
In a recent audit, OIG found that providers inappropriately billed for 
orthodontic services provided to 43 of 100 sampled beneficiaries in 
New York City, totaling an estimated $7.8 million in inappropriate 
reimbursement.8  Some of these services were provided without the 
required approval, whereas other services were undocumented or were 
never provided.  These deficiencies occurred because the State agency and 
providers did not ensure that cases were reviewed annually to determine 
 
6 Clifford J. Levy and Michael Luo, New  York Medicaid Fraud May Reach Into  
Billions, The New York Times, July 18, 2005.  Accessed  at http://www.nytimes.com/  
2005/07/18/nyregion/18medicaid.html  on January 9, 2013.   Also  see New York  State 
Education Department, Office of the Professions, Summaries of Regents Actions on  
Professional Misconduct and  Discipline, November 2010.  Accessed at 
http://www.op.nysed.gov/opd/nov10.htm  on January 9, 2013. 
7 U.S. Department of Justice (DOJ),  National Dental Management Company Pays 
$24 Million  to Resolve Fraud Allegations, January 20, 2010.   Accessed at 
http://www.justice.gov/opa/pr/2010/January/10-civ-052.html on July 13, 2012. 
8 OIG,  New York Improperly Claimed Medicaid Reimbursement for Orthodontic  Services 
to Beneficiaries in New York City, A-02-11-01003, October 2013. 
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   2   
   
the need for continuing care and did not ensure that services were 
adequately documented.  OIG is also conducting a number of audits of 
individual dental providers to determine whether they inappropriately 
billed Medicaid for pediatric dental services.9  
METHODOLOGY 
We based our analysis on New York Medicaid fee-for-service paid claims  
with service dates between January 1, 2012, and December 31, 2012.10   We  
excluded claims for services provided on a managed care basis or with 
special payment rates, such as those submitted by Federally Qualified 
Health Centers; State and local agencies; and facilities operated by 
university dental-school clinics.11  
To compare dentists to their peers, we focused our analysis on general 
dentists and excluded dentists who indicated a specialty on their claims, 
such as pediatric dental specialists, oral surgeons, and dental 
anesthesiologists.12   We excluded these specialists because their billing 
patterns are often different from those of general dentists.  We looked at 
rendering dentiststhe dentists who provided the services, as opposed 
to billing dentiststo ensure that we compared claims from the dentists 
who provided the services. Our analysis focused on 719 general dentists 
who provided services to 50 or more Medicaid children during 2012.  
These dentists served a total of 119,102 Medicaid children.  We conducted 
a separate analysis of 165 orthodontists who provided services to 50 or 
more Medicaid children during this same time period.13 These 
orthodontists served a total of 83,894 Medicaid children.  We analyzed the 
orthodontists separately because their billing patterns differed from those 
of general dentists. 
 
9 OIG,  Dental Services for ChildrenInappropriate Billing, OAS-W-00-10-31135, 
OAS-W-00-11-31135, and  OAS-W-00-12-3113, forthcoming. 
10 Over three-quarters of New York Medicaid pediatric dental fee-for-service claims were  
for services provided before  July 1, 2012.  Although New York  began offering most 
dental services through managed care on that date, and began offering orthodontic  
services through managed care in  October 2012, it paid for fee-for-service claims for 
services provided until the end of December 2012. 
11  We also excluded services provided in a hospital setting because dental services 
provided in hospitals differ greatly from those provided in an  office setting.  In total, we 
identified 3,194 dental providers who provided  services to Medicaid  children in 2012 on  
a fee-for-service basis.   
12 Two  hundred  and four  dentists reported  one of the following specialties on their 
claims:  oral surgeon, pediatric dental  specialist, endodontist, oral pathologist, 
periodontist, or anesthesiologist.  We did  not include these dentists in  our analysis. 
13 A total of  238  orthodontists provided services to Medicaid children in  2012 on a 
fee-for-service basis.  Of these, 165  orthodontists provided services to  50 or more 
Medicaid children.    
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   3   
   
