Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
Q B  
UESTIONABLE  ILLING 
 
 
M P
FOR  EDICAID  EDIATRIC 
 
 
D S  
ENTAL  ERVICES 
 
I  
IN  NDIANA 
 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections 
 
November 2014 
OEI-02-14-00250   
   
EXECUTIVE SUMMARY:  QUESTIONABLE BILLING FOR MEDICAID PEDIATRIC 
DENTAL SERVICES IN INDIANA 
OEI-02-14-00250 
 
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 in the process. 
 
HOW WE DID THIS STUDY  
We based our analysis on Indiana 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 in Indiana. 
 
WHAT WE FOUND 
We identified 94 general dentists and 1 oral surgeon in Indiana with questionable billing.  These 
providers are extreme outliers when compared to their peers.  Medicaid paid these providers 
$30.5 million for pediatric dental services in 2012.   
 
These 95 dental providersrepresenting 11 percent of the providers we reviewedreceived 
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, which are often referred to as baby root canals, and behavior management, which 
includes techniques to calm or restrain a child.  Notably, two-thirds of the general dentists with 
questionable billing worked for four dental chains in Indiana.  Three of these chains have been 
the subject of Federal and State investigations.  A concentration of such providers in chains 
raises concerns that these chains may be encouraging their providers to perform unnecessary 
procedures to increase profits. 
 
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 our findings do not prove that providers either 
billed fraudulently or provided medically unnecessary services, providers who bill for extremely 
large numbers of services warrant further scrutiny. 
 
WHAT WE RECOMMEND  
We recommend that the Indiana Family & Social Services Administration (1) enhance its 
monitoring of dental providers to identify patterns of questionable billing; (2) closely monitor 
billing by providers in dental chains; (3) ensure that dental providers appropriately bill for 
behavior management and educate providers on the use of behavior management; and (4) take 
appropriate action on the dental providers identified as having questionable billing.  The Indiana 
Family & Social Services Administration concurred with all four of our recommendations. 
   
   
 
TABLE OF CONTENTS 
 
Objective......................................................................................................1 

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

Methodology................................................................................................4 

Findings........................................................................................................8 

Ninety-four general dentists and one oral surgeon in Indiana  
had questionable billing in 2012......................................................8 

Conclusion and Recommendations ............................................................14 

Agency Comments and Office of Inspector General Response .................16 

Appendix....................................................................................................17 

Agency Comments.........................................................................17 

Acknowledgments......................................................................................21 

   
   
OBJECTIVE 
To identify dental providers with questionable billing for Medicaid 
pediatric dental services in Indiana in 2012. 
BACKGROUND 
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.1  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.2  Medicaid dental services must include diagnostic and preventive 
services, as well as needed treatment and followup care.  Diagnostic 
services may include x-rays of the mouth; preventive 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.   
In recent years, a number of individual dental providers 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, in 2013, an orthodontist with 
practices in both Indiana and Texas was convicted for health care fraud in 
Texas and was sentenced to 50 months in prison.3  He provided medically 
unnecessary services and billed for services that were never provided.  He  
also maximized Medicaid reimbursement by sometimes scheduling more 
than 100 Medicaid patients per day.         
In addition, FORBA Holdings, LLC (referred to hereafter as FORBA), 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 
____________________________________________________________ 
1 Thomas P. Wall, Dental Medicaid  2012, American Dental Association (ADA),  2012. 
See also Centers for Medicare & Medicaid Services (CMS), Annual EPSDT Participation 
Report, Form  CMS-416 (National), Fiscal Year  2012, April 3,  2014. 
2 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.  Indiana is 
among the States that have done so. 
3 The United States Attorneys Office for the  Northern District of Texas, Amarillo, Texas, 
Orthodontist Sentenced to  50  Months in Federal Prison on  Health Care Fraud 
Conviction, April 9, 2013.  Accessed at http://www.justice.gov/usao/txn/PressRelease/ 
2013/APR2013/apr9goodwin_michael_HCF_sen.html  on  May 8,  2014. 
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   1   
   
