Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
Q B  
UESTIONABLE  ILLING 
 
 
M P
FOR  EDICAID  EDIATRIC 
 
 
D S  
ENTAL  ERVICES 
 
L  
IN  OUISIANA 
 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections 
 
August 2014 
OEI-02-14-00120   
   
EXECUTIVE SUMMARY:  QUESTIONABLE BILLING FOR MEDICAID 
PEDIATRIC DENTAL SERVICES IN LOUISIANA 
OEI-02-14-00120 
 
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 to them in the process. 
 
HOW WE DID THIS STUDY  
We based our analysis on Louisiana 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.   
 
WHAT WE FOUND 
We identified 26 general dentists and 1 oral surgeon in Louisiana with questionable 
billing. These providers are extreme outliers when compared to their peers.  Medicaid 
paid these providers $12.4 million for pediatric dental services in 2012.   
 
These 27 dental providersrepresenting 5 percent of the providers we reviewed 
received 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 pulpotomiesoften referred to as baby root canalsand 
extractions. Notably, almost a third of the providers with questionable billing worked for 
two dental chains. A concentration of such providers in chains raises concerns that these 
chains may be encouraging their providers to perform unnecessary procedures to increase 
profits. In addition, four of the providers with questionable billing had actions taken 
against them by the State Board of Dentistry. 
 
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 some of their billing may 
be legitimate, providers who bill for extremely large numbers of services warrant further 
scrutiny. 
 
WHAT WE RECOMMEND  
We recommend that the Louisiana Department of Health and Hospitals (1) enhance its  
monitoring of dental providers to identify patterns of questionable billing and (2) take 
appropriate action on the dental providers identified as having questionable billing.  The 
Louisiana Department of Health and Hospitals concurred with both of our 
recommendations.  
   
   
   
 
TABLE OF CONTENTS 
 
Objective......................................................................................................1 

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

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

Findings........................................................................................................7 

Twenty-six general dentists and one oral surgeon in Louisiana  

had questionable billing in 2012......................................................7 

Conclusion and Recommendations ............................................................... 12  

Agency Comments and Office of Inspector General Response ....... 14  

Appendix ....................................................................................................... 15 

Agency Comments ........................................................................... 15  

Acknowledgments .........................................................................................17 
 
   
   
OBJECTIVE 
To identify dental providers with questionable billing for Medicaid 
pediatric dental services in Louisiana 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.1,2  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 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, FORBA Holdings, LLC 
(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 
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. 
 
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  2012, April 3,  2014. 
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.  Louisiana is 
among the States that have done so. 

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. 
 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   1   
   
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   
Louisiana Medicaid Dental Claims 
Louisiana covers biannual dental screenings for children with Medicaid, 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. Louisiana has a number of 
specific policy guidelines for when certain services are covered, as well as 
frequency limitations for certain services.  Additionally, the State requires 
dental providers to seek prior authorization before providing certain 
services, such as stainless steel crowns, pulpotomies, and certain 
extractions and fillings.  During the period that we reviewed, Louisiana 
covered dental services on a fee-for-service basis.  However, the State 
transitioned these services from fee-for-service to managed care on July 1, 
2014. 
Louisiana has several systems in place to oversee Medicaid pediatric 
dental claims. The State has claims-processing editssystem processes 
to ensure proper payment of claims.  Before paying for submitted claims, 
the State uses these edits to review them.  These edits ensure, among other 
 
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 is 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 they 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 Louisiana (OEI-02-14-00120)   2   
   
things, that the services were provided by Medicaid-enrolled providers and 
do not exceed frequency limitations.  The edits also check (when 
applicable) whether the State granted prior authorization.   
The State conducts additional analyses to verify provider compliance with 
Medicaid policies and regulations.  Reviews can be based on referrals, 
complaints received, or internal analyses.  The State may focus on specific 
children with Medicaid who received services, on specific services, or on  
dental providers. If the State is looking at providers, it generates billing 
reports by provider, as well as detailed information about 20 randomly 
selected children with Medicaid who received services from each of the 
providers reviewed.  For each sampled child, the State requests treatment 
records from the provider.  Under the direction of a dentist, a dental 
hygienist reviews these records. Providers who are found to be out of 
compliance with Medicaid regulations may be subject to having their 
Medicaid payments recouped or to administrative sanctions, including 
withholding of Medicaid payments, referral to the Attorney Generals 
Office and/or the State Board of Dentistry for investigation, and 
termination from the Medicaid program.   
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.8 Medicaid paid 
these providers $13.2 million for pediatric dental services in 2012.  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.  
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.9  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 
 