We developed a number of measures to identify dentists with questionable 
billing who are extreme outliers when compared to their peers.  We  
developed these measures based on input from officials from CMS, the 
New York State Office of the Medicaid Inspector General, the New York 
State Department of Health, The American Academy of Pediatric 
Dentistry, and The American Dental Association.  We developed these 
measures to capture several different types of fraud and abuse.  For these 
measures, we included only the Medicaid children served by these general 
dentists or orthodontists; we did not include other children whom they 
served.  
For each general dentist, we calculated the following three measures for 
2012: 
  the average Medicaid payment per child served,  
  the average number of services provided per child, and 
  the average number of services provided per day. 
We developed four additional measures for general dentists who provided 
selected services in 2012.  For each dentist who provided the following 
service, we calculated the proportion of Medicaid children who received:   
  fillings,  
  extractions,  
  stainless steel crowns, and 
  pulpotomies.  
For each measure, we analyzed the averages and the distribution for all 
general dentists. 
Next, we set a threshold for each measure that, if exceeded, indicated that  
the dentist had billed an extremely large amount compared to other general 
dentists in the State.  We modified a standard technique for identifying 
outliers, known as the Tukey method.14  Under the Tukey method, outliers 
are those values greater than the 75th percentile plus 1.5 times the 
interquartile range. 15   To determine extreme outliers, we employed a more 
conservative approach, looking at those values greater than the 
75th percentile plus three times the interquartile range.  We considered 
dentists who exceeded one or more of these thresholds to have  
questionable billing. 
 
14 See J.W. Tukey, Exploratory Data  Analysis.  Addison-Wesley, 1977.  
15 The interquartile range is calculated  by subtracting the value at the 25th  percentile from  
the value at the 75th   percentile.   
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   4   
   
We did a separate analysis of orthodontists.  New York State has strict 
criteria for orthodontic services; in addition, orthodontists may bill for 
only a limited number of services.  Providers receive a one-time payment  
for comprehensive orthodontic treatmentgenerally, this is the initial 
placement of braces on the teeth.  They may also bill for periodic 
treatment services once per quarterregardless of the number of visits 
providedwhich covers the ongoing maintenance of the orthodontia.  The 
remaining few orthodontic services may be billed for as they are 
provided. In addition to billing for orthodontic treatment services, 
orthodontists may also bill for related diagnostic services, such as x-rays.  
For our analysis of orthodontists, we calculated two measures for each 
orthodontist: (1) the total number of children served and (2) the average 
number of services provided per child.  As with our analysis for general 
dentists, for each of these measures, we set the thresholds for extreme 
outliers at the 75th percentile plus 3 times the interquartile range.  
Orthodontists who exceeded these thresholds were extreme outliers 
compared to their peers, and we considered them to have questionable 
billing.16   
For each general dentist or orthodontist who exceeded one or more of the 
thresholds, we conducted Internet searches on the providers background 
and analyzed his or her claims and payment history. In a number of cases, 
we excluded dentists or orthodontists who were affiliated with university  
dental-school clinics or who were actually specialists but had not indicated 
this on their claims.  For the remaining providers, we researched public 
records available on LexisNexis and from the New York and New Jersey 
State licensing boards to determine whether the providers had malpractice 
lawsuits brought against them.      
Limitations 
We designed this study to identify general dentists and orthodontists who 
warrant further scrutiny.  None of the measures we analyzed confirm that a 
particular provider is engaging in fraudulent or abusive practices.  Some  
providers may be billing extremely large amounts for legitimate reasons.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
 
16 We did  not determine whether orthodontists  exceeded thresholds for the four  selected 
services that we analyzed for general dentists.  Orthodontists generally provide a limited  
set of services, bundled together into a broad orthodontic  treatment claim, and do  not  
usually provide the four selected services that we analyzed for general  dentists.   
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   5   
   
FINDINGS 
Twenty-nine general dentists and orthodontists in 
New York had questionable billing in 2012 
We identified 23 general dentists and 6 orthodontists with questionable 
billing. We identified these providers by looking at general dentists and 
orthodontists in New York who provided services to more than 
50 Medicaid children in 2012. 
The providers with questionable billing patterns are extreme outliers when  
compared to their peers and make up 3 percent of the general dentists and 
orthodontists we reviewed. 17 In aggregate, they provided care to 
14 percent of the Medicaid children served by the providers we reviewed.  
Medicaid paid these 29 providers $13.2 million for pediatric dental 
services in 2012. 
Almost a third of the general dentists with questionable billing were 
associated with a single dental chain that had settled with the 
U.S. Government, as well as with New York State,  for providing services 
that were medically unnecessary or that failed to meet professionally 
recognized standards of care to children.     
These billing patterns indicate that certain dental providers may be billing 
for services that are not medically necessary or were never provided.  
Although some of this billing may be legitimate, providers who bill for 
extremely large amounts of services warrant further scrutiny.  
Five General Dentists Received Extremely High Payments Per 
Child  
General dentists who served 50 or more Medicaid children in New York 
received an average payment of $206 for each Medicaid child.  Five 
dentists, however, averaged more than two times this amount, receiving an 
average of more than $482 per child. One dentist averaged $878 per child. 
For more than 20 children, this dentist was paid over $1,500 per child, or 
7 times the average payment.  Extremely high payments per child raise 
concerns about whether these dentists are billing for services that are 
unnecessary or that they did not provide.  
   
