November 6, 2013

MaineCare dentists say minor clerical errors draw massive fines

Some clinics face more than $200,000 in penalties under a new audit system that threatens to wipe out services for kids.

By Joe Lawlor
Staff Writer

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.

click image to enlarge

Kristina Lake Harriman poses for a portrait at her 93 Main St. dental office in Waterville on Tuesday. Dentists are being fined exorbitant amounts by the state DHHS over computer glitches in MaineCare system. Some dentists say it's going to put them out of business. It has to do with a new contractor fining the dentists over billing problems.

Michael G. Seamans/Staff Photographer

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.

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