medically unnecessary or performed in a manner that failed to meet 
professionally recognized standards of care to children with Medicaid.4   
As part of the settlement, FORBA agreed to enter into a 5-year Corporate 
Integrity Agreement with the Office of Inspector General (OIG).  FORBA  
subsequently changed its name to Church Street Health Management, 
LLC, and was then acquired by CSHM, LLC. 
In 2012, the Senate Finance and Judiciary Committees investigated CSHM 
and concluded that contrary to CSHMs claims, it is the de facto owner of 
the Small Smiles clinics and that the ownership structure undermined the 
independent, professional, and clinical judgment of Small Smiles 
dentists.5  In April 2014, OIG excluded CSHM from participation in 
Medicaid, Medicare, and all other Federal health care programs for a 
period of 5 years.6 Other dental chains have also been investigated for 
allegedly encouraging their providers to perform unnecessary procedures 
to increase profits.7   
Indiana Medicaid Dental Claims 
Indiana covers biannual dental screenings for children with Medicaid 
under the age of 21, as well as covering medically necessary treatment 
services. The biannual screenings generally consist of an examination,  
x-rays, cleaning, a topical fluoride application, and oral hygiene 
instruction.  Treatment services include fillings, crowns, and oral 
surgery.  The State has a number of specific policy guidelines for when 
certain services are covered, as well as frequency limitations for certain  
services. Indiana covers dental services on a fee-for-service basis; it 
currently does not cover these services through managed care. 
____________________________________________________________ 
4 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 February 20, 2014.  
5 U.S. Senate Committee on Finance and Committee on the Judiciary,  Joint Staff Report 
on the Corporate Practice of  Dentistry in the Medicaid Program, page 10.  Accessed at 
www.finance.senate.gov/library/prints/download/?id=1c7233e0-9d08-4b83-a530-
b761c57a900b on  February 20, 2014. 

6 The exclusion was effective  September 30, 2014.  OIG,  OIG Excludes Pediatric Dental 
 
Management Chain From Participation in Federal Health  Care Programs. Accessed at 

http://oig.hhs.gov/newsroom/news-releases/2014/cshm.asp on  April 4, 2014. 

7 In addition to CSHM, the Senate Finance and Judiciary Committees investigated the 

following chains:  Kool Smiles, ReachOut Healthcare  America, Heartland Dental Care, 

and Aspen  Dental Management.  In addition,  other dental chains have also  been the 

subject of Federal and State investigations.  For example, in 2012, the All Smiles chain 
 
and its owner agreed to  pay the United States and State of Texas $1.2 million to resolve 

allegations that All Smiles violated the civil False Claims Act and the Texas Medicaid 

Fraud Prevention Act.  DOJ,  Texas Orthodontic Clinic and Former Owner Resolve 

Allegations of False Medicaid  Claims, March 21, 2012.  Accessed at 
 
http://www.justice.gov/usao/txn/PressRelease/2012/MAR2012/mar21Malouf_AllSmiles_ 
Settlement_PR.html on June  13, 2014.  
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   2   
   
Indiana also allows dental providers to use behavior management 
techniques when treating children.  Behavior management may range from  
soothing an uncooperative child to using physical restraints, such as a 
papoose board, to stabilize the child.8  Dental providers must document 
the reason for the use of behavior management in the medical record and 
provide evidence that the child required more management than was 
reasonable and necessary compared to other children of the same age.9   
According to the American Academy of Pediatric Dentistry (AAPD), 
physical restraints should be used only when less restrictive methods are 
not effective and should not be used frequently because they have the 
potential to produce physical or psychological harm.10    
Indiana has several systems in place to oversee Medicaid pediatric dental 
claims.  The State has claims-processing editssystem processes to 
ensure proper payment of claimsthat it uses to review submitted claims  
before paying for them.  These edits ensure, among other things, that the 
services were provided within State frequency limitations or at certain 
time intervals.  In addition, the State analyzes claims to identify providers 
with unusual billing patterns, such as overutilization, upcoding, or 
unbundling.11  For example, Indianas recent analyses, which used 
algorithms based on the States coverage policies, included reviews of 
dental cleanings, fluoride applications, and oral examinations.  The State 
also conducted a review for potential upcoding for certain services, such 
as simple extractions that were upcoded to surgical extractions.   
Related Work 
This report is part of a series. Other reports in this series will examine 
Medicaid dental providers in other States.   An additional report covering 
multiple States will determine the extent to which children enrolled in 
Medicaid received dental services. 
The first report in this series identified 23 general dentists and  
6 orthodontists with questionable billing in New York.12 Medicaid paid 
these providers $13.2 million for pediatric dental services in 2012.  Almost 
a third of these 23 general dentists were associated with a single dental 
chain that had settled lawsuits for providing services that were medically 
____________________________________________________________ 
8 A papoose board is a board  with straps that is used to limit a patients movement and 

hold the patient steady during a medical procedure. 
 