 
17 The 719  general dentists and 165 orthodontists whom we reviewed served a total of  
194,225 Medicaid children.  Some children were seen by  both a general dentist and an  
orthodontist.   
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   6   
   
Two General Dentists Provided an Extremely Large Number of 
Services Per Child 
General dentists in New York provided an average of five services per 
Medicaid child. Two dentists, however, averaged 12 or more services per 
child, with one dentist averaging 16 services per child.   
Both of these dentists provided not only extremely large numbers of 
services per child, but also extremely large numbers of services per visit, 
raising concerns about the quality of care provided.  For example, one 
dentist provided fillings on 42 separate tooth surfaces for the same child 
during the same visit.  
Thirteen General Dentists Provided an Extremely Large Number 
of Services Per Day 
General dentists in New York provided an average of 10 services per day 
to Medicaid children. Thirteen dentists, however, averaged more than 
23 services per day, with 1 dentist averaging 54 services per day.   One 
dentist provided 179 services in a single day. If this dentist spent only 
5 minutes performing each service, it would have taken him over 15 hours 
to complete all of these services.  An extraordinarily large number of  
services per day raises concerns that a dentist may be billing for services 
that were not necessary or were never provided.  It also raises concerns 
about the quality of care being provided.  See Table 1 for more  
information on general dentists with extremely high average payments or 
large numbers of services. 
Table 1: General Dentists With Extremely High Average Payments or  
Large Numbers of Services  
Average for General  Threshold for  Number of Dentists 
Measure   Dentists *   Questionable   Who Exceeded 
    Billing   Threshold  
Average Payments Per 
$206  $482   5 
Child 
Average Number of 
5  12  2 
Services Per Child 
Average Number of 
10  23  13 
Services Per Day 
 
Source:  OIG analysis of New York Medicaid claims data, 2013.                           
Note: Three dentists exceeded two thresholds. 
* Includes general  dentists who served 50 or more Medicaid children in 2012.  
 
 
   
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   7   
   
Six General Dentists Provided Selected Services to an 
Extremely High Proportion of Children 
Four general dentists performed extractions on an extremely high 
proportion of Medicaid children. Over 38 percent of the children served 
by these dentists had one or more teeth extracted, compared to an average 
of 10 percent of children served by all general dentists providing 
extractions in the State.  One dentist performed extractions on 76 percent 
of the children he served.  These four dentists provided an average of three 
extractions per child. 
Two general dentists provided pulpotomiesoften referred to as baby 
root canalsto an extremely high proportion of Medicaid children.  At 
least 14 percent of the children served by these dentists received 
pulpotomies, compared with only 4 percent of children served by all 
general dentists who provided pulpotomies.  These dentists frequently 
provided three or more pulpotomies during a single visit, with one dentist 
performing as many as six pulpotomies during the same visit on a 2-year-
old child.18  See Table 2 for more information on general dentists who 
provided selected services to an extremely high proportion of children. 
 
Table 2: General Dentists Who Provided Selected Services to an Extremely  
High Proportion of Children They Served  
Average for General  Threshold for  Number of Dentists 
Measure   Dentists *   Questionable   Who Exceeded 
    Billing   Threshold  
Proportion of children with 
10%  38%   4 
extractions  
Proportion of children with 
4%  14%   2 
pulpotomies 
 
Source:  OIG analysis of New York Medicaid claims data, 2013.  
* Includes general  dentists who served 50 or more Medicaid children in 2012. 
 
