Almost $6.4 Million in Medicaid Dental Payments Violated State's Program Rules

An evaluation of the state’s Medicaid dental program for recipients under 21 years old found that approximately $6.4 million in claims payments made between July 1, 2012, and June 30, 2016, violated program rules, the Legislative Auditor said in a report released today.

The Louisiana Department of Health (LDH) oversees the state’s Medicaid program, including the coordination of dental benefits and services. On July 1, 2014, LDH moved from a fee-for-service model, where the Department paid all claims submitted by Medicaid dental providers, to a Prepaid Ambulatory Health Plan (PAHP).

Under a PAHP, the Department pays a per member per month fee to a management company that administers the dental benefits, including processing and paying all claims for Medicaid recipients. Managed Care of North America (MCNA) has the contract for the PAHP and is responsible for processing and paying all dental claims except for the Intermediate Care Facilities for the Developmentally Disabled population, which remains under the fee-for-service model. The contract runs through June 30, 2017.

Auditors found that between July 1, 2012, and June 30, 2016, LDH paid $5,747,446 for 88,586 fee-for-service claims that violated program rules, while MCNA paid $684,365 for 18,456 claims that violated program rules.

The violations included claims for diagnostic services for recipients who did not meet the age requirements, restorative services that did not have prior authorization, and endodontic services that did not have prior authorization. According to LDH, these violations could have occurred because provider manuals were not updated to account for changes that were decided upon by the Department.

In addition to the rules violations, auditors found problems with LDH’s oversight of the program, including a lack of documentation for specific procedures and insufficient documentation for overrides of claims payment decisions.