9 Providers may bill for behavior management only once per visit.   

10 AAPD, Guideline on Behavior  Guidance for the Pediatric Dental Patient, 2011. 

11 Overutilization is the provision of services beyond what is medically necessary.  

Upcoding is the practice of billing for a service that is more expensive than the service 

that was actually provided.   Unbundling is the practice of maximizing reimbursement by
  
billing separately for the components of a procedure that has an all-inclusive payment 

code. 

12 OIG,  Questionable Billing for Medicaid Pediatric Dental  Services in New York, 
OEI-02-12-00330, March  2014. 
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   3   
   
unnecessary or that failed to meet professionally recognized standards of 
care to children.  
The second report in this series identified 26 general dentists and 1 oral 
surgeon with questionable billing in Louisiana.13 Medicaid paid these 
providers $12.4 million for pediatric dental services in 2012.  Almost a 
third of the providers worked for two dental chains. 
In addition, a recent OIG audit 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.14  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 
the need for continuing care and did not ensure that services were 
adequately documented.   
METHODOLOGY   
We based our analysis on Medicaid paid dental claims provided by Indiana 
with service dates from January 1, 2012, through December 31, 2012.  We  
excluded claims for services with special payment rates, such as those 
submitted by Federally Qualified Health Centers.15   We analyzed claims  
from rendering dental providersthe providers who provided the 
services, as opposed to billing providersto ensure that we compared 
claims from the providers who performed the services. 
We focused our analysis on general dentists and oral surgeons.  We  
analyzed the two provider types separately because their billing patterns 
varied significantly.  We did not include pediatric dental specialists 
because the wide variation in their billing behavior made it difficult to 
analyze them as one peer group. Some  pediatric dental specialists provide 
services that make them similar to general dentists, while others in this 
group provide more complex services.  In addition, we did not do a 
____________________________________________________________ 
13 OIG,  Questionable Billing for Medicaid Pediatric Dental  Services in Louisiana, 
OEI-02-14-00120, August 2014. 

14 OIG,  New York Improperly Claimed Medicaid Reimbursement for Orthodontic 

Services to Beneficiaries in New York City, A-02-11-01003, October 2013. 

15  We also excluded services provided in a  hospital setting because these services differ 
from services provided in an office setting.  In total, we identified  1,524 dental providers 
who  provided  services to children  with Medicaid in  2012  on a fee-for-service basis.   
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   4   
   
separate analysis of other dental specialists because there were too few to 
analyze.16  
General Dentists  
Our analysis focused on 787 general dentists who provided services to 
50 or more children with Medicaid during 2012.  These dentists served a 
total of 264,851 children with Medicaid.  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 American Academy of 
Pediatric Dentistry, and The American Dental Association.  We also 
discussed these measures, as well as the States oversight of Medicaid 
pediatric dental claims, with staff from the State Medicaid agencythe 
Indiana Family & Social Services  Administrationand with the States 
Fraud & Abuse Detection System contractor.  We developed these 
measures to capture several different types of fraud, waste, and abuse.  For 
these measures, we included only the children with Medicaid served by 
these dental providers; 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 day, and 
   the average number of services provided per child per visit. 
We developed five additional measures for general dentists who provided 
selected services in 2012.  For each dentist who provided the following 
service, we calculated the proportion of children with Medicaid who 
received: 
  fillings,  
  extractions,  
  stainless steel crowns, 
  pulpotomies, and 
  behavior management.17  
____________________________________________________________ 
16 In  2012, five  periodontists, three orthodontists, and two prosthodontists provided 
services to  50  or more children  with Medicaid in  Indiana.  (Prosthodontists specialize in  
dental  prostheses, such as crowns, bridges, implants, and dentures.)  
17 For this study, we added a measure on  behavior management because the State has few 
restrictions on  its use, compared to the other States we are reviewing.  For example, 
New York allows behavior management to  be used  only with  developmentally disabled 
children.  
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   5   
   