   
 
18 Note that  no dentists exceeded the thresholds for the proportions of Medicaid children  
receiving stainless steel crowns or fillings.  General dentists provided stainless steel 
crowns to an average of 7 percent of children served;  however,  none of the dentists  
exceeded  the threshold of 23 percent.  Similarly, general dentists provided  fillings to an  
average of 29 percent of children  served; however, none of the dentists exceeded the 
threshold of 85 percent.  
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   8   
   
Almost a Third of the General Dentists With Questionable 
Billing Were Associated With a Single Dental Chain   
Seven of the twenty-three general dentists with questionable billing were 
associated with the same dental chain.19  The chains two clinics in 
New York stopped billing Medicaid in  April 2012, after their management  
company decided to close the clinics and stop practicing in the State.   
The closures took place after the chain settled with the U.S. Government, 
as well as with New York State, to resolve allegations of providing 
services that were either medically unnecessary or were performed in a 
manner that failed to meet professionally recognized standards of care to 
children. 
For one additional dentist not associated with that chain, a State Board of 
Dentistry initiated disciplinary action  against the dentist for negligence, 
malpractice, or incompetence.   The Board had investigated the dentist 
after receiving several complaints.   Two other dentists not associated with 
the chain had malpractice lawsuits brought against them. 
 
Five Orthodontists Provided Services to an Extremely High  
Number of Children; One Orthodontist Provided an Extremely 
Large Number of Services Per Child 
Orthodontists in New York provided services to an average of  
531 Medicaid children in 2012.  Five orthodontists, however, each 
provided services to more than 2,100 children, and one of these 
orthodontists provided services to 4,870 children. 
All five of these orthodontists most often provided periodic treatment 
visits, which are billed for on a quarterly basis, regardless of how many 
visits occurred during the quarter.  Periodic treatment accounted for almost 
half of the services these orthodontists provided in 2012.  These 
5 orthodontists had a minimum of 43,564 visits with 17,365 children over 
the course of the year.  The orthodontist who provided services to 
4,870 children had at least 12,598 visits with these children in 2012.  
The high volume of children seen by each of these five orthodontists raises 
concern about whether they are able to ensure that each child receives 
treatment that meets professionally recognized quality-of-care standards.  
Moreover, it is possible that the orthodontists billed for services that they 
did not even provide.  As noted earlier, a recent OIG audit found 
inappropriate billing by providers in New York State for orthodontic 
 
19 Six  of these dentists worked  for this dental chain in  2012, whereas one dentist had  
previously worked for the dental chain  but was working at another dental clinic in 2012.   
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   9   
   
services provided to a significant proportion of sampled beneficiaries.20   
Some of these services were provided without the required approval, while 
other services were undocumented or were never provided.   
Additionally, one orthodontist provided a large number of services per 
child. This orthodontist averaged seven services per child, compared with 
an average of four services per child for all orthodontists.  See Table 3 for 
more information on orthodontists who provided services to an extremely 
high number of children or provided an extremely high average number of 
services per child.  
Table 3: Orthodontists Who Provided Services to an Extremely High 
Number of Children or Provided an Extremely Large Number of Services 
Per Child 
Average for  Threshold for  Number of  
Measure   Orthodontists *   Questionable   Orthodontists Who 
    Billing   Exceeded Threshold  
Total Number of Children 
531  2,181   5 
Served 
Average Number of 
4  7  1 
Services Per Child 
 
Source:  OIG analysis of New York Medicaid claims data, 2013.   
* Includes orthodontists who served 50 or more Medicaid  children in 2012.                
 
   
 
20 OIG,  New York Improperly Claimed Medicaid Reimbursement for Orthodontic 
Services to Beneficiaries in New York City, A-02-11-01003, October 2013. 
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   10   
   
