Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

QUESTIONABLE BILLING 

FOR MEDICAID PEDIATRIC 

DENTAL SERVICES 

IN NEW YORK 

Brian P. Ritchie 

Acting Deputy Inspector General 

for Evaluation and Inspections 

March 2014 

OEI-02-12-00330 
 

EXECUTIVE SUMMARY: QUESTIONABLE BILLING FOR MEDICAID 

PEDIATRIC DENTAL SERVICES IN NEW YORK 

OEI-02-12-00330 

WHY WE DID THIS STUDY 

Medicaid is the primary source of dental coverage for children in low-income families and 

provides access to dental care for approximately 35 million children. In recent years, a 

number of dentists and dental chains have been prosecuted for providing unnecessary dental 

procedures to Medicaid children, as well as for causing harm to children while performing 

these procedures. 

HOW WE DID THIS STUDY 

We based our analysis on New York Medicaid fee-for-service paid claims for general 

dentists and orthodontists who provided services to 50 or more children in 2012. Using 

several measures, we identified dental providers with questionable billing who are extreme 

outliers when compared to their peers. 

WHAT WE FOUND 

We identified 23 general dentists and 6 orthodontists in New York with questionable billing. 

These providers are extreme outliers when compared to their peers. Medicaid paid these 

providers $13.2 million for pediatric dental services in 2012. 

Notably, these 29 general dentists and orthodontists—representing 3 percent of dental 

providers we reviewed—received extremely high payments per child; provided an extremely 

large number of services per child; or provided certain selected services, such as 

pulpotomies or extractions, to an extremely high proportion of children. Additionally, 

almost a third of the general dentists were associated with a single dental chain that had 

settled lawsuits for providing services that were medically unnecessary or that failed to meet 

professionally recognized standards of care to children. 

Our findings raise concerns that certain providers may be billing for services that are not 

medically necessary or were never provided. They also raise concerns about the quality of 

care provided to Medicaid children. Although some of their billing may be legitimate, 

providers who bill for extremely large amounts of services warrant further scrutiny. 

WHAT WE RECOMMEND 

We recommend that the New York State Department of Health (1) continue to monitor 

general dentists and orthodontists to identify patterns of questionable billing, (2) ensure that 

the State employs adequate safeguards to monitor general dentists and orthodontists under 

managed care, and (3) ensure appropriate followup on the general dentists and orthodontists 

identified as having questionable billing. The New York State Department of Health neither 

agreed nor disagreed with our recommendations. However, it identified actions it has taken 

or plans to take that support our first recommendation. It also outlined current requirements 

and processes that are in place that support our second recommendation. It did not indicate 

whether any steps were planned to address our third recommendation. 
 

TABLE OF CONTENTS 

Objectives.................................................................................................... 1 

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

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

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

Twenty-nine general dentists and orthodontists in New York 

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

Conclusion and Recommendations ........................................................... 11
 

Agency Comments and Office of Inspector General Response .... 13 

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

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

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

 

 

OBJECTIVE 

To identify general dentists and orthodontists with questionable billing for 

Medicaid pediatric dental services in New York. 

BACKGROUND 

Medicaid is the primary source of dental coverage for children in 

low-income families and provides access to dental care for approximately 

35 million children.1,2 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 preventative 

services, as well as needed treatment and follow-up care. Diagnostic 

services may include x-rays of the mouth; preventative services may 

include cleanings, topical fluoride applications, and dental sealants. 

Dental treatment covers a wide range of services such as fillings; tooth 

extractions; and pulpotomies, which are often referred to as “baby root 

canals.” 

New York’s Medicaid program also provides limited services for 

orthodontia. The State does not allow orthodontic treatment for purely 

cosmetic purposes; however, it will allow such treatment in instances of a 

“severe handicapping malocclusion.”4 This type of malocclusion occurs 

when a child’s teeth are so far out of position that he or she cannot engage 

in normal activities—such as eating and talking—without difficulty. 5 It is 

commonly associated with other medical conditions such as Down 

syndrome, muscular dystrophy, or craniofacial anomalies such as a cleft 

lip or palate. A provider must receive prior approval from the State before 

providing orthodontic treatment to a child. 

