(WBNG Binghamton) The state Department of Health improperly paid an Oneonta dentist $66,402 for 2,361 inflated or questionable Medicaid claims he submitted for unwarranted services, including “behavior management,” and dentures that were not delivered to the recipients, according to an audit released Monday by New York State Comptroller Thomas P. DiNapoli.
“This dentist took advantage of a system that routinely fails to catch errors and overpayments to line his own pockets,” DiNapoli said in a news release. “Numerous audits by my office have shown the state’s Medicaid program to be subject to this kind of waste and abuse. DOH needs to figure out how to stop letting taxpayer dollars go to waste.”
According to a news release from DiNapoli's office:
DOH administers the Medicaid program in New York State. Medicaid claims are processed and paid by an automated system called eMedNY. When eMedNY processes claims, they are subject to various automated controls that are supposed to prevent waste, which DiNapoli’s auditors often find are flawed or fail to catch errors or fraud.
From June 1, 2009 through Sept. 30, 2012, auditors found Medicaid paid Dr. Prosper Bonsi about $593,000 for 10,700 claims for dental services he provided to 915 Medicaid recipients; an average of 12 claims per recipient.
Medicaid allows a dentist to submit a claim for additional reimbursement services for patients who are developmentally disabled or mentally ill. In these instances, dental staff often must provide additional time, skill, and/or assistance to such patients to render treatment properly. These services are commonly referred to as “behavior management.” Medicaid also allows a dentist to bill an additional fee for emergency treatment provided between the hours of 10 p.m. and 8 a.m.
Bonsi submitted 2,361 claims were for behavior management and after-hours office visits. DiNapoli’s auditors determined that $52,866 worth of claims for behavior management should not have been paid because the patients were not eligible for such services. In one case, Bonsi tacked on behavior management fees for each member of a family of four, even though no family member was eligible for this assistance.
Bonsi was also paid $11,776 for 533 claims for after-hours office visits that were provided during normal office hours.
Auditors found that eMedNY had no automated or manual controls to prevent the overpayments.
Medicaid rules also mandate that claims for dentures should not be submitted until the recipient receives the dentures, but Bonsi often billed for dentures when he took the impression of the recipient’s mouth, rather than when he provided the dentures to his patients. While this practice is improper under Medicaid rules, there is no overpayment if the patient eventually receives the dentures. However, in two instances, enrollees did not receive their dentures. Thus, Medicaid overpaid Bonsi $1,760 for these claims.
DiNapoli recommended DOH:
• Recover the $66,402 in payments improperly claimed by Bonsi, as identified in this report.
• Actively monitor claims submitted by Bonsi, particularly those for behavior management and after-hours office visits.
• Develop and implement eMedNY system edits or other controls to preclude payments for improper claims for behavior management and after-hours office visits.