On March 9, 2017 the OIG published a report with an astonishing statistic: “Of the 600 dental services in our 6 stratified random samples, 542 did not comply with Medicare requirements.” Click this URL for more information. When the report went on to clarify the statistic, the number got even worse:
We did not determine Medicare compliance for 3 dental services because the payments were refunded before our audit work, and we did not determine Medicare compliance for 28 dental services because the providers of those services submitted claims to a different Medicare contractor. Medicare contractors properly paid providers for the remaining 27 dental services.
27? Out of 600?
Only 27 out of 600 Medicare contractors properly paid dental providers. The OIG recommended that CMS (Centers for Medicare & Medicaid Services) implement “national edits for hospital outpatient dental services.” CMS pushed back on this recommendation “stating that it would be difficult to implement because dental coverage is based on the specific clinical needs of the beneficiary.” That being said, CMS did reconfirm its commitment to “ensure that payments made to providers for dental services comply with Medicare requirements.”
The report also points out the complexity of billing Medicare for dental services:
Medicare generally does not cover hospital outpatient dental services. Under the general exclusion provisions of the Act, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures) are not covered (§ 1862(a)(12)). Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.
For hospital outpatient dental services to be covered, they must be performed as incident to and as an integral part of a procedure or service covered by Medicare. For example, Medicare covers extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw, but a tooth extraction performed because of tooth decay is not covered.
The above illustrates the inherent difficulty dental providers have in determining whether a payment can be covered by Medicare; but regardless of the challenges it is clear that changes need to be made. In light of the drastic statistics it is time for dental providers to prepare so that when the OIG or state equivalent organization comes to their doorsteps they are ready to answer their questions.
As always, if you have specific questions about compliance, data availability, the nuances of a particular source, or the best place to find the data you’re looking for, please don’t hesitate to reach out to me directly at firstname.lastname@example.org or to call me at 800-780-5901, Extension 103.