1

 Thomas P. Wall, Dental Medicaid – 2012, American Dental Association (ADA), 2012. 2

 Centers for Medicare & Medicaid Services (CMS), Annual EPSDT Participation 

Report, Form CMS-416 (National), Fiscal Year 2011, December 20, 2012. 3

 Social Security Act (SSA) § 1905(r)(3); 42 CFR § 441.56. Dental services are covered 

up to age 18, but States may choose to extend eligibility through age 21. New York is 

among the States that have done so. 

4

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

May 15, 2011. 

5

 Christine Ellis, University of Texas Southwestern Medical Center, Division of Oral and
 

Maxillofacial Surgery, written Congressional testimony, Is Government Adequately 

Protecting Taxpayers from Medicaid Fraud?, April 25, 2012. Accessed at
 

http://oversight.house.gov/wp-content/uploads/2012/04/4-25-12-Ellis-Testimony.pdf on
 

October 30, 2013. 

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In recent years, a number of individual dentists and chains have been 

prosecuted for providing services that were medically unnecessary or that 

failed to meet professionally recognized standards of care. These 

providers have often been found to have suspect Medicaid billing patterns 

when compared to their peers. For example, a dental provider in New 

York billed Medicaid for 991 procedures on a single day; she was later 

convicted of grand larceny and her license was revoked.6 In addition, 

FORBA Holdings LLC, a dental management company that manages 

clinics nationwide known as “Small Smiles Centers,” settled with the 

United States in 2010 for $24 million to resolve allegations of providing 

services that were either medically unnecessary or performed in a manner 

that failed to meet professionally recognized standards of care to Medicaid 

children.7 As part of the settlement, FORBA agreed to enter into a 5-year 

corporate integrity agreement with OIG. 

In 2012, New York State transitioned Medicaid pediatric dental services 

from fee-for-service to managed care. Prior to this transition, New York 

offered Medicaid pediatric dental services both on a fee-for-service and 

managed care basis; however, after July 2012, most dental services were 

offered through managed care. Orthodontic services were offered through 

managed care after October 2012. 

This report is part of a series. Other reports will examine Medicaid 

dentists in a number of other States. An additional report will determine 

the extent to which children enrolled in Medicaid received dental services 

in these States. 

Related Work 

In a recent audit, OIG found that providers inappropriately billed for 

orthodontic services provided to 43 of 100 sampled beneficiaries in 

New York City, totaling an estimated $7.8 million in inappropriate 

reimbursement.8

 Some of these services were provided without the 

required approval, whereas other services were undocumented or were 

never provided. These deficiencies occurred because the State agency and 

providers did not ensure that cases were reviewed annually to determine 

6

 Clifford J. Levy and Michael Luo, “New York Medicaid Fraud May Reach Into 

Billions,” The New York Times, July 18, 2005. Accessed at http://www.nytimes.com/ 

2005/07/18/nyregion/18medicaid.html on January 9, 2013. Also see New York State 

Education Department, Office of the Professions, Summaries of Regents Actions on 

Professional Misconduct and Discipline, November 2010. Accessed at 

http://www.op.nysed.gov/opd/nov10.htm on January 9, 2013. 7

 U.S. Department of Justice (DOJ), National Dental Management Company Pays 

$24 Million to Resolve Fraud Allegations, January 20, 2010. Accessed at 

http://www.justice.gov/opa/pr/2010/January/10-civ-052.html on July 13, 2012. 8

 OIG, New York Improperly Claimed Medicaid Reimbursement for Orthodontic Services 

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

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the need for continuing care and did not ensure that services were 