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 high amount or number compared to 
other general dentists in the State.  We used a standard technique for 
identifying outliers, known as the Tukey method.18  Under the Tukey 
method, outliers are values greater than the 75th percentile plus 1.5 times 
the interquartile range. Additionally, under this method, extreme outliers 
are values greater than the 75th percentile plus 3 times the interquartile 
range. For this study, we only employed this more conservative approach 
to identify extreme outliers.  We considered dentists who exceeded the 
threshold for one or more of the eight measures to have questionable 
billing. 
Oral Surgeons   
Unlike general dentists, who provide a variety of services, oral surgeons 
typically perform a more complex set of procedures.  For this analysis, we 
analyzed 81 oral surgeons who provided services to 50 or more children 
with Medicaid in 2012.19   These oral surgeons served a total of 
10,338 children with Medicaid. 
For this analysis, we calculated three measures for each oral surgeon:   
   the average Medicaid payment per child served,  
   the average number of services provided per day, and  
   the average number of services provided per child per visit.   
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.  Oral surgeons who exceeded these thresholds were 
extreme outliers compared to their peers and were considered to have 
questionable billing. 
Additional Analysis 
For each general dentist or oral surgeon who exceeded the threshold for 
one or more of the measures, we conducted Internet searches on the 
providers background and analyzed his or her claims and payment 
history.  In a few cases, we excluded providers who were actually 
specialists but had not indicated this on their claims.  For the remaining 
providers, we identified providers who worked for a dental chain in 2012, 
____________________________________________________________ 
18 See J.W. Tukey, Exploratory Data  Analysis.  Addison-Wesley, 1977.  

19 A total of 117  oral surgeons  provided services to children  with Medicaid in 2012.  Of 

these, 81  oral surgeons provided services to  50 or more children with Medicaid.  
 
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   6   
   
based on the billing addresses associated with their claims.20  We  
researched public records to determine whether any of these chains had 
been subject to State or Federal investigations.   
Limitations 
We designed this study to identify general dentists and oral surgeons 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 or numbers 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. 
   
____________________________________________________________ 
20  We  defined a dental chain as an entity with  five  or more locations  within a State or 
around the country. 
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   7   
   
FINDINGS 
Ninety-four general dentists and one oral surgeon in 
Indiana had questionable billing in 2012 
We identified 94 general dentists and 1 oral surgeon with questionable 
billing.21  We identified these providers by looking at general dentists and 
oral surgeons in Indiana who served more than 50 children with Medicaid  
in 2012. 
The providers with questionable billing are extreme outliers when 
compared to their peers.  Although they made up only 11 percent of the 
general dentists and oral surgeons we reviewed, they provided care to 
39 percent of the children with Medicaid served by the providers we 
reviewed.22  Medicaid paid these 95 providers $30.5 million for pediatric 
dental services in 2012. 
Two-thirds of the general dentists with questionable billing worked for 
four dental chains. Three of these chains have been the subject of State 
and Federal investigations. 
These billing patterns indicate that certain dental providers may be billing 
for services that are not medically necessary or were never provided.  
They also raise concerns about quality of care and whether children 
treated by these providers were harmed by these procedures.  Although our 
findings do not prove that providers either billed fraudulently or provided 
medically unnecessary services, providers who bill for extremely large 
numbers of services warrant further scrutiny.  
Nine General Dentists Received Extremely High Payments Per 
Child  
General dentists in Indiana received an average payment of $254 for each  
child with Medicaid. Nine dentists, however, received an average of more 
than $650 per child.23  One dentist averaged $1,082 per child.  Four of 
these dentists received more than $3,000 per child for a total of 
57 children. Extremely high payments raise concerns about whether these 
dentists are billing for unnecessary services or services that they did not 
____________________________________________________________ 
21 Several dental providers exceeded the threshold for more than one measure. 
22 The 787  general dentists and 81 oral surgeons we reviewed served a total of  
268,538 children with Medicaid.  Some children were seen by  both a general dentist and 
an oral surgeon.   
23 Dental providers sometimes exceeded (rather than just meeting) the thresholds for 
questionable billing, and therefore the numbers in the text are sometimes greater than  
those for the thresholds  presented in the tables on  pages 9 and 10.  
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   8   
   
provide.  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 of  Number of Dentists 
Measure   Dentists *   Questionable   Who Exceeded 
    Billing  Threshold  
Average Payments Per 
$254  $645  9 
Child 
Average Number of 
18  51  64 
Services Per Day   
Average Number of 
Services Per Child Per  4  7  4 
Visit  
Source:  OIG analysis of  Indiana Medicaid  claims data, 2014. 
                          
