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NC Medicaid Dentists: June 12, 2018, Is Recoupment Day

June 12, 2018, is…

the 163rd day of the year. There will be 202 days left in 2018. It is the 24th Tuesday and the 85th day of spring. It is the Filipino Independence Day. And it is Recoupment Day for 80% or more of NC Medicaid dentists.

DHHS sent an important message to The Society of Oral and Maxillofacial Surgeons that 80% of dentists who accept Medicaid will be undergoing a recoupment – some for over $25,000. But for claims for dates of service 2013 and 2014. Claims that are 4 and 5 years old! Here is the message:

Please read the following email from Dr. Mark Casey with DMA regarding upcoming recoupment of funds from dentists:

Over a year ago, the Division of Medical Assistance (DMA) and our fiscal agent, CSRA, identified defects in NCTracks that had resulted in overpayments to enrolled dental providers in 2013-2014. DMA has been working on a plan to implement two (2) NCTracks system recoupments (claims reprocessing) that will affect a fairly large number of providers. We believe that giving the NCSOMS, other dental professional organizations and our enrolled dental providers plenty of advance notice prior to the recoupment date is a good idea. The number of providers impacted will not be as large as the Medicaid for Pregnant Women (MPW) recoupment of 2015.  You will find a summary of the notice below that will be sent to dental professional membership organizations as well as the two dental schools in the state.

DMA has gone through a lengthy process of identifying all providers who received overpayments and developing a plan for the NCTracks system recoupment.

I have seen the list of providers affected and we expect that a large majority (around 80%) will be able to repay the overpayment in one checkwrite based on their past claims activity. There will be some practices/providers who will be responsible for amounts approaching $25,000 or more. Practices with multiple offices will have multiple amounts recouped based on the multiple organization NPIs used for billing for each office. As you can see from the list of CDT codes that were overpaid below – diagnostic/preventive, restorative, denture repairs, extraction and the expose and bond codes (procedure codes where tooth numbers were reported and tooth surfaces were either reported or not reported) — we expect that general dentists, pediatric dentists and oral surgeons will be the dental provider types most affected by this recoupment.

As I indicated above, the messages that the dental professional organizations and the individual providers will be receiving over the next week or so will offer more detail than this email notice from me. If you have any questions or concerns regarding my email, please do not hesitate to contact me.

Mark W. Casey DDS, MPH

Dental Officer
Division of Medical Assistance
North Carolina Department of Health and Human Services
919 855-4280 office

Reprocessing of Dental Claims for Overpayment

Issue:  Some dental claims that processed in NCTracks beginning July 1, 2013 through April 20, 2014 paid incorrectly resulting in overpayments to providers.

Duplicate dental claims that included a tooth number and no tooth surface such as procedure codes D0220, D0230, D1351, D2930, D2931, D2932, D2933, D2934, D3220, D3230, D3240, D3310, D3320, D3330, D5520, D5630, D5640, D5650, D5660, D7111, D7140, D7210, D7220, D7230, D7240, D7241, and D7250, D7280, and D7283 processed and paid incorrectly in NCTracks between July 1, 2013, and April 20, 2014.

Additionally, duplicate dental claims for restorative services that included a tooth number and one or more tooth surfaces such as procedure codes D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2391, D2392, D2393, and D2394 processed and paid incorrectly in NCTracks between July 1, 2013 through October 14, 2013.

Based on NC Medicaid billing guidelines, these duplicate claims should have denied.  This caused an overpayment to providers.

Action: Duplicate dental claims identified with the two issues documented will be recouped and reprocessed in NCTracks to apply the duplicate editing correctly.  Any overpayments identified will be recouped.

Timing: Applicable dental claims will be reprocessed in the June 12, 2018, checkwrite to recoup the overpayments.

Remittance Advice: Reprocessed claims will be displayed in a separate section of the paper Remittance Advice with the unique Explanation of Benefits (EOB) code 10007 ‘DENTAL CLAIM REPROCESSED DUE TO PREVIOUS DUPLICATE PAYMENT’. The 835 electronic transactions will include the reprocessed claims along with other claims submitted for the checkwrite (there is no separate 835 for these reprocessed claims.)

Can DHHS recoup claims that are 4 and 5 years old? How about a mass recoupment without any details as to the reasons for the individual claims being recouped? How about a mass recoupment with no due process?

While we do not have a definitive answer from our court system, my answer is a resounding, “No!



RAC Audits: If It Walks Like a Duck and Quacks Like a Duck, It IS a RAC Audit

Recently, hundreds of dentists across North Carolina received Tentative Notices of Overpayment (TNOs) from Public Consulting Group (PCG) demanding recoupment for reimbursements made to dentists who rendered services on Medicaid for Pregnant Women (MPW) eligible recipients. There was no dispute at this hearing that these women were eligible for MPW according to the Department of Health and Human Services’ (DHHS) portal. There was also no dispute that these woman had delivered their babies prior to the date of dental service. So the question becomes: If DHHS informs a dentist that a woman is MPW eligible on the date of the service, does that dentist have an individual and separate burden to determine whether these women are pregnant. And if so, what is it? Have them pee in a cup prior to dental services?  See blog, and blog, and blog.

We do not have a definitive answer to the above-posed question, as the Judge has not rendered his decision. However, he did substantially limit these “nameless audits” or “non-RAC” audits to the RAC program limitations. In an Order on our Motion for Partial Summary Judgment, the Administrative Law Judge (ALJ) found that, even if the State does not agree that an audit is a RAC audit, if the audit conducted falls within the definition of a RAC audit, then the audit is a RAC audit.

