Going to the Dentist? You May Need to Take a Pregnancy Test!

I go to the dentist for teeth cleaning. I go to an ob/gyn for my lady parts. They each are not entwined.

Recently, a number of dentists have contacted me they are receiving Tentative Notices of Overpayment (TNOs) stating that they owe money back to the state for dental services completed on women who had already given birth.

What?

First, what is Medicaid for Pregnant Women?

Basically, Medicaid for Pregnant Women (MPW) is a self-defining type of Medicaid coverage.  It is Medicaid coverage for pregnant women.

According to DHHS, “Medicaid for Pregnant Women (MPW) only covers services related to pregnancy:

  • Prenatal care, delivery and 60 days postpartum care
  • Services to treat medical conditions which may complicate the pregnancy (some services require prior approval)
  • Childbirth classes
  • Family planning services

A pregnant woman may apply for this program before or after she delivers. A woman who has experienced a recent pregnancy loss may also be eligible.”

And routine dental services are covered for MPW recipients through the date of delivery.

But, the day after the child is born…BOOM…no routine dental visits.

Here is a hypothetical example of this new issue that I have recently been made aware:

Mary is pregnant and is covered by MPW.  She makes a dental appointment for August 1, 2015.  She is due September 1, 2015.  She gives birth to a bouncing, baby boy, whom she names Paul on July 28, 2015.  Even though Paul is early, he is healthy (this is a happy hypothetical).  She shows up for her dental appointment with Dr. Peter on August 1, 2015.

Herein lies a delicate subject…due to its sensitive nature, I will now revert the hypothetical to myself, personally, and only for this narrow topic.

I had my beautiful 10-year old daughter at 28 weeks.  She came three months early. Despite the early delivery, I had expanded in the stomach area at least as much as a normal pregnant woman, if not more so.  Chalk it up to Harris Teeter birthday cakes. After my daughter was born, the insensitive, yet rule-following nurse actually had the audacity to place me on a scale (while I was conscious and alert!).  I was horrified to discover that after all that I went through that I had lost a mere 4 pounds.  She must have seen my look because she quickly explained that I had been pumped with so much fluid during the procedure that my weight was inflated. Likely story, I thought.  The point of this short anecdote is that I looked the same after giving birth that I did prior to giving birth.  Embarrassingly, my transition back to a normal, un-pregnant body extended for a much longer than expected period of time. Chalk it up to Harris Teeter birthday cakes.

Ok, going back to our hypothetical…

Mary really wants her teeth cleaned because, once she gives birth, she knows full well that she will not be able to undergo a teeth cleaning.  So when she presents herself at Dr. Peter’s  office and Dr. Peter asks whether she is still pregnant, she answers, “Yes, sir.”

Dr. Peter, undergoing all the due diligence that a dentist can be expected, has his assistant log on to NCTracks.  According to NCTracks, Mary is eligible for MPW. No changes are noted on her eligibility.  Satisfied with his due diligence, Dr. Peter cleans Mary’s teeth.

Two years later, Dr. Peter receives a TNO stating that he owes $10,000 back for services rendered to women after they gave birth.

Dr. Peter conducted his due diligence.  Dr. Peter inquired as to the pregnancy status to the patient.  Dr. Peter checked eligibility status with NCTracks.

What more would the state expect Dr. Peter do to determine whether his dental patients are indeed still pregnant? Ask them to pee in a cup? Hire a onsite ob/gyn?

You can imagine the consequences of each.

Yet, according to a number of dentists who have communicated with me, the state is placing the burden of knowing whether the dental patient is still pregnant on the dentist.

Talk about accountability! If NCTracks shows that the patient is eligible for MPW, shouldn’t NCTracks be held liable instead of the dentist?

Call me crazy, but I may or may not be extremely angry if my dentist asks me to pee in cup.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on July 29, 2015, in "Single State Agency", Agency, Alleged Overpayment, Dental Medicaid Providers, Dentistry Services, Division of Medical Assistance, Eligibilty, Health Care Providers and Services, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Advocate, Medicaid Appeals, Medicaid Attorney, Medicaid Eligibility, Medicaid Providers, Medicaid Recipients, Medicaid Recoupment, Medicaid Reimbursements, Medicaid Services, NC, NCTracks, NCTracks Billing Issues, North Carolina, OAH, Office of Administrative Hearings, Post-Payment Reviews, Provider Medicaid Contracts, Tentative Notices of Overpayment and tagged , , , , , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 4 Comments.

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