MIC and MFCU Dental Audits On the Rise

MIC and MFCU Dental Audits Introduction

Medicaid dental fraud is growing worse throughout the country, and not just in states traditionally prone to fraud like Florida and Texas. Because of this, Medicaid dental audits and investigations are uncovering fraudulent dental practices in states such as Rhode Island, Connecticut, Massachusetts, and Virginia, as well as the rest of the country.

In fact, dental providers in Connecticut were recently indicted for operating a fraudulent Medicaid billing scheme, stealing nearly $20 million from the Connecticut Medicaid Program. In this case, although the chief architect of the scheme had been excluded from the Medicare and Medicaid programs in 1998, he continued to operate several dental practices in the Northeast from 2005 until his arrest in 2012. In addition, he recruited other dentists to serve as the face of the dental practice entities which billed millions of dollars in false or unnecessary dental service claims. Federal agents recently arrested all the alleged conspirators and charges are currently pending.

Use of MIC Dental Audits Increasing

What this and other cases bring to light is the fact that more and more often, both Federal and state governments are focusing on dentistry as a source of significant fraud, waste, and abuse. Investigators and auditors alike are recognizing that there are sometimes serious deficiencies in dental claims billing, and more importantly, they are redoubling their efforts to fix it. If you are a provider of dental services, expect that both Medicare and Medicaid contractors (ZPICs and RACs for Medicare and MICs and MRACs for Medicaid) will be gearing up to audit dental claims throughout the country. To be clear, Medicare only covers dental services that are  necessary due to an underlying covered condition. Medicare contractors, therefore, only audit dental claims to the extent they relate to a covered condition. Nevertheless, MIC audit efforts have already begun in states such as Texas, where both government contractors and the state’s Health and Human Services Commission (HHSC) Office of Inspector General (OIG) have initiated reviews.

Steps to Avoiding a MIC Dental Audit

So what can you do as a dental provider to reduce the risk of a Medicaid audit? As dental Medicaid audits become more common, you need to ensure that both your business operations and your billing and coding functions are performed in compliance will all applicable guidelines and regulations, both Federal and state. The simplest way to do this is to designate a compliance officer and implement an effective Compliance Plan for your practice. The benefits of a Compliance Plan are innumerable; by creating a roadmap for excellence in internal operations, your office will operate more efficiently and recognize and follow your affirmative duties as a Medicare/Medicaid provider. In addition, your staff will better understand their unique role in your organization and work hard to ensure that treatment and revenue management are conducted in accordance with applicable laws. Finally, your risk of exposure, both to government audits and investigations and to medical malpractice claims, will be reduced by the implementation and maintenance of an effective Compliance Plan.

Unfortunately, even with the best tools, dentists, orthodontists, and other providers may still find themselves subject to audits. Reviewers and auditors employed by Medicare and Medicaid contractors are highly experienced, knowledgeable and skilled in assessing the propriety of a claim.  They have years of experience handling audits and excel at identifying deficiencies in your documentation, regardless of how minor you may believe those  deficiencies might be.  While it is essential to understand your obligations as a Medicare/Medicaid participant, it is equally important to understand how and why practices get audited.  As discussed in earlier articles, while you may not be able to avoid an audit, you can do your very best to help ensure that upon review, a CMS contractor will find that your practices fully meet specific Medicaid rules and regulations.  The development, implementation and adherence to an effective Compliance Plan are the most important steps you can take to avoid regulatory problems.

Robert Liles is the managing member of Liles Parker PLLC. Located in our Washington, D.C., office, Robert represents providers in Medicare and Medicaid post-payment audits and appeals. In addition, Robert counsels clients on regulatory compliance issues, performs gap analyses and internal reviews, and trains healthcare professionals on various legal issues. For a free consultation, call Robert today at 1-800-475-1906.