adequately documented. OIG is also conducting a number of audits of 

individual dental providers to determine whether they inappropriately 

billed Medicaid for pediatric dental services.9 

METHODOLOGY 

We based our analysis on New York Medicaid fee-for-service paid claims 

with service dates between January 1, 2012, and December 31, 2012.10 We 

excluded claims for services provided on a managed care basis or with 

special payment rates, such as those submitted by Federally Qualified 

Health Centers; State and local agencies; and facilities operated by 

university dental-school clinics.11 

To compare dentists to their peers, we focused our analysis on general 

dentists and excluded dentists who indicated a specialty on their claims, 

such as pediatric dental specialists, oral surgeons, and dental 

anesthesiologists.12 We excluded these specialists because their billing 

patterns are often different from those of general dentists. We looked at 

“rendering dentists”—the dentists who provided the services, as opposed 

to billing dentists—to ensure that we compared claims from the dentists 

who provided the services. Our analysis focused on 719 general dentists 

who provided services to 50 or more Medicaid children during 2012. 

These dentists served a total of 119,102 Medicaid children. We conducted 

a separate analysis of 165 orthodontists who provided services to 50 or 

more Medicaid children during this same time period.13 These 

orthodontists served a total of 83,894 Medicaid children. We analyzed the 

orthodontists separately because their billing patterns differed from those 

of general dentists. 

9

 OIG, Dental Services for Children—Inappropriate Billing, OAS-W-00-10-31135, 

OAS-W-00-11-31135, and OAS-W-00-12-3113, forthcoming. 

10 Over three-quarters of New York Medicaid pediatric dental fee-for-service claims were 

for services provided before July 1, 2012. Although New York began offering most 

dental services through managed care on that date, and began offering orthodontic 

services through managed care in October 2012, it paid for fee-for-service claims for 

services provided until the end of December 2012. 11 We also excluded services provided in a hospital setting because dental services 

provided in hospitals differ greatly from those provided in an office setting. In total, we 

identified 3,194 dental providers who provided services to Medicaid children in 2012 on 

a fee-for-service basis. 

12 Two hundred and four dentists reported one of the following specialties on their 

claims: oral surgeon, pediatric dental specialist, endodontist, oral pathologist, 

periodontist, or anesthesiologist. We did not include these dentists in our analysis. 

13 A total of 238 orthodontists provided services to Medicaid children in 2012 on a 

fee-for-service basis. Of these, 165 orthodontists provided services to 50 or more 

Medicaid children. 

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We developed a number of measures to identify dentists with questionable 

billing who are extreme outliers when compared to their peers. We 

developed these measures based on input from officials from CMS, the 

New York State Office of the Medicaid Inspector General, the New York 

State Department of Health, The American Academy of Pediatric 

Dentistry, and The American Dental Association. We developed these 

measures to capture several different types of fraud and abuse. For these 

measures, we included only the Medicaid children served by these general 

dentists or orthodontists; we did not include other children whom they 

served. 

For each general dentist, we calculated the following three measures for 

2012: 

• the average Medicaid payment per child served, 

• the average number of services provided per child, and 

• the average number of services provided per day. 

We developed four additional measures for general dentists who provided 

selected services in 2012. For each dentist who provided the following 

service, we calculated the proportion of Medicaid children who received: 

• fillings, 

• extractions, 

• stainless steel crowns, and 

• pulpotomies. 

For each measure, we analyzed the averages and the distribution for all 

general dentists. 

Next, we set a threshold for each measure that, if exceeded, indicated that 

the dentist had billed an extremely large amount compared to other general 

dentists in the State. We modified a standard technique for identifying 

outliers, known as the Tukey method.14 Under the Tukey method, outliers 

are those values greater than the 75th percentile plus 1.5 times the 

interquartile range. 15 To determine extreme outliers, we employed a more 

conservative approach, looking at those values greater than the 

75th percentile plus three times the interquartile range. We considered 

dentists who exceeded one or more of these thresholds to have 

questionable billing. 

14 See J.W. Tukey, Exploratory Data Analysis. Addison-Wesley, 1977. 15 The interquartile range is calculated by subtracting the value at the 25th percentile from 

the value at the 75th percentile. 

