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ODA| Feature


Medicaid Dental Program: Compliance Audits by M. Edmund Braly, DDS, ODA Vice President


 healthcare laws have brought very       are becoming aware of the results of embedding dental insurance within medical insurance policies. However, an even more direct  can be found in the changes to the 


new laws, Medicaid dental providers are now subject to several   record.


  new programs to all dental Medicaid providers. According to a recent poll of our members, approximately 33% of Oklahoma            components of the Centers for Medicare & Medicaid Services   the CMS website (www.cms.gov) under “Medicaid Compliance                 ODA members as possible aware of the audits and the new 


There are two types of audits in the program: Program Integrity Audits (PIA) and those conducted Medicaid Recovery Audit               by the federal statutes. At the state level, there is the State Medicaid Agency, the Medicaid Recovery Audits, the Medicaid  At the federal level the agencies involved are the CMS, the Payment Error Rate Measurement program (PERM), the Medicaid Integrity Contractors (MIC), the Health and Human                  reducing fraud. Currently, most of the audits in Oklahoma are Program Integrity Audits, which are being conducted “in house”  audits having taken place in Oklahoma yet, but several other states are already experiencing the rollout of that program.


PIA Audits          by the Oklahoma State Department of Health conducted the audits. Now, PIA audits are being done by OSDH-employed RNs.


34 ODA JOURNAL December 2014


They are not dental nurses, but they have received some limited training in reading dental charts. They are trained to evaluate  records to those same standards. Of obvious concern to dental     applied to dental charts and many are not currently taught   program (SoonerCare) provide training for its cadre of Medicaid 


These random audits have caught many providers by surprise, as  than previous SoonerCare      at quality of care, these new audits are concerned with  by looking at the audit names (Medicaid Recovery, Program Integrity, Medicaid Fraud Control, etc.). These audits are born out of the Payment Error Rate Measurement (PERM) study, and are concerned mostly with controlling costs and recovering funds back to the CMS.


Of particular concern is the fact that nes for “errors in documentation” are not based directly on the amount of overpayment.


                    overpayment. Rather, an error rate is extrapolated, and that percentage applied to the total paid over the period covered by the audit (which could be years) as an overpayment. As an            Assume the provider delivered $200,000 of Medicaid care during that period, and a one-dollar mistake was found in 150 of the 600 charts reviewed. That seemingly equates to a $150 ($1 x 150 charts) overpayment. However, PIA audits do not  were documented erroneously, and would require repayment     Another concern: Contractors doing the audits are being paid based on the monies recovered.


                


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