Medicaid Dental Post-Payment Audits Gone Awry: A Hypothetical Example

A dental practice was audited by Public Consultant Group (PCG). Here is their story: (Insert a Dum, Dum, Dum).

For those of you who do not know who PCG is: CONGRATULATIONS!

But there are those of us who know that PCG is a hired contractor by the state or the Division of Medical Assistance (DMA) to investigate providers who accept Medicaid in North Carolina to detect clinically suspect behaviors or administrative billing patterns, which could indicate potentially abusive or fraudulent activities.

Whew!! Sounds serious!!

I am SURE that, for such a serious mission, PCG employs only the most-highly competent employees who are super, duper knowledgeable about the esoteric idiosyncrasies of the Medicaid system, the appropriate policy(ies),and  federal and state rules and regulations, right?

Hmmmm…out of sheer curiosity I googled employment opportunities at PCG.  I found a position in Albany, NY for an “Instructional Trainer.”  Duties include:

“Coaches agencies and providers on programs and information to ensure compliance with departmental, state, and federal laws, rules, regulations, guidelines, processes, and procedures.”

Dag on!!! Shut the front door! This person will be coaching agencies and providers, ensuring compliance with laws, rules, regulations, guidelines….SURELY this person must be a lawyer, right????

So then I looked at the “required experience:”

Required Experience:

  • BS degree in a related field preferred
  • Experience in development and delivery of instructional materials or training
  • Experience in health & human services is desirable
  • Experience working in a team-oriented, collaborative environment
  • Advanced Knowledge of Curriculum Design and Training Delivery
  • Advanced Knowledge of Office Skills such as Word Processing and Data Collection
  • Advanced Knowledge of the Principles for Providing Customer Service

A BS degree is a related field preferred??

First, what is a related field for regulations and compliance? Political Science?

Folks, I double-majored in English and Political Science and I can promise you that after graduating from NCSU with a double major in English and “Poli Sci” I was NOWHERE competent enough to handle a Medicaid audit of a provider.  I may have been able to draft a darn good essay or quote the U.S. Senators and their bipartisan affiliations, but a Medicaid expert, I was not.  And this position was for an “Instructional Trainer!” A TRAINER!! As in, one who trains.  Implicit in the job title is “One who has been trained” or “One who has the knowledge to train.”

I give this background to set the stage:

The Characters:

On one side: Dentists who have been managing a successful dental practice for years and years after attending college and dental school.

And on the other side:  A college Political Science major who is able to recite all the states and its capitols and all the governors of each state (This is not to say that all employees at PCG are inept…or not qualified for  their particular position.  I actually know a couple of PCG employees of whom I think highly (this is not directed toward you, my fine two friends).  This is merely a generalization and stage-setting for the all-too-common errors I see committed by the “entry-level” auditors).

The stage:

A well-established dental practice.  All the walls are wooden (painted white) and there are 200+ handprints on the lobby wall with all the little pediatric customers’ names on them.  There is a waiting room with toys and books.

The script:

Act 1: A few entry-level PCG auditors knock on the door of the dental practice (They don’t actually knock, because it is a dental practice, not a home, but you get the drift).

Receptionist: How may we help you?

Auditor 1: We are here to conduct a Medicaid post-payment audit.

Receptionist: Huh? (With an open, gape-jawed expression)

Auditor 2: A post-payment Medicaid audit.

Auditor 1: We need to see all the documents of your Medicaid clients from February 2011 through May 2011.

Receptionist: Huh?

All right, folks, I am sure you get the point.  So the audit occurs and a few months later, the dental practice receives a Tentative Notice of Overpayment for $300,000.00.  The #1 main reason PCG found noncompliance was:

“The attending provider number billed does not match the individual dentist who rendered the service and does not support service billed.  Citation: Clinical Coverage Policy No. 4A: January 1, 2011 Attachment A.1 Instructions for filing a Dental Claim 53-56…”

Now, mind you, in the DMA Clinical Policy No. 4A, revised March 1, 2013, the policy states “Enter the attending provider’s NPI for the individual dentist rendering service. (This number must correspond to the signature in field 53.)”

In 2013, it is quite clear that the attending provider and the provider rendering the services must be identical.  But this audit was a post-payment review, meaning that the documents audited were from 2011, not 2013.

In 2011, the DMA Clinical Policy No. 4A, revised January 1, 2011, states “Enter the attending provider’s NPI for the individual dentist rendering service. (This number should correspond to the signature in field 53.)”

 See the difference? (One of these things is not  like the others).

Must v. Should

Must equals no other choice.  Should denotes guidance; simply a suggestion.

However, think of this, if you were a college graduate who majored in Political Science and were now auditing Medicaid providers, would you think to distinguish the difference between “should” and “must?”

 

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on May 23, 2013, in Clinical Policy 4A, Dentistry Services, DHHS, Division of Medical Assistance, Health Care Providers and Services, Legal Analysis, Medicaid, Medicaid Audits, Medicaid Recoupment, North Carolina, Post-Payment Reviews, RAC, RAC Audits, Tentative Notices of Overpayment and tagged , , , , , , , , , , , , , , , . Bookmark the permalink. 1 Comment.

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