The reason this is important is because RAC auditors yield such powerful and overwhelming tools against health care providers, the Affordable Care Act (ACA) limits the RAC auditors’ ability to look-back on older claims. For example, even though a provider is, generally, required to maintain records for six (6) years, the federal regulations only allow RAC auditors to look-back three (3) years, unless credible allegations of fraud exist.

Thus, when an auditor reviews documents over three-years-old, I always argue that the review of claims over 3-years-old violates the statute of limitations and federal law.

During hearings, inevitably, the state argues that this particular audit…the one at issue here…is not a RAC audit. The opposing side could no more identify which acronym this audit happens to be, but this audit is not a RAC. “I don’t know what it is, but I know what it’s not!”

Well, an ALJ looked past the rhetoric and pleas by the State that “this is not a RAC” and held that if it walks like a duck and quacks like a duck, then it is a RAC audit and, subsequently, the RAC audit limitations do apply.

In the case for this dentist, Public Consulting Group (PCG) audited claims going back as far as six years! The Department of Health and Human Services’ argument was that this audit is not a RAC audit. So what is it? What makes it NOT a RAC? Because you say so? We all know that PCG has a contract with DHHS to perform RAC audits. Is this audit somehow outside its contractual purview?

So I filed a Motion for Summary Judgment requesting the Judge to throw out all claims outside the three-year look-back period per the RAC limitations.

Lo, and behold, I was right!! (The good guys win again!)

To understand this fully, it is important to first understand what the RAC program is and its intention. (“It depends on what the definition of “is” is”).

Under 42 U.S.C. § 1396a(a)(42):

the State shall—(i) establish a program under which the State contracts (consistent with State law and in the same manner as the Secretary enters into contracts with recovery audit contractors under section 1893(h), subject to such exceptions or requirements as the Secretary may require for purposes of this title or a particular State) with 1 or more recovery audit contractors for the purpose of identifying underpayments and overpayments and recouping overpayments under the State plan and under any waiver of the State plan with respect to all services for which payment is made to any entity under such plan or waiver[].

(emphasis added).

RAC is defined as an entity that “…will review claims submitted by providers of items and services or other individuals furnishing items and services for which payment has been made under section 1902(a) of the Act or under any waiver of the State Plan to identify underpayments and overpayment and recoup overpayments for the States.” 42 CFR § 455.506(a).

Under this definition, PCG is clearly a recovery audit contractor. And the Judge agreed. If it walks like a duck and quacks like a duck, just because the duck protests it is a donkey, it is still a duck. (Hmmmm..wonder how this logic would carry over to the whole transgender bathroom issue…another topic for another blogger…)

RACs must follow certain limitations as outlined in the Code of Federal Regulations. For example, pursuant to 42 C.F.R. § 455.508(f), a Medicaid RAC “must not review claims that are older than 3 years from the date of the claim, unless it receives approval from the State.”

In this particular case, there were 15 claims at issue. Eleven (11) of those claims were outside the three-year look-back period!! With one fell swoop of an ALJ’s signature, we reduced the claims at issue from 15 to 4. Nice!

In DHHS’ Response to our Motion for Partial Summary Judgment, DHHS argued that, in this case, PCG was not acting as a RAC; therefore, the limitations do not apply. In support of such decision, DHHS supplied an affidavit of a DMA employee. She averred that the audit of this particular dentist was not per the RAC program. No rules were cited. No contract in support of her position was provided. Nothing except an affidavit of a DMA employee.

Obviously, it is my opinion that the ALJ was 100% accurate in ruling that this audit was a RAC audit and was limited in scope to a 3-year look-back period.

If it walks like a duck, quacks like a duck, it is not a donkey. No matter how much it pleads that it is, in fact, a donkey!

Remember the Super Bowl Ad of the Puppy, Baby, Monkey?:


That is so NOT ok!

Federal Audit Spurs NC to Recoup from Dentists Who Accept MPW!!

When providers receive Tentative Notices of Overpayment (TNOs), we appeal the findings. And, for the most part, we are successful. Does our State of NC simply roll over when the federal government audits it??

A recent audit by Health and Human Services (HHS) Office of Inspector General (OIG) finds that:

“We recommend that the State agency:

  • refund $1,038,735 to the Federal Government for unallowable dental services provided to MPW beneficiaries after the day of delivery; and
  • increase postpayment reviews of dental claims, including claims for MPW beneficiaries, to help ensure the proper and efficient payment of claims and ensure compliance with
    Federal and State laws, regulations, and program guidance.”

MPW is Medicaid for Pregnant Women.  Recently, I had noticed that a high number of dentists were receiving TNOs.  See blog.  I hear through the grapevine that a very high number of dentists recently received TNOs claiming that the dentists had rendered dental services to women who had delivered their babies.

Now we know why…

However, my question is: Does NC simply accept the findings of HHS OIG without requesting a reconsideration review and/or appeal?

It seems that if NC appealed the findings, then NC would not be forced to seek recoupments from health care providers.  We already have a shortage of dentists for Medicaid recipients.  See blog and blog.

And if the federal auditors audit in similar fashion to our NC auditors, then the appeal would, most likely, be successful. Or, in the very least, reduce the recouped amount, which would benefit health care providers and taxpayers.

Whenever NC receives a federal audit with an alleged recoupment, NC should fight for NC Medicaid providers and taxpayers!!  Not simply roll over and pay itself back with recoupments!

This audit was published March 2015.  It is September.  I will look into whether there is an appeal on record.

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.


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.