Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

QUESTIONABLE BILLING 

FOR MEDICAID PEDIATRIC 

DENTAL SERVICES 

IN LOUISIANA 

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 providers—representing 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 pulpotomies—often referred to as “baby root canals”—and 

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 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.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 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 

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 “edits”—system 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 General’s 

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. 

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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 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 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 measures—as well as the State’s oversight of Medicaid 

pediatric dental claims—with 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 provider’s 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. 

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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 

Measure Average for General 

Dentists * 

Threshold of 

Questionable 

Billing 

Number of Dentists 

Who Exceeded 

Threshold 

Average Payments Per 

Child $264 $663 6 

Average Number of 

Services Per Day 

27 134 3 

Average Number of 

Services Per Child Per 

Visit 

4 6 10 

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 

Measure Average for General 

Dentists * 

Threshold of 

Questionable 

Billing 

Number of Dentists 

Who Exceeded 

Threshold 

Proportion of children 

who received pulpotomies 3% 13% 6 

Proportion of children 

who received extractions 11% 36% 6 

Proportion of children 

who received stainless 

steel crowns 

6% 26% 1 

Proportion of children 

who received fillings 33% 91% 1 

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 provider’s billing patterns 

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raise concerns both about potential fraudulent billing and about quality of 

care and children’s 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 parent’s 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. 

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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 providers—representing 

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. 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 report’s 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 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 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 Department’s 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 of each 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 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.