Note:  One dentist exceeded two thresholds. 

* Includes general  dentists who served 50 or more  children with Medicaid in 2012.  
 
Sixty-Four General Dentists Provided an Extremely Large 
Number of Services Per Day 
General dentists in Indiana provided an average of 18 services per day to 
children with Medicaid. Sixty-four dentists each averaged at least  
51 services per day, with 1 dentist averaging 144 services per day.  These 
dentists provided extremely large numbers of services on certain days of 
the year, with 1 dentist providing over 250 services per day on  
13 different days.  On 1 day, she provided 343 services.  If this dentist 
spent only 5 minutes performing each service, it would have taken over  
28 hours to complete all 343 of these services.  An extraordinarily large 
number of services per day raises concerns that a dentist may be billing for 
services that were not medically necessary or were never provided, as well 
as raising concerns about the quality of care being provided.   
Four General Dentists Provided an Extremely Large Number of 
Services Per Child Per Visit 
General dentists in Indiana provided an average of four services per 
Medicaid child during a single visit.  Four dentists, however, averaged 7 or 
more services per child per visit, with 1 dentist averaging 12 services per 
child per visit. 
These dentists provided extremely large numbers of services to certain 
children during a single visit, raising concerns both about potential 
fraudulent billing and about quality of care.  Each of these dentists 
provided more than 20 services in a single visit to a total of 49 children.  
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   9   
   
One dentist provided 39 services to a child during a single visit.  These 
services consisted primarily of fillings and extractions.   
Twenty-Seven General Dentists Provided Selected Services to 
an Extremely High Proportion of Children They Served 
When compared to their peers in the State, 27 general dentists provided 
selected services to an extremely high proportion of children with 
Medicaid that they served.  This billing behavior warrants further scrutiny, 
as it may indicate billing for services that were not medically necessary or 
were never provided. It also raises concerns about quality of care and 
whether or not children treated by these dentists were harmed by these 
procedures. 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 With Medicaid They  Served  
Threshold of  Number of Dentists 
Average for General  Questionable   Who Exceeded 
Measure   Dentists *   Billing  Threshold  
Proportion of children 
9%  28%   9 
who received extractions 
Proportion of children 
2%  9%   6 
who received pulpotomies 
Proportion of children 
who received stainless  4%  22%   2 
steel crowns  
Proportion of children 
31%  86%   1 
who received fillings 
Proportion of children 
who received behavior  5%  17%   13 
management  
 
Source:  OIG analysis of  Indiana Medicaid claims data, 2014. 

Note: Four dentists exceeded two thresholds. 

* Includes general  dentists who served 50 or more  children with Medicaid in 2012.  
 
Extractions. Nine general dentists performed extractions on an extremely 
high proportion of the children with Medicaid that they served.   
Twenty-eight percent or more of the children served by these dentists had 
one or more teeth extracted, compared to an average of 9 percent of 
children served by general dentists performing extractions in the State.  
Three dentists performed extractions on more than half the children they 
served, with one dentist performing extractions on 92 percent of the 
children he served. 
Pulpotomies. Six general dentists provided pulpotomies to an extremely 
high proportion of children with Medicaid that they served.  Eleven 
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   10   
   
