OHCA Dental Audit Findings Summary
Leon Bragg, DDS, MEd, with more than 20 years of experience in private practice and dental health education, is Chief Dental Officer for the Oklahoma Health Care Authority (OHCA). He is also vice president of the Medicaid CHIP State Dental Association (MSDA). MSDA is a membership organization whose mission is to contribute to the optimal oral health of Medicaid and State Children’s Health Insurance Program (SCHIP) beneficiaries by developing, promoting, and promulgating evidence and best-practices, based on state and national Medicaid/ SCHIP oral health policies and practices.
Lately, there have been many questions about program integrity audits conducted by the Oklahoma Health Care Authority (OHCA), which operates the SoonerCare (Oklahoma Medicaid) program. In order to receive federal matching funds OHCA must comply with federal rules set forth by the Centers for Medicare & Medicaid Services (CMS). As contracted OHCA providers, SoonerCare dentists must also adhere to CMS regulations in order to be reimbursed for services rendered.
Program Integrity at OHCA
OHCA’s Program Integrity & Accountability Unit has responsibility for maintaining oversight of the SoonerCare program. Program integrity (PI) is essential to any successful business venture by helping ensure that the directed mission is met, securing the trust of stakeholders, and verifying that operations comply with applicable laws. When taxpayer dollars fund the venture, as with SoonerCare, program integrity is even more vital. One way we address this task is through provider audits that are used to determine if billed services are appropriate and allowable. All OHCA providers are subject to such review.
Review begins when a questionable issue surfaces, at which time we perform a preliminary investigation. Te results of this investigation go before a case internal selection committee that determines if an audit is necessary. OHCA PI and dental staff conduct dental PI audits; PI staff
consists of a dental hygienist and registered nurses, all of whom are certified coders. OHCA dental staff is consulted throughout the dental review process.
Te audit is a comprehensive review of dental records for the services rendered. PI staff examines treatment plans and treatment notes, reviews radiographs to determine if services are compensable, and validates that appropriate payments are made to legitimate providers, to eligible members, and for medically necessary services. Upon completion, an initial audit report is submitted to the provider notifying them of the audit findings and what follow-up actions they may take.
Providers may submit a request for informal reconsideration of audit findings. Tey can submit additional documentation/explanation to support billed services. Dentists review all informal reconsiderations. Upon completion, OHCA submits a final audit report to the provider notifying them of the results and that they may file a formal appeal. At this point, providers may file an appeal with OHCA and present their case to an administrative law judge.
Findings consisted of insufficient documentation, inaccurate procedure coding, policy violation, medical necessity not established, and no documentation (details below). Tese findings are consistent with those of other provider types.
Insufficient Documentation: Te documentation provided did not substantiate that the service(s) billed were rendered, and/ or medical necessity could not be determined because the documentation was lacking the necessary details to validate the services.
Inaccurate procedure coding: Claims were upcoded (submitted for higher CDT/CPT procedure codes than were actually performed), resulting in higher reimbursement to providers by OHCA.
Policy violations: Policy violations may include (but are not limited to) radiographs not of diagnostic quality, exams not appropriate (limited exams being billed during visits for treatment-planned services, comprehensive exams being billed before allowed, fluoride/prophylaxis being billed before allowed, etc.), and smoking cessation not documented according to policy with separate note.
Medical necessity not established: In many instances of “Insufficient Documentation,” medical necessity also overlapped with the finding. Because the documentation was insufficient, medical necessity could not be determined.
No documentation: Documentation was not in evidence during an on-site review.
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