Purpose

To determine the extent of implementation of the three recommendations included in our initial report Group Health Incorporated: New York State Dental Program - Payments for Scaling and Root Planing Procedures (Report 2009-S-95).

Background

Our initial audit report, which was issued on July 28, 2010, examined whether Group Health Incorporated (GHI) established adequate controls over the payment of scaling and root planing procedures and whether GHI overpaid for scaling and root planing services. Our audit covered the period January 1, 2005 through December 31, 2008. New York State provides dental insurance benefits to certain State employees and their dependents. The New York State Department of Civil Service contracts with Group Health Incorporated (GHI) to process dental claims on behalf of the State. Emblem Health is the parent company of GHI and HIP Health Plan of New York, formed when the two companies affiliated in 2006. At that time, existing GHI contracts such as the New York State dental contract were continued under the same terms and conditions. GHI processes and pays approximately $57 million a year for dental services provided to eligible members. Services covered by GHI include periodontal scaling and root planing for the treatment of periodontal disease. Scaling involves the removal of tartar, plaque, and toxins from above and below the gum line. Root planing involves a smoothing of the rough spots on root surfaces. Scaling and root planing are covered by GHI for the treatment of periodontal disease, and according to GHI's policies, they are not intended to be prophylactic in nature. Instead, they are used when periodontal disease is indicated. The objective of the treatment is to help shrink periodontal pockets, heal gum tissue, and thereby prevent tooth loss.

Key Finding

GHI officials have made progress in correcting the problems we identified in the initial report. However, improvements are still needed. Of the three prior audit recommendations, two recommendations had been implemented and one recommendation was no longer applicable.

Key Recommendations

None

Other Related Audit/Report of Interest

Group Health Incorporated New York State Dental Program:  Payments for Scaling and Root Planing Procedures (2009-S-95)