8 OIG,  Questionable Billing for Medicaid Pediatric Dental  Services in New York, 
OEI-02-12-00330, March  2014. 

9 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 Louisiana (OEI-02-14-00120)   3   
   
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 
Louisiana 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; State and local 
agencies; and facilities operated by university dental-school clinics.10  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 provide 
more complex services.  In addition, we did not do a separate analysis of 
orthodontists or endodontists because there were too few to analyze.11    
General Dentists    
Our analysis focused on 512 general dentists who provided services to  
50 or more children with Medicaid during 2012.12   These dentists served a 
total of 316,955 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 measuresas well as the States oversight of Medicaid 
pediatric dental claimswith staff from the State Medicaid agency, i.e., 
the Louisiana Department of Health and Hospitals.  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.  
 
10  We also excluded services provided in a  hospital setting because these services differ 
greatly from services provided in an office setting.   In total, we identified  840  dental 
providers who  provided services to children with Medicaid  in 2012 on a fee-for-service 
basis. 
11 Only seven orthodontists and three endodontists received payment for services in 2012.   
12 A total of  704 general  dentists provided  services to children with Medicaid in  2012. 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   4   
   
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 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 children with Medicaid 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 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.13  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 employed this more conservative approach to 
identify extreme outliers.  We considered dentists who exceeded one or 
more of these thresholds 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 41 oral surgeons who provided services to 50 or more children 
with Medicaid in 2012.14   These oral surgeons served a total of 
8,358 children with Medicaid. 
For this analysis, we calculated three measures for each oral surgeon:   
   the average Medicaid payment per child served,  
 
13 See J.W. Tukey, Exploratory Data  Analysis.  Addison-Wesley, 1977.  

14 A total of  58 oral surgeons provided services to children with Medicaid in 2012.   Of 

these, 41  oral surgeons provided services to  50 or more children with Medicaid.  
 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   5   
   
   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 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 few cases, we 
excluded dentists or oral surgeons who were actually specialists but had 
not indicated this on their claims.  For the remaining providers, we 
determined which providers worked for a dental chain in 2012, based on 
the billing names associated with their claims.15  Finally, we researched 
public records available on LexisNexis and from the Louisiana State 
licensing board to determine whether the providers had ever been 
sanctioned by the board. 
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. 
   
 
15  We considered a company to be a dental chain if it  had five or more locations within a 
State or around the country. 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   6   
   
FINDINGS 
Twenty-six general dentists and one oral surgeon in 
Louisiana had questionable billing in 2012 
We identified 26 general dentists and 1 oral surgeon with questionable 
billing.16   We identified these providers by looking at general dentists and 
oral surgeons in Louisiana who served more than 50 children with 
Medicaid in 2012. 
The providers with questionable billing are extreme outliers when 
compared to their peers.  They make up 5 percent of the general dentists 
and oral surgeons we reviewed, and they provided care to 9 percent of the 
children with Medicaid served by the providers we reviewed.17 Medicaid 
paid these 27 providers $12.4 million for pediatric dental services in 2012.   
Almost a third of the providers with questionable billing worked for two 
dental chains. In addition, four of the providers with questionable billing 
had previously been sanctioned by the State Board of Dentistry.  
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 
some of their billing may be legitimate, providers who bill for extremely 
large numbers of services warrant further scrutiny. 
Six General Dentists Received Extremely High Payments Per 
Child  
General dentists in Louisiana received an average payment of $264 for 
each child with Medicaid.  Six dentists, however, received more than two 
times this amount, or an average of more than $700 per child.18   These 
dentists received more than $2,000 per child for a total of 237 children.  
One of these dentists received more than $8,000 for services provided to 
one child over the course of three visits.  Extremely high payments raise 
concerns about whether these dentists are billing for unnecessary services 
or services that they did not provide.  See Table 1 for more information on 
 
