Attention Medicaid Dental Providers: OMIG Audit Protocols Released

The New York State Office of the Medicaid Inspector General (OMIG) has released its final audit protocols for Dental providers in the Medicaid program. These protocols became effective October 1, 2014 and are the OMIG’s audit tool that they will use when conducting their audits of dental providers.  The protocols contain 18 areas of potential disallowances based upon various documentation requirements, timelines and other applicable rules.

The protocols explain what will constitute an error or a disallowance to the OMIG and lead to the OMIG attempting to recoup money previously paid for Medicaid claims.  These protocols provide the best source of information as to what the OMIG will be looking for during a dental audit, as well as what criteria dental providers should be auditing themselves against.

Potential audit disallowances include, but are not limited to, the following:

•  missing, inadequate and/or incorrect documentation and dental forms;
• no documentation of medical necessity;
• duplicate billing, frequency exceeded and/or conflicting service provision;
• maximum fee exceeded;
• no treatment visits during paid orthodontic quarter;
• premature claiming and payment for comprehensive orthodontic treatment;
• incorrect procedure codes;
• noncompliant diagnostic imaging;
• services provided not in conformance with prior approval;
• requesting payment from the recipient;
• incorrect billing for anesthesia;
• service not ordered, rendered and/or referred by primary dentist;
• service provided not a covered or essential service;
• billing Medicaid for services for which a third party is liable;
• billing for services included in a facility’s rate; and
• failing to enroll in a group practice or failing to be added to a group practice.

This post was written by David R. Ross, Shareholder of O’Connell and Aronowitz.  Mr. Ross served as General Counsel and Director of Audits and Investigations at the OMIG and was also the Acting Medicaid Inspector General under Governors Pataki and Spitzer. Please contact Mr. Ross for more information at dross@oalaw.com.