Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

QUESTIONABLE BILLING 

FOR MEDICAID PEDIATRIC 

DENTAL SERVICES 

IN INDIANA 

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 providers—representing 11 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 

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 
 

 

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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 Medicaid’s 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 Attorney’s 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. 

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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 CSHM’s 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. 

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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 “edits”—system processes to 

ensure proper payment of claims—that 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, Indiana’s recent analyses, which used 

algorithms based on the State’s 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 patient’s 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. 

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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 providers”—the providers who provided the 

services, as opposed to billing providers—to 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 
 

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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 State’s oversight of Medicaid 

pediatric dental claims, with staff from the State Medicaid agency—the 

Indiana Family & Social Services Administration—and with the State’s 

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 
 

 

 

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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 

provider’s 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. 

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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. 

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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. 

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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 

Measure 

Average for General 

Dentists * 

Threshold of 

Questionable 

Billing 

Number of Dentists 

Who Exceeded 

Threshold 

Average Payments Per 

Child $254 $645 9 

Average Number of 

Services Per Day 

18 51 64 

Average Number of 

Services Per Child Per 

Visit 

4 7 4 

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. 

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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 

Measure 

Average for General 

Dentists * 

Threshold of 

Questionable 

Billing 

Number of Dentists 

Who Exceeded 

Threshold 

Proportion of children 

who received extractions 9% 28% 9 

Proportion of children 

who received pulpotomies 2% 9% 6 

Proportion of children 

who received stainless 

steel crowns 

4% 22% 2 

Proportion of children 

who received fillings 31% 86% 1 

Proportion of children 

who received behavior 

management 

5% 17% 13 

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 

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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 dentist’s 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. 

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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 provider’s billing patterns 

raise concerns both about potential fraudulent billing and about quality of 

care and children’s 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 

America’s Poorest Children, The Center for Public Integrity, June 26, 2012. Accessed at 

http://www.publicintegrity.org/2012/06/26/9187/business-behind-dental-treatmentamerica-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. 

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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 parent’s 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 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. 

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 State’s 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 

State’s 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 Administration’s efforts to protect the program integrity of 

pediatric dental services in Indiana. The full text of the Administration’s 

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 fi·01n 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 OIG’s 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.