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Maine Dentists Protest Huge Medicaid Fines
11/06/2013   Reported By: A.J. Higgins

Maine dentists treating low-income children under the state's Medicaid program are fed up with a new state auditing system that is finding minor errors in their billing, and levying huge fines as a result. In many instances, the dentists say the errors are occurring because of a software glitch. A.J. Higgins has more.

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As part of the Affordable Care Act, Maine is required to ensure program integrity for its Medicaid program known as MaineCare by hiring an auditor. The state chose HMS, a New York firm with a national reputation for audit recovery.
Candace Hill, executive director of the Community Dental Center in Waterville, says she was shocked when a number of clerical errors in the billing - unrelated to the delivery of services or amounts charged - were identified by HMS as the basis for a massive fine.

"We owe somewhere in the neighborhood of $50,000 or $60,000, which would just not work for us - it would shut us down," Hill says.

Hill says there were instances in which one dentist at Community Dental might have performed a service for a patient that wound up being billed under the name of a different dentist in the same practice. These errors, she said were used as a benchmark by HMS to form the basis of a finding against the dental center stretching back three years.

The problem, Hill says, is that the sample HMS used was only 100 files, less than 1 percent of three years' worth of files at the center. Hill recently told lawmakers on the Health and Human Services Committee that HMS has agreed to reduce the fine - but not by much.

"They did reduce the amount by $10,000, but we still owe this phenomenal amount that we do not have in our back pocket," she said, "because you know that MaineCare pays about 50 cents on the dollar, and we are objecting mightily that it's less than 1 percent of three years' worth of patients. So how is that an appropriate sample?" Hill said.

Lisa Kavanaugh, CEO at Community Dental, is also suspicious of the methodology. She doesn't like the fact that HMS is paid on a contingent fee basis, which she says gives the company financial incentive to find errors in the absence of fraud.
So far, about $800,000 dollars has been assessed statewide in fines against Community Dental and other practices based on what Kavanaugh and others are describing as clerical errors.

"We are wondering, where's the oversight to prevent predatory auditing?" Kavanaugh said. "Because it's in their interests to identify overpayments."

Rep. Richard Farnsworth, the House chair of the Legislature's Health and Human Services Committee, suspects the dentists are being penalized inappropriately because of the software program being used by the providers.

"My feeling is that if your software package isn't doing the job that it's supposed to, that they dentists shouldn't be held unnecessarily responsible for that," Farnsworth says.

At the state Department of Health and Human Services, Commissioner Mary Mayhew says she's looking into the complaints lodged by Maine dental groups. But she says the state has a legal obligation under the Affordable Care Act to ensure that there is program integrity in the state Medicaid system.

"So to the extent that questions are being raised about practices that are not permitted by Medicaid - and I mean in terms of there is a federal prohibition - we need to be sure we are educating folks about that," Mayhew says. "But certainly where there are concerns about the process, or issues around confusion about the process, we are working with providers to better address those concerns," Mayhew says.

Meanwhile, lawmakers such as Rep. Richard Farnsworth of Portland, say they hope the issue can be resolved before many Maine dentists simply opt to stop accepting Medicaid patients in order to avoid undeserved penalties.


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