percent or more of the children served by these dentists received 
pulpotomies, compared to an average of only 2 percent of children served 
by all general dentists who provided pulpotomies.  One dentist provided 
pulpotomies to 15 percent of the children he served.  Another dentist 
provided 5 or more pulpotomies per child per visit for 12 children. 
Stainless Steel Crowns. Two general dentists provided stainless steel 
crowns to an extremely high proportion of children with Medicaid whom  
they served. Twenty-four percent or more of the children served by these 
dentists received stainless steel crowns, compared to an average of only  
4 percent of children served by all general dentists who provided stainless 
steel crowns. 
Fillings. One general dentist provided fillings to an extremely high 
proportion of the children with Medicaid that he served.  Eighty-eight 
percent of the children served by this dentist received fillings, compared to 
an average of 31 percent of children served by all general dentists who 
provided fillings. 
Behavior Management. Thirteen general dentists provided behavior 
management to an extremely high proportion of children with Medicaid 
that they served. As previously noted, Indiana allows providers to bill for 
behavior management, which can include the use of additional staff or the 
use of physical restraints. Four of the thirteen dentists provided behavior 
management to more than half of the children they served; one dentist 
used behavior management for 98 percent of the children she served.  
Although Indiana does not have strict criteria for when a dentist may 
provide behavior management, a dentists providing a high proportion of 
children with this service raises questions as to whether such a service was 
necessary.  In particular, providers must carefully consider whether 
physical restraints should be used at all, because they have the potential to 
produce physical or psychological harm.24  
In addition, 11 of the 13 dentists billed for behavior management 
inappropriately.  These dentists were paid more than once for behavior 
management for the same child for the same visit, when the State requires 
that providers bill for it only once.  One of these dentists received such 
multiple payments for 448 visits.  In total, these 11 dentists received about 
$46,000 for behavior management.  
 
   
____________________________________________________________ 
24 AAPD, Guideline on Behavior  Guidance for the Pediatric Dental Patient, 2011. 
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   11   
   
One  Oral Surgeon  Provided an Extremely Large Number of 
Services Per Day 
Oral surgeons in Indiana provided an average of six services per day to 
children with Medicaid in 2012. One oral surgeon, however, provided an 
average of 19 services per day.   He provided over 30 services on 15 days 
and 72 services on 1 day. Forty percent of the services he provided were 
extractions. Given that procedures performed by oral surgeons may take 
more time than routine dental services, this providers billing patterns 
raise concerns both about potential fraudulent billing and about quality of 
care and childrens safety.  
Two-Thirds of the General Dentists With Questionable Billing 
Worked for Four Dental Chains; Three of Which Have Been the 
Subject of State and Federal Investigations  
Of the 94 general dentists with questionable billing, 62 worked for four 
dental chains in Indiana.   Three of these chains have been the subject of 
Federal and State investigations. These investigations found that dentists 
provided services that were either medically unnecessary or were 
performed in a manner that failed to meet professionally recognized 
standards of care to children. A concentration of dental providers with 
questionable billing in a small number of dental chains raises concerns 
that these chains may be encouraging their providers to perform 
unnecessary procedures to increase profits. 
One chain has been under scrutiny in several States for providing 
unnecessary services.25  For example, in Georgia, it was the subject of two 
State audits and was found to have provided numerous instances of 
medically unnecessary services and poor-quality care.26 As a result, two 
Medicaid managed care organizations in the State excluded this chain 
from their networks in 2007.27  Thirty-one dentists whom we identified 
with questionable billing worked for this chain.  
A second chain settled with the U.S. Government for $24 million 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.28  It was also the 
____________________________________________________________ 
25 David  Heath and Jill Rosenbaum,  The Business Behind Dental Treatment for 

Americas Poorest Children, The Center for Public Integrity, June 26, 2012.  Accessed at 

http://www.publicintegrity.org/2012/06/26/9187/business-behind-dental-treatment-
america-s-poorest-kids on  April 21, 2014.  

26 Ibid. 

27 Ibid. 

28 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. 

Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   12   
   
subject of lawsuits on behalf of more than 100 plaintiffs in Ohio, 
New York, and Oklahoma for allegedly providing unnecessary or 
excessive services.29   The chain was recently excluded from participation 
in Medicaid, Medicare, and all other Federal health care programs for a 
period of 5 years because of material breaches in its Corporate Integrity 
Agreement with OIG.  Sixteen dentists whom we identified as having 
questionable billing worked for this chain. 
The third chain, which operates mobile school-based clinics, has been the 
subject of investigations arising from complaints that dentists affiliated 
with it had treated children without their parents permission and had 
provided medically unnecessary services.30   The Senate Finance and 
Judiciary Committees also investigated this chain, citing a potential 
pattern of treatment without parental consent.31  For example, according to  
the Committees report, a 4-year-old medically fragile boy in Arizona 
was treated without a parents consent, receiving pulpotomies and stainless 
steel crowns while being physically restrained by three staff 
members.32  Subsequent examinations initiated by the family suggested 
that the dental work provided was unnecessary.  Thirteen dentists with 
questionable billing worked for this chain. 
   