CONCLUSION AND RECOMMENDATIONS 
Dentists who participate in Medicaid provide much-needed access to 
dental services for children in this program.  When children lack such 
access, untreated decay and infection in their mouths may result in more 
complicated and expensive dental and medical interventions later in life.  
At the same time, we have concerns  about the extreme billing patterns of a 
number of general dentists and orthodontists in New York.  Specifically, 
29 general dentists and orthodontistsrepresenting 3 percent of dental 
providers we reviewedreceived extremely high payments per child; 
provided an extremely large number of services per child; or provided 
certain selected services, such as pulpotomies or extractions, to an 
extremely high proportion of Medicaid children.  Although some of their 
billing may be legitimate, providers who bill for extremely large amounts 
of services warrant further scrutiny.  
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 these children.   
Prior OIG reports have also found evidence of vulnerabilities in the 
oversight of Medicaid dental providers.  Additionally, OIG has identified 
some specific vulnerabilities regarding the practices of certain dental 
chains. Notably, almost a third of the general dentists with questionable 
billing were associated with a single dental chain that had settled lawsuits  
for providing services that were medically unnecessary or that failed to 
meet professionally recognized standards of care to children.    
Together, these findings demonstrate the need to improve the oversight of 
Medicaid pediatric dental services.  OIG is committed to conducting 
additional studies of dental providers and may issue recommendations to 
CMS in a future report.  We are also committed to examining access to 
Medicaid dental services and to continuing to conduct investigations and 
audits of specific dental providers with questionable billing.   
The State must also use the tools at its disposal to effectively identify and 
fight fraud, waste, and abuse, while at the same time ensuring that children 
have adequate access to quality dental care in the Medicaid program.   
Therefore, we recommend that the New York State Department of Health: 
Continue to monitor general dentists and orthodontists to 
identify patterns of questionable billing  
The State currently provides oversight of billing practices in numerous 
ways. Among other things, the State has claims-processing edits 
(system processes to ensure proper payment of claims), conducts prior 
approval reviews for certain services, investigates complaints, and 
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   11   
   
performs data analysis that may result in investigations.  The State should  
continue to rely on its ongoing monitoring in this area and consider this 
reports findings when developing further enhancements to its systems for 
monitoring billing by dental providers.  Monitoring pediatric dental 
services can result in cost savings, as well as ensuring that children receive 
quality dental care. 
Ensure that the State employs adequate safeguards to monitor 
general dentists and orthodontists under managed care 
As part of its transition to a managed care environment, the State must 
ensure that managed care entities employ adequate safeguards to monitor 
dental providers. Managed care claims by dentists and orthodontists 
should be subject to claims-processing edits and prior approval reviews, 
just as fee-for-service claims were prior to the transition.  Additionally, the 
State should collect detailed data from its managed care entities to conduct 
proactive data analysis. These data should include the specialty of the 
dentist and all of the services provided by each dentist.  
Ensure appropriate followup on the general  dentists and 
orthodontists  identified as having questionable billing 
In a separate memorandum, we will refer for appropriate action the dental 
providers whom we identified as having questionable billing.   
 
   
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   12   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The New York State Department of Health (the Department) neither 
agreed nor disagreed with our recommendations.  However, the 
Department identified actions it has taken or plans to take that support our 
first recommendation. It stated that the New York State Office of the 
Medicaid Inspector General (OMIG) is actively investigating and 
monitoring numerous orthodontists and general dentists.  It noted that 
OMIG is also developing a system to identify questionable billing for 
orthodontic treatments and that OMIGs dental staff will continue its 
oversight of billing practices by conducting prepayment reviews and 
record reviews to actively identify overpayments, unacceptable practices, 
and criminal activity.  We continue to emphasize the importance of using 
the methods outlined in this report as a basis for further enhancements to 
the Departments ongoing monitoring activities.    
The Department also outlined current requirements and processes that are 
in place that support our second recommendation.  It noted that managed 
care plans are required to develop special investigation units that detect 
possible fraud and abuse. In addition, the Department stated that it closely 
monitors managed care dental managers andthrough ongoing review of 
fair hearing results for dental servicesevaluates whether they are 
following proper procedures. It also stated that it routinely reviews dental 
vendors who manage the dental benefit to ensure that they are following 
standard practices as prescribed by law.  Lastly, it noted that the dental 
vendors evaluate the provision of services and authorize them only when 
they are medically necessary.  
The Department did not indicate whether any steps were planned to 
address our third recommendation.  It stated that OMIG will continue to 
monitor encounter data from managed care organizations as well as fee-
for-service claims data in order to identify questionable billing by dental 
providers. 
The full text of the Departments comments is provided in the Appendix. 
   
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   13   
   
APPENDIX 
Agency Comments 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   14   
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   15   
   
 
 
 
  
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   16   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New  York regional 
office, and Nancy Harrison and Meridith Seife, Deputy Regional 
Inspectors General.  
Judy Kellis served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the New York regional office who 
conducted the study include Lucia Fort.  Central office staff who provided 
support include Clarence Arnold, Meghan Kearns, and Christine Moritz.  
 
Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330)   17   
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
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