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We did a separate analysis of orthodontists. New York State has strict 

criteria for orthodontic services; in addition, orthodontists may bill for 

only a limited number of services. Providers receive a one-time payment 

for “comprehensive orthodontic treatment”—generally, this is the initial 

placement of braces on the teeth. They may also bill for periodic 

treatment services once per quarter—regardless of the number of visits 

provided—which covers the ongoing maintenance of the orthodontia. The 

remaining few orthodontic services may be billed for as they are 

provided. In addition to billing for orthodontic treatment services, 

orthodontists may also bill for related diagnostic services, such as x-rays. 

For our analysis of orthodontists, we calculated two measures for each 

orthodontist: (1) the total number of children served and (2) the average 

number of services provided per child. As with our analysis for general 

dentists, for each of these measures, we set the thresholds for extreme 

outliers at the 75th percentile plus 3 times the interquartile range. 

Orthodontists who exceeded these thresholds were extreme outliers 

compared to their peers, and we considered them to have questionable 

billing.16 

For each general dentist or orthodontist who exceeded one or more of the 

thresholds, we conducted Internet searches on the provider’s background 

and analyzed his or her claims and payment history. In a number of cases, 

we excluded dentists or orthodontists who were affiliated with university 

dental-school clinics or who were actually specialists but had not indicated 

this on their claims. For the remaining providers, we researched public 

records available on LexisNexis and from the New York and New Jersey 

State licensing boards to determine whether the providers had malpractice 

lawsuits brought against them. 

Limitations 

We designed this study to identify general dentists and orthodontists who 

warrant further scrutiny. None of the measures we analyzed confirm that a 

particular provider is engaging in fraudulent or abusive practices. Some 

providers may be billing extremely large amounts for legitimate reasons. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

16 We did not determine whether orthodontists exceeded thresholds for the four selected 

services that we analyzed for general dentists. Orthodontists generally provide a limited 

set of services, bundled together into a broad “orthodontic treatment” claim, and do not 

usually provide the four selected services that we analyzed for general dentists. 

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FINDINGS 

Twenty-nine general dentists and orthodontists in 

New York had questionable billing in 2012 

We identified 23 general dentists and 6 orthodontists with questionable 

billing. We identified these providers by looking at general dentists and 

orthodontists in New York who provided services to more than 

50 Medicaid children in 2012. 

The providers with questionable billing patterns are extreme outliers when 

compared to their peers and make up 3 percent of the general dentists and 

orthodontists we reviewed. 17 In aggregate, they provided care to 

14 percent of the Medicaid children served by the providers we reviewed. 

Medicaid paid these 29 providers $13.2 million for pediatric dental 

services in 2012. 

Almost a third of the general dentists with questionable billing were 

associated with a single dental chain that had settled with the 

U.S. Government, as well as with New York State, for providing services 

that were medically unnecessary or that failed to meet professionally 

recognized standards of care to children. 

These billing patterns indicate that certain dental providers may be billing 

for services that are not medically necessary or were never provided. 

Although some of this billing may be legitimate, providers who bill for 

extremely large amounts of services warrant further scrutiny. 

Five General Dentists Received Extremely High Payments Per 

Child 

General dentists who served 50 or more Medicaid children in New York 

received an average payment of $206 for each Medicaid child. Five 

dentists, however, averaged more than two times this amount, receiving an 

average of more than $482 per child. One dentist averaged $878 per child. 

For more than 20 children, this dentist was paid over $1,500 per child, or 

7 times the average payment. Extremely high payments per child raise 

concerns about whether these dentists are billing for services that are 

unnecessary or that they did not provide. 

17 The 719 general dentists and 165 orthodontists whom we reviewed served a total of 

194,225 Medicaid children. Some children were seen by both a general dentist and an 

orthodontist. 

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Two General Dentists Provided an Extremely Large Number of 

Services Per Child 

General dentists in New York provided an average of five services per 

Medicaid child. Two dentists, however, averaged 12 or more services per 

child, with one dentist averaging 16 services per child. 

Both of these dentists provided not only extremely large numbers of 

services per child, but also extremely large numbers of services per visit, 

raising concerns about the quality of care provided. For example, one 

dentist provided fillings on 42 separate tooth surfaces for the same child 

during the same visit. 

Thirteen General Dentists Provided an Extremely Large Number 

of Services Per Day 

General dentists in New York provided an average of 10 services per day 

to Medicaid children. Thirteen dentists, however, averaged more than 

23 services per day, with 1 dentist averaging 54 services per day. One 

dentist provided 179 services in a single day. If this dentist spent only 

5 minutes performing each service, it would have taken him over 15 hours 

to complete all of these services. An extraordinarily large number of 

services per day raises concerns that a dentist may be billing for services 

that were not necessary or were never provided. It also raises concerns 

about the quality of care being provided. See Table 1 for more 

information on general dentists with extremely high average payments or 

large numbers of services. 

Table 1: General Dentists With Extremely High Average Payments or 

Large Numbers of Services 

Measure 

Average for General 

Dentists * 

Threshold for 

Questionable 

Billing 

Number of Dentists 

Who Exceeded 

Threshold 

Average Payments Per 

Child $206 $482 5 

Average Number of 

Services Per Child 5 12 2 

Average Number of 

Services Per Day 10 23 13 

Source: OIG analysis of New York Medicaid claims data, 2013. 

Note: Three dentists exceeded two thresholds. 

* Includes general dentists who served 50 or more Medicaid children in 2012. 

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Six General Dentists Provided Selected Services to an 

Extremely High Proportion of Children 

Four general dentists performed extractions on an extremely high 

proportion of Medicaid children. Over 38 percent of the children served 

by these dentists had one or more teeth extracted, compared to an average 

of 10 percent of children served by all general dentists providing 

extractions in the State. One dentist performed extractions on 76 percent 

of the children he served. These four dentists provided an average of three 

extractions per child. 

Two general dentists provided pulpotomies—often referred to as “baby 

root canals”—to an extremely high proportion of Medicaid children. At 

least 14 percent of the children served by these dentists received 

pulpotomies, compared with only 4 percent of children served by all 

general dentists who provided pulpotomies. These dentists frequently 

provided three or more pulpotomies during a single visit, with one dentist 

performing as many as six pulpotomies during the same visit on a 2-yearold child.18 See Table 2 for more information on general dentists who 

provided selected services to an extremely high proportion of children. 

Table 2: General Dentists Who Provided Selected Services to an Extremely 

High Proportion of Children They Served 

Measure 

Average for General 

Dentists * 

Threshold for 

Questionable 

Billing 

Number of Dentists 

Who Exceeded 

Threshold 

Proportion of children with 

extractions 10% 38% 4 

Proportion of children with 

pulpotomies 4% 14% 2 

Source: OIG analysis of New York Medicaid claims data, 2013. 

* Includes general dentists who served 50 or more Medicaid children in 2012. 

18 Note that no dentists exceeded the thresholds for the proportions of Medicaid children 

receiving stainless steel crowns or fillings. General dentists provided stainless steel 

crowns to an average of 7 percent of children served; however, none of the dentists 

exceeded the threshold of 23 percent. Similarly, general dentists provided fillings to an 

average of 29 percent of children served; however, none of the dentists exceeded the 

threshold of 85 percent. 

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Almost a Third of the General Dentists With Questionable 

Billing Were Associated With a Single Dental Chain 

Seven of the twenty-three general dentists with questionable billing were 

associated with the same dental chain.19 The chain’s two clinics in 

New York stopped billing Medicaid in April 2012, after their management 

company decided to close the clinics and stop practicing in the State. 

The closures took place after the chain settled with the U.S. Government, 

as well as with New York State, to resolve allegations of providing 

services that were either medically unnecessary or were performed in a 

manner that failed to meet professionally recognized standards of care to 

children. 

For one additional dentist not associated with that chain, a State Board of 

Dentistry initiated disciplinary action against the dentist for negligence, 

malpractice, or incompetence. The Board had investigated the dentist 

after receiving several complaints. Two other dentists not associated with 

the chain had malpractice lawsuits brought against them. 

Five Orthodontists Provided Services to an Extremely High 

Number of Children; One Orthodontist Provided an Extremely 

Large Number of Services Per Child 

Orthodontists in New York provided services to an average of 

531 Medicaid children in 2012. Five orthodontists, however, each 

provided services to more than 2,100 children, and one of these 

orthodontists provided services to 4,870 children. 

All five of these orthodontists most often provided periodic treatment 

visits, which are billed for on a quarterly basis, regardless of how many 

visits occurred during the quarter. Periodic treatment accounted for almost 

half of the services these orthodontists provided in 2012. These 

5 orthodontists had a minimum of 43,564 visits with 17,365 children over 

the course of the year. The orthodontist who provided services to 

4,870 children had at least 12,598 visits with these children in 2012. 

The high volume of children seen by each of these five orthodontists raises 

concern about whether they are able to ensure that each child receives 

treatment that meets professionally recognized quality-of-care standards. 

Moreover, it is possible that the orthodontists billed for services that they 

did not even provide. As noted earlier, a recent OIG audit found 

inappropriate billing by providers in New York State for orthodontic 

19 Six of these dentists worked for this dental chain in 2012, whereas one dentist had 

previously worked for the dental chain but was working at another dental clinic in 2012. 

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services provided to a significant proportion of sampled beneficiaries.20 

Some of these services were provided without the required approval, while 

other services were undocumented or were never provided. 

Additionally, one orthodontist provided a large number of services per 

child. This orthodontist averaged seven services per child, compared with 

an average of four services per child for all orthodontists. See Table 3 for 

more information on orthodontists who provided services to an extremely 

high number of children or provided an extremely high average number of 

services per child. 

Table 3: Orthodontists Who Provided Services to an Extremely High 

Number of Children or Provided an Extremely Large Number of Services 

Per Child 

Measure 

Average for 

Orthodontists * 

Threshold for 

Questionable 

Billing 

Number of 

Orthodontists Who 

Exceeded Threshold 

Total Number of Children 

Served 531 2,181 5 

Average Number of 

Services Per Child 4 7 1 

Source: OIG analysis of New York Medicaid claims data, 2013. 

* Includes orthodontists who served 50 or more Medicaid children in 2012. 

20 OIG, New York Improperly Claimed Medicaid Reimbursement for Orthodontic 

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

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CONCLUSION AND RECOMMENDATIONS 

Dentists who participate in Medicaid provide much-needed access to 

dental services for children in this program. When children lack such 

access, untreated decay and infection in their mouths may result in more 

complicated and expensive dental and medical interventions later in life. 

At the same time, we have concerns about the extreme billing patterns of a 

number of general dentists and orthodontists in New York. Specifically, 

29 general dentists and orthodontists—representing 3 percent of dental 

providers we reviewed—received extremely high payments per child; 

provided an extremely large number of services per child; or provided 

certain selected services, such as pulpotomies or extractions, to an 

extremely high proportion of Medicaid children. Although some of their 

billing may be legitimate, providers who bill for extremely large amounts 

of services warrant further scrutiny. 

Our findings raise concerns that certain providers may be billing for 

services that are not medically necessary or were never provided. They 

also raise concerns about the quality of care provided to these children. 

Prior OIG reports have also found evidence of vulnerabilities in the 

oversight of Medicaid dental providers. Additionally, OIG has identified 

some specific vulnerabilities regarding the practices of certain dental 

chains. Notably, almost a third of the general dentists with questionable 

billing were associated with a single dental chain that had settled lawsuits 

for providing services that were medically unnecessary or that failed to 

meet professionally recognized standards of care to children. 

Together, these findings demonstrate the need to improve the oversight of 

Medicaid pediatric dental services. OIG is committed to conducting 

additional studies of dental providers and may issue recommendations to 

CMS in a future report. We are also committed to examining access to 

Medicaid dental services and to continuing to conduct investigations and 

audits of specific dental providers with questionable billing. 

The State must also use the tools at its disposal to effectively identify and 

fight fraud, waste, and abuse, while at the same time ensuring that children 

have adequate access to quality dental care in the Medicaid program. 

Therefore, we recommend that the New York State Department of Health: 

Continue to monitor general dentists and orthodontists to 

identify patterns of questionable billing 

The State currently provides oversight of billing practices in numerous 

ways. Among other things, the State has claims-processing “edits” 

(system processes to ensure proper payment of claims), conducts “prior 

approval” reviews for certain services, investigates complaints, and 

Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330) 11 
 

performs data analysis that may result in investigations. The State should 

continue to rely on its ongoing monitoring in this area and consider this 

report’s findings when developing further enhancements to its systems for 

monitoring billing by dental providers. Monitoring pediatric dental 

services can result in cost savings, as well as ensuring that children receive 

quality dental care. 

Ensure that the State employs adequate safeguards to monitor 

general dentists and orthodontists under managed care 

As part of its transition to a managed care environment, the State must 

ensure that managed care entities employ adequate safeguards to monitor 

dental providers. Managed care claims by dentists and orthodontists 

should be subject to claims-processing edits and “prior approval” reviews, 

just as fee-for-service claims were prior to the transition. Additionally, the 

State should collect detailed data from its managed care entities to conduct 

proactive data analysis. These data should include the specialty of the 

dentist and all of the services provided by each dentist. 

Ensure appropriate followup on the general dentists and 

orthodontists identified as having questionable billing 

In a separate memorandum, we will refer for appropriate action the dental 

providers whom we identified as having questionable billing. 

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AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

The New York State Department of Health (the Department) neither 

agreed nor disagreed with our recommendations. However, the 

Department identified actions it has taken or plans to take that support our 

first recommendation. It stated that the New York State Office of the 

Medicaid Inspector General (OMIG) is actively investigating and 

monitoring numerous orthodontists and general dentists. It noted that 

OMIG is also developing a system to identify questionable billing for 

orthodontic treatments and that OMIG’s dental staff will continue its 

oversight of billing practices by conducting prepayment reviews and 

record reviews to actively identify overpayments, unacceptable practices, 

and criminal activity. We continue to emphasize the importance of using 

the methods outlined in this report as a basis for further enhancements to 

the Department’s ongoing monitoring activities. 

The Department also outlined current requirements and processes that are 

in place that support our second recommendation. It noted that managed 

care plans are required to develop special investigation units that detect 

possible fraud and abuse. In addition, the Department stated that it closely 

monitors managed care dental managers and—through ongoing review of 

“fair hearing” results for dental services—evaluates whether they are 

following proper procedures. It also stated that it routinely reviews dental 

vendors who manage the dental benefit to ensure that they are following 

standard practices as prescribed by law. Lastly, it noted that the dental 

vendors evaluate the provision of services and authorize them only when 

they are medically necessary. 

The Department did not indicate whether any steps were planned to 

address our third recommendation. It stated that OMIG will continue to 

monitor encounter data from managed care organizations as well as feefor-service claims data in order to identify questionable billing by dental 

providers. 

The full text of the Department’s comments is provided in the Appendix. 

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APPENDIX 

Agency Comments 

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Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330) 15 
 

 

Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330) 16 
 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Jodi Nudelman, Regional 

Inspector General for Evaluation and Inspections in the New York regional 

office, and Nancy Harrison and Meridith Seife, Deputy Regional 

Inspectors General. 

Judy Kellis served as the team leader for this study. Other Office of 

Evaluation and Inspections staff from the New York regional office who 

conducted the study include Lucia Fort. Central office staff who provided 

support include Clarence Arnold, Meghan Kearns, and Christine Moritz. 

Questionable Billing for Medicaid Pediatric Dental Services in New York (OEI-02-12-00330) 17 
 

Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(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.