A nonprofit service provider says it will change how it files documentation - but not necessarily how it practices - in the wake of a Medicaid fraud settlement with the state Attorney General's Office.
Baker Victory Health Services Dental Center in Lackawanna paid the state $325,000 in restitution to resolve a case focusing on excess payments received on claims for dental services. According to the AG's office, an audit investigation by the Medicaid Fraud Control Unit found the agency received payments over a four-year period for dental clinic services for which Medicaid reimbursements were not authorized. The audit-investigation, which covered a period ending Dec. 31, 2009, determined that in addition to performing unnecessary procedures, the clinic performed cleanings, X-rays and dental exams over multiple visits, resulting in additional fraudulent reimbursements.
But Baker Victory CEO James Casion says the patients - most of whom are developmentally or physically disabled - were rightfully receiving cleanings more frequently, and had their other procedures spread out over multiple visits, because their conditions prevent care from being delivered in the typical timeframe for a non-disabled patient.
"About 40 percent of our base here are special needs people," he says. "Many of these people can't handle extended periods of time in the chair, or their wheelchair, with their mouth being operated on."
The real issue, Casion says, is that medical staff did not indicate on the charts for every single visit that the patients had disabilities that medically necessitated additional visits. The case really boils down to a documentation issue, the agency says, where it followed all recommendations from the Department of Health in the care for such individuals, but didn't feel it was necessary to repeat documenting their condition at every single visit.
Casion, who has a 28-year-old son with developmental disabilities, has first-hand knowledge of just how difficult it is to care for the teeth of someone in this condition.
"My son has seven teeth left and has had major surgeries, and he had cleanings four times a year," he says. "Their mouths tend to be smaller, which presents additional challenges for dental hygiene."
The AG's office says Medicaid regulations authorize reimbursements only for teeth cleanings performed every six months, barring medical necessity. However, in some cases Baker Victory patients were receiving cleanings every three to four months. In other cases, procedures such as cleanings, X-rays and dental exams were performed over multiple, separate visits instead of one office visit, in violation of Medicaid regulations.
The audit looked at 200 cases, ultimately focusing on 27 patients for whom excess payments were made. Of those, 25 fell into the medically-frail category. The total over-payments for those individuals totaled $2,300, a figure that extrapolated to more than $840,000 according to the fraud unit's system.
Baker Victory negotiated the total down to $325,000 for the restitution. Casion says the funds to pay the restitution will come from its foundation and other fundraiser dollars.