____________________________________________________________ 
29 United States Bankruptcy Court for the Middle District of Tennessee, Nashville 
Division,  Affidavit of Martin McGahan, the Chief Restructuring  Officer of Church  Street  
Health Management, LLC, in Support of Chapter 11 Petitions and First Day Pleadings. 
See also District Court for the Northern District  of Ohio, Western Division, Parnell v. 
FORBA Holdings, LLC;   District Court  of Oklahoma County, State of  Oklahoma, 
Hernandez v. Forba Holdings, LLC; and Supreme Court,  Onondaga County, Varano v. 
FORBA Holdings, LLC. 
30 Sydney P. Freedberg, Dental Abuse Seen  Driven by Private Equity Investments, 
Bloomberg News, May 16, 2012.  Accessed at http://www.bloomberg.com/news/2012-
05-17/dental-abuse-seen-driven-by-private-equity-investments.html  on April 25, 2014.  
31 U.S. Senate Committee on Finance and Committee on the Judiciary,  Joint Staff Report 
on the Corporate Practice of  Dentistry in the Medicaid Program.  Accessed at 
www.finance.senate.gov/library/prints/download/?id=1c7233e0-9d08-4b83-a530-
b761c57a900b on  February 20, 2014. 

32 Ibid. 

Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   13   
   
CONCLUSION AND RECOMMENDATIONS 
Dental providers who participate in Medicaid provide much-needed access to 
dental services for children in the program.   When children lack such access, 
untreated decay and infection in their mouths can 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 one oral surgeon in Indiana.  Specifically, these 95 dental providers 
representing 11 percent of the providers we reviewedreceived 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.  
Medicaid paid these providers $30.5 million for pediatric dental services in 2012.  
Although our findings do not prove that providers either billed fraudulently or 
provided medically unnecessary services, providers who bill for extremely large 
numbers of services warrant further scrutiny.  
Our findings raise concerns that certain dental 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 vulnerabilities in the oversight of Medicaid dental providers.  
Additionally, OIG has identified some specific vulnerabilities regarding the 
practices of certain dental chains.  Notably, two-thirds of the general dentists with 
questionable billing worked for four dental chains in Indiana.  Three of these 
chains have been the subject of Federal and State investigations.  A concentration 
of such providers in chains raises concerns that these chains may be encouraging 
their providers to perform unnecessary procedures to increase profits. 
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.  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.   
Indiana must 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 Indiana Family & Social Services  
Administration: 
Enhance its monitoring of dental providers to identify patterns of 
questionable billing 
The State should enhance its monitoring of Medicaid dental providers.  To do this, 
it should use the measures that we developed for this report to better identify 
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   14   
   
providers with patterns of questionable billing.  State monitoring can result in cost 
savings, as well as ensuring that children receive quality dental care. 
Closely monitor billing by providers in dental chains  
A concentration of dental providers with questionable billing in a small number of 
dental chains raises concerns that these chains may be encouraging their providers 
to perform unnecessary procedures to increase profits.  We recommend that the 
State more closely monitor claims that are submitted by providers in dental  
chains. To do so, it must (1) identify the chains in its State, (2) identify all 
Medicaid providers in each chain, and (3) review claims from providers in each 
chain for patterns of questionable billing.  The State should then follow up on 
individual providers and chains as warranted.     
Ensure that dental providers bill only once per visit for behavior 
management and educate providers on the use of behavior 
management 
The State should ensure that dental providers bill only once per visit for behavior 
management.  It should do this by implementing a claims processing edit that 
would automatically limit billing for behavior management to once per visit.  The 
State should also educate providers about the potential physical or psychological 
harm that may result from excessive or inappropriate use of behavior 
management.  
Take appropriate action on the dental providers identified as having 
questionable billing 
In a separate memorandum, we will refer to the State the dental providers that we 
identified as having questionable billing.  The State should review these 
providers billing patterns; review dental records and supporting documentation; 
and/or perform unannounced site visits.  Then the State should determine what 
action(s) are most appropriate.  These actions include, but are not limited to 
(1) law enforcement actions, if fraud is identified; (2) referral to the States board 
of dentistry for licensure violations; (3) recoupment of payments, if the State 
determines that claims were paid in error; (4) revocation of Medicaid billing 
privileges; (5) education about how to appropriately bill for pediatric dental 
services; and (6) no action, if the State determines that a given provider does not 
demonstrate a vulnerability to the program or to children with Medicaid.   
 
