Payers should not neglect reviewing dental claims for fraud, waste and abuse. An Office of Inspector General (OIG) report released this month found questionable billing for pediatric dental services, including dentists who provided an aberrant number of services per day and dentists performing an unusual number of services per patient per visit. Also, the OIG found inappropriate billed claims for behavior management services. Though the findings are important for reviewing dental claims, they also have significant implications for claims from providers across all specialties.

It is imperative for payers to review claim data for unusual patterns in service and patient volume. The OIG report found a provider who billed 343 services in a day, when the average is 18 services per day. One dentist averaged 144 services per day. Aberrances like these cannot go unnoticed, and need to be investigated. The OIG report states, “An extraordinarily large number of services per day raises concerns that a dentist may be billing for services that were not medically necessary or were never provided, as well as raising concerns about the quality of care being provided.”

An unusual number of services per patient is equally important for payers to monitor. There was an average from the report of four services per patient per day across the sample of dentists reviewed. However, four dentists averaged seven or more services per patient per day, and one dentist averaged 12 services per patient per day. One notable variance was a dentist who provided 39 services for a patient in a single visit – exceeding with one patient the number of services the average dentist performs in an entire day. Even if subsequently proven to be factual, variances such as these need to be investigated when discovered.

Behavior management is a service the OIG report found was inappropriately billed in a significant number (85%) of claims reviewed. Private payers as well as government payers have guidelines for the billing and payment of dental behavior management, or CPT code D9920. Payer guidelines may impose frequency limits per patient, age restrictions, and diagnosis criteria for the use of this code.   Payers need to monitor providers’ use of D9920 against payer guidelines due to the higher probability of errors associated with the use of this code.

This OIG report underscores the importance of monitoring claims for outliers occurring in high volume of services and high patient volume per day as well as reviewing single CPT codes that have known probability for error.

The OIG report can be found at: http://oig.hhs.gov/oei/reports/oei-02-14-00250.asp

For more FWA Briefs articles: Tips for Payers to Improve Monitoring Hospital Admissions for Fraud