Dentists who treat low-income patients under the state’s MaineCare program say they are getting hit with major fines for minor clerical errors in their reimbursement claims under a new auditing system adopted by the state to comply with the federal Affordable Care Act.
The new system gives auditors, who work for a private contractor, financial incentives to find small errors by paying them more for each mistake they discover.
“It’s almost to the level of ‘You forgot a comma,’ ” said Michael Dowling, co-owner of Falmouth Pediatric Dentistry. He would not say Tuesday how much his practice has been fined, but described it as a “substantial” amount.
“This is not finding fraud and abuse,” he said. “This is a clawback. They (state officials) are trying to take back money that we billed them legitimately.”
Some dentists indicated that they will have to stop treating MaineCare patients, or sharply reduce their services, if the fines are upheld on appeal. Dentists met with state Department of Health and Human Services officials to contest the fines.
Officials in the DHHS, which administers MaineCare programs, did not respond to several requests for comment.
Rep. Richard Farnsworth, D-Portland, co-chairman of the Legislature’s Health and Human Services Committee, said fines totaling about $800,000 have been levied statewide, with some clinics fined more than $200,000.
“The more flyspecks (contractors) find, the more they get paid,” he said.
MaineCare is funded with a combination of federal and state money, so any fines collected, after the contractors are paid, end up back in government coffers.
The audits are intended to root out fraud and abuse, but dentists told the Portland Press Herald that auditors are finding typographical or clerical errors that do not compromise patients’ care or defraud the government.
MaineCare, the state’s Medicaid program, reimburses dentists for care they provide. Most of the people who qualify for the dental benefit are children, dentists said.
It’s unclear how many patients are treated under the program, but Dowling said about 10,000 MaineCare patients are treated at the clinic in Falmouth, which he owns with another dentist.
Dowling said the fines have the “potential to completely destroy that safety net” for low-income dental patients, who make up more than half of the patients at the clinic in Falmouth.
Dentists receive less than their regular fees for MaineCare patients, so they have a financial incentive to limit or refuse service to them. Concerns about an onerous auditing system will only further discourage dentists from serving a vulnerable population, Dowling said.
Kristina Lake Harriman, director of Community Dental in Waterville, said her small clinic may have to close if she has to pay a $58,000 fine that she is appealing.
“Our mission is to serve underprivileged children,” Harriman said. “I actually started crying when I got the audit. It doesn’t seem right.”
Rep. Farnsworth said the problem stems from the way the state is implementing new Medicaid rules. For example, he said, the DHHS permits the auditing contractor to examine 100 patient files, then extrapolate the volume of errors found in that sample to all of the patients at a clinic.
Farnsworth said the DHHS could direct the contractor to limit fines to the errors actually found, rather than assuming that the same errors would occur at the same rate throughout the patient population.
Dowling said he believes that the auditors, from New York-based HMS, did not pick a random sample but instead pulled records that were more likely to contain errors.
He said MaineCare patients’ records that are submitted to the state include procedural codes, and the auditors chose records with codes that were more likely to include errors. That makes it unfair and inaccurate to extrapolate the errors over the entire patient population, he said.
Dowling said DHHS officials made conflicting statements, at a legislative hearing and then in a private meeting with dentists, about whether the samples were random.
HMS did not respond to requests for comment Tuesday.
Even the problems that have been discovered are coding errors that have nothing to do with Medicaid abuse, said Dowling and Harriman.
For example, if a patient sees one dentist but the bill goes out under the name of another dentist in the same practice, that is considered an error and the dentists are fined 20 percent of the cost of service, Dowling and Harriman said.
Harriman said most of her errors fell into that category, which is not fraud or overbilling but a computer glitch.
“Nobody got hurt by these errors,” said John Bastey, director of government affairs for the Maine Dental Association.
Bastey and a group of dentists, including Harriman and Dowling, met with state officials Tuesday. The dentists said they did not come away confident that the fines will be reduced.
The Legislature could pass laws outlawing contracts that give auditors financial incentives to find errors or forbidding the kind of extrapolation that leads to the giant fines, Farnsworth said, but that won’t help dentists who have already been fined and are in danger of losing their practices.
Dowling said the system is unfair to dentists who are forgoing higher pay to serve underprivileged children.
“Those who help the most are getting hurt the most,” he said.
Joe Lawlor can be contacted at 791-6376 or at: