HCN News & Notes

Auditor Calls on Dental Practices to Repay $290,417 to MassHealth

BOSTON — State Auditor Suzanne Bump released an audit of dental periapical radiograph claims submitted by Hampshire Family Dental of Northampton and Orchard Family Dental of Indian Orchard, both of which are owned by Dr. Samer Tahoun. The audit found that both practices improperly billed MassHealth for these radiographs, totaling approximately $290,417. Bump called on Tahoun to collaborate with MassHealth to repay these improper payments and take steps to prevent future improper billings.

“MassHealth providers must adhere to the regulations of the program and must document their claims,” Bump said. “MassHealth must now recover the improper payments made to these offices and decide whether further action should be taken against Dr. Tahoun. Additionally, MassHealth should take steps to identify these wrongful patterns of practice more quickly.”

Periapical radiographs are a type of X-ray that shows an entire tooth from the top of the jaw, and are used to identify problems with a tooth and surrounding area. Under state regulations, MassHealth will pay for this procedure only once every three years as part of a full-mouth series, or for specific areas when extraction is anticipated, or an infection or other anomaly is suspected and documented.

The audit found these dental practices performed and billed MassHealth for these radiographs as part of routine dental exams without a full-mouth series or documentation of pain, infections, or other issues. The audit examined these types of claims submitted by the practices to MassHealth from July 1, 2010 through June 30, 2015.

Bump’s office used advanced data analytics on dental X-ray claims billed to MassHealth to identify service trends and billing anomalies indicating potential fraud, waste, or abuse. These dental practices were selected for audit because claims for periapical radiographs represented 46{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of total X-rays billed, significantly higher than the 28{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} average.

MassHealth agreed with Bump’s findings and stated its intention to recover the overpayments and work with the practices to prevent future improper billings and ensure appropriate record keeping.

In fiscal year 2015, MassHealth paid healthcare providers $13.6 billion. Massachusetts receives a reimbursement from the federal government for 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of most services provided to MassHealth members. MassHealth expenditures account for roughly 38{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the state’s total annual budget.