16 Several dental providers exceeded multiple questionable billing thresholds. 
17 The 512  general dentists and 41 oral surgeons we reviewed served a total of  
318,960 children with Medicaid;  some children were seen  by both a general dentist and  
an oral surgeon.   
18 Dental providers commonly 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 8 and 9.   
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   7   
   
general dentists with extremely high average payments or numbers of 
services. 
Table 1: General Dentists With Extremely High Average Payments or Large 
Numbers of Services 
Threshold of  Number of Dentists 
Measure   Average for General  Questionable   Who Exceeded 
  Dentists *   Billing   Threshold  
        
Average Payments Per 
$264   $663  6 
Child 
Average Number of 
27  134  3 
Services Per Day   
Average Number of 
Services Per Child Per  4  6  10 
Visit  
 
Source:  OIG analysis of Louisiana Medicaid claims data, 2013.   
                        
Note: Three dentists exceeded two thresholds. 

* Includes general  dentists who served 50 or more  children with Medicaid in 2012.  
 
Three General Dentists Provided an Extremely Large Number of 
Services Per Day 
General dentists in Louisiana provided an average of 27 services per day 
to children with Medicaid. Three dentists each averaged 146 or more 
services per day. These dentists provided extremely large numbers of 
services on certain days of the year, with 1 dentist providing 376 services 
in a single day.  If this dentist spent only 5 minutes performing each 
service, it would have taken over 31 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, as well as raising concerns about the quality of 
care being provided. 
Ten General Dentists Provided an Extremely Large Number of 
Services Per Child Per Visit 
General dentists in Louisiana provided an average of four services per 
Medicaid child during a single visit.  Ten dentists, however, averaged 6 or 
more services per child per visit, with 1 dentist averaging 11 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.  Seven of these dentists 
provided more than 20 services in a single visit to a total of 170 children.  
One dentist provided more than 30 services to a child during a single visit.  
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   8   
   
These services primarily consisted of large numbers of fillings and direct 
pulp caps. (A direct pulp cap is an alternative to a root canal.) 
Additionally, as a part of these services, these dentists also provided a 
large number of x-rays, which can raise concerns about potentially 
unnecessary exposure to radiation. For example, 3 of these dentists 
provided 6 x-rays per visit to at least 700 children; 2 of these dentists 
provided 6 x-rays to more than 1,200 children.  On average, general 
dentists provided only one x-ray per child per visit.   
Thirteen General Dentists Provided Selected Services to an 
Extremely High Proportion of Children They Served 
When compared to their peers in the State, 13 general dentists provided 
selected services to an extremely high proportion of children with 
Medicaid that they served.19  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 
Measure   Average for General  Questionable   Number of Dentists 
  Dentists *   Billing   Who Exceeded 
      Threshold  
Proportion of children 
3%  13%   6 
who received pulpotomies 
Proportion of children 
11%  36%   6 
who received extractions 
Proportion of children 
who received stainless  6%  26%   1 
steel crowns  
Proportion of children 
33%  91%   1 
who received fillings 
 
Source:  OIG analysis of Louisiana Medicaid claims data, 2013. 

Note:  One dentist exceeded two thresholds. 

* Includes general  dentists who served 50 or more  children with Medicaid in 2012.  
 