   
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   15   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The Indiana Family & Social Services Administration (the Administration) 
concurred with all four of our recommendations. 
The Administration concurred with our first recommendation and stated that it 
would enhance its monitoring of dental providers through its existing fraud and 
abuse detection system. 
The Administration concurred with our second recommendation and described its 
efforts to closely monitor billing by providers in dental chains.  It stated that it 
will work with other State agencies to develop the means to link all providers who 
are in the same chain.  The Administration added that, moving forward, its risk 
assessment process will identify whether a single provider is part of a larger 
network and determine whether all members in the same dental chain should be 
reviewed.  
The Administration concurred with our third recommendation and described its 
efforts to ensure that dental providers bill only once per visit for behavior  
management and to educate providers on the use of behavior management.  The 
Administration stated that it is changing its payment system to stop the service 
code from being paid multiple times during the same visit.  Further, it noted that it 
will recoup any erroneous payments from providers. In addition, the 
Administration will review all paid claims for behavior management to identify 
dental providers who are outliers amongst their peers.  Finally, the Administration 
reported that it will develop a publication to all dental providers reiterating the 
States guidelines on billing for behavior management.   
The Administration concurred with our fourth recommendation and described its 
plans to take appropriate action with the dental providers that we identified as 
having questionable billing. It indicated that the State has an established process 
to investigate and take action with providers identified as having questionable 
billing. The State said that this process includes (1) targeted auditing and onsite 
reviews; (2) recovery of funds provided in error; (3) prepayment review; 
(4) provider suspension and termination; and (5) referral to the dental licensing 
board and/or referral to prosecutors or the State Attorney General for investigation 
and criminal action.  The Administration noted that it will validate the 
questionable billing we identified and that it will take appropriate action with the 
providers with substantiated erroneous billing.   
OIG supports the Administrations efforts to protect the program integrity of 
pediatric dental services in Indiana.   The full text of the Administrations 
comments is provided in the Appendix.  
   
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   16   
   
APPENDIX 
Agency Comments 
   
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   17   
   
APPENDIX 
Agency Comments (continued) 
   
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   18   
   
APPENDIX 
Agency Comments (continued) 
   
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)   19  APPENDIX 

Agency Comments (continued) 

Additionally, a second data query lws been developed to review all claims paid by Indiana Medicaid 
lor Behavior Management to identify those dental providers who are outliers amongst their peers in 
the use of code 09920.  Additional investigation into the billing patterns of these outliers will 
determine any other areas of concern associated with these select providers.  Based upon the results 
of this query, remediation may take place through additional provider education or medical record 
audits of the potentially problematic providers to recover any related overpayments and improve the 
integrity ofthe Indiana Medicaid program. 
Recomme/1(/alion: 

Take appropriate action on the dental providers identified as having questionable billing. 

State Response: Indiana concurs with this recommendation 
Indiana has an established process to investigate and take action on providers identified as having 
questionable billing, including targeted auditing and onsite reviews, recovery of funds provided in 
error, probationary prepayment review, provider suspension and termination, referral to the dental 
licensing board and/or referral to prosecutors or the State Attorney General for investigation and 
criminal action. Upon receipt of the provider-specific audit findings fi01n HHS-OIG, Indiana will 
validate the identified questionable billings to eliminate any potential false-positive findings. Indiana 
will then determine .and take the appropriate action on the providers with substantiated erroneous 
billing.. Indiana will provide a report to the HHS-OIG on the results of the review of these providers 
upon completion. 
The State appreciates your consideration of the information provided in this letter.  If you have any 
questions or require additional inlormation,  please contact James Waddick at  317-234-7484 or 
.hui.I<.:s. W ;tdd ick([!)fs~<LUI.()V. 
Sincerely, 
Joseph Moser 
Medicaid Director 
4 
\ 
Questionable Billing for Medicaid Pediatric Dental Services in Indiana (OEI-02-14-00250)  20   
   
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 Indiana (OEI-02-14-00250)   21   
   
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  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.