Purpose

To determine if Medicaid made improper payments for dental claims submitted by Dr. Prosper Bonsi. The audit period was June 1, 2009 through September 30, 2012.

Background

The Department of Health administers New York State's Medicaid program. The Department's Medicaid Dental Policy and Procedure Code Manual describes the services eligible for Medicaid reimbursement and the rules under which claims for eligible services will be paid. Medicaid allows a dentist to bill an additional fee when dental staff must provide additional time, skill, and/ or assistance to properly treat patients. Such 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 10:00 p.m. and 8:00 a.m. Payments for behavior management and services after normal business hours are in addition to the base fees for the treatments otherwise provided.

Prosper Bonsi, DMD, owns and operates Advanced Family Dentistry in Oneonta. In 2009, Dr. Bonsi enrolled in the Medicaid program. From June 1, 2009 through September 30, 2012, Medicaid paid Dr. Bonsi about $593,000 for the claims he submitted. Many of these payments were for claims for behavior management and emergency treatments provided after normal office hours.

Key Findings

• Medicaid paid Dr. Bonsi $66,402 for 2,361 improper claims he submitted for behavior management, after-hours office visits and dentures that were not delivered to the recipients. The payments included:
  • $52,866 for 1,825 improper claims for behavior management. The recipients in question were not eligible for behavior management services; and
  • $11,766 for 533 improper claims for after-hours office visits. Most of the claims were for services that were provided during normal office hours.

• Medicaid had no computer system edits or manual controls to prevent payments of the improper claims for behavior management and after-hours office visits that we identified.

Key Recommendations

• Recover the $66,402 in improper payments made to Dr. Bonsi.
• Develop and implement Medicaid system edits or other controls to preclude payments for improper claims for behavior management and after-hours office visits.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Payments for Dental Consultations (2010-S-12)
Department of Health: Medicaid Payments for Excessive Dental Services (2009-S-46)