Pulpotomies. Six general dentists provided pulpotomies to an extremely 
high proportion of children with Medicaid that they served.  Fourteen 
 
19 As  previously noted, pulpotomies, stainless steel crowns, and certain extractions and 
fillings  require prior authorization.  
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   9   
   
percent or more of the children served by these dentists received 
pulpotomies, compared to an average of only 3 percent of children served 
by all general dentists who provided pulpotomies.  One dentist provided 
pulpotomies to 19 percent of the children that he served. 
In addition, these dentists provided a large number of pulpotomies per 
child during a single visit in 2012. For example, one of these dentists 
provided 13 pulpotomies during the same visit to a 3-year old child.  
During this same visit, the dentist provided the child a total of 31 services, 
including 10 stainless steel crowns and 4 fillings.   
Extractions. Six general dentists performed extractions on an extremely 
high proportion of the children with Medicaid that they served.   
Forty percent or more of the children served by these dentists had one or 
more teeth extracted, compared to an average of 11 percent of children 
served by general dentists performing extractions in the State.  One dentist 
performed extractions on 70 percent of the children he served.   
Stainless Steel Crowns. One general dentist provided stainless steel 
crowns to an extremely high proportion of the children with Medicaid that 
she served. Thirty-two percent of the children served by this dentist 
received stainless steel crowns, compared to an average of 6 percent of 
children served by all general dentists who provided stainless steel 
crowns. This dentist provided four or more stainless steel crowns during a 
single visit to over 100 children with Medicaid.  These children ranged in 
age from 1 to 8 years, with an average age of 4 years.  In the most extreme 
example, this dentist provided 10 stainless steel crowns to a 2-year-old 
child during a single visit. 
Fillings. One general dentist provided fillings to an extremely high 
proportion of the children with Medicaid that he served.  Ninety-two 
percent of the children served by this dentist received fillings, compared to 
an average of 33 percent of children served by all general dentists who 
provided fillings. 
One  Oral Surgeon  Provided an Extremely Large Number of 
Services Per Day 
Oral surgeons in Louisiana provided an average of 10 services per day to 
children with Medicaid in 2012. One oral surgeon, however, provided an 
average of 31 services per day.  Moreover, he provided 50 or more 
services on 12 days and 73 services in 1 day.   This provider primarily 
performed extractions, which made up 61 percent of the services he 
provided in 2012. Given that procedures performed by oral surgeons may 
take more time than routine dental services, this providers billing patterns 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   10   
   
raise concerns both about potential fraudulent billing and about quality of 
care and childrens safety.    
Almost a Third of the Providers With Questionable Billing 
Worked for Two Dental Chains 
Of the 27 dental providers with questionable billing, 8 worked for 2 dental 
chains. A concentration of dental providers with questionable billing in 
chains raises concerns that these chains may be encouraging their 
providers to perform unnecessary procedures to increase profits. 
Four of the eight providers worked for a chain that operates mobile 
school-based clinics around the country.   This chain 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.20 The Senate Finance and Judiciary 
Committees also investigated this chain, citing a potential pattern of  
treatment without parental consent. 21  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.  Subsequent examinations initiated by the family suggested that 
the dental work provided was unnecessary.   
Another four providers worked for a Louisiana-based chain.  All four 
providers performed extractions on an extremely high proportion of the 
children with Medicaid that they served.  In addition, two of these 
providers received extremely high payments per child.    
Four of the Providers With Questionable Billing Had Actions 
Taken Against Them by the State Board of Dentistry 
Two of the general dentists with questionable billing had previously been 
subject to disciplinary action by the Louisiana Board of Dentistry.   The 
Board initiated disciplinary action against one dentist for illegally or  
illegitimately prescribing, dispensing, or administering habit-forming or 
other legally controlled substances, as well as failing to maintain accurate 
logs of controlled substances. The Board initiated disciplinary action 
against the other dentist for failing to provide access to treatment records.  
 
20 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.  
21 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. 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   11   
   
Additionally, two other dentists had received violations from the Board for 
advertising that included fraudulent, false, deceptive, or misleading 
content.  
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   12   
   
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 Louisiana.  Specifically, these 27 providersrepresenting 
5 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 $12.4 million for pediatric dental services in 2012.  Although 
some of their billing may be legitimate, 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, almost a third of the providers with 
questionable billing worked for two chains.  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, four of the providers 
with questionable billing had actions taken against them by the State Board of 
Dentistry.  
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.   
Louisiana 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 Louisiana Department of Health and Hospitals: 
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 this reports measures to better identify providers with patterns of 
questionable billing. In addition, the State should monitor dental chains to 
determine whether providers with questionable billing are concentrated in certain 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   13   
   
chains. The State should also ensure that it is appropriately authorizing services 
prior to payment.  Further, as the State transitions to managed care, it should 
continue to collect detailed data that will allow it to conduct proactive data 
analysis. The State should also ensure that managed care entities employ 
adequate safeguards to monitor dental providers.  Such monitoring can result in 
cost savings, as well as ensuring that children receive quality dental care.   
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 whom  
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 Louisiana (OEI-02-14-00120)   14   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The Louisiana Department of Health and Hospitals (the Department) concurred 
with both of our recommendations. The Department noted that as a result of our 
review, it has implemented corrective actions to address both recommendations. 
The Department concurred with our first recommendation and described its 
efforts to enhance its monitoring of dental providers.  As of July 1, 2014, all 
children with Medicaid in Louisiana are provided dental services through the 
Medicaid Dental Benefits Manager (DBM).  The Department stated that it 
requires the DBM to monitor, investigate, and report egregious billing patterns of 
dental providers serving Medicaid recipients. Additionally, the Department said 
that its Program Integrity Unit will closely monitor the new DBM to ensure that  
activities to prevent and detect fraud, waste, and abuse are in place to ensure the 
programmatic and fiscal integrity of the dental plan.  The Department added that 
it will put measures in place to identify providers with questionable billing  
patterns and that it will recommend safeguards, such as auditing of records, to the 
DBM in order to provide assurance that Medicaid recipients receive quality, 
medically necessary dental care.   
The Department concurred with our second recommendation and described its 
plans to take appropriate action regarding the dental providers identified as having 
questionable billing. The Department stated that it will perform a comprehensive 
audit of these providers by requesting dental records and supporting 
documentation.  In addition, the Department said that it will perform a thorough 
review of these providers practice types against their respective billing histories 
to validate the outlier analysis.  The Department stated that it will take appropriate 
actions, depending on what it finds in its analysis. 
The full text of the Departments comments is provided in the Appendix. 
   
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   15   
   
APPENDIX 
Agency Comments 
 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   16 APPENDIX A 

Agency Comments (continued) 

Ritchie, Brian P. 

July 24,2014 

Page 2 

 	 Audit the 27 dental providers identified by the OIG: 
Upon receipt of the data and/or listing of providers identified in the OIG report, DHH 
will perform a comprehensive audit by requesting dental records and supporting 
documentation, A comprehensive analysis ofeach of the identified providers' billing 
patterns is necessary to isolate questionable claims and anomalies. This area of review 
will be significant because Louisiana has small group of providers with very large 
practices that target our Medicaid population. Once the identities of the twenty-seven 
providers are known, we will perform a thorough review of their practice type against 
their billing history to validate the outlier analysis and determine whether the seemingly 
excessive billing practices are anomalies, an abuse of the billing system, or merely the 
result of a high volume-low margin business model. Dependent upon DHH's independent 
findings, we will take appropriate actions based on the results which may include but are 
not limited to termination/exclusion, recoupment/sanctions, and if necessary, referral to 
the appropriate law enforcement agencies. 
In relation to this audit, we would like to thank your staff for their courtesy, and we look forward 
to working with your office in the future. 
If you have any questions or need any additional information about this matter, please do not 
hesitate to contact me. 
Sincerely, 
J. Ruth Kennedy 
Medicaid Director 
JRK/JK 
c: 	 Michael Breland 
Mary Johnson 
John Korduner 
Jeff Reynolds 
Bill Root 
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)  17   
   
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.  
Lucia Fort and Judy Kellis served as the team leaders for this study.  Central 
office staff who provided support include Clarence Arnold, Meghan Kearns, and 
Christine Moritz.  
Questionable Billing for Medicaid Pediatric Dental Services in Louisiana (OEI-02-14-00120)   18   
   
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.