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RAC audits focus on prophy codes

'Targeting $22 visit' in Nebraska

July 15, 2014

By Craig Palmer

image of Dr. Jessica Meeske
RAC audits: Dr. Jessica Meeske testifies at Capitol Hill hearing that Medicaid RAC audit process lacks transparency and opportunity for feedback, offers recommendations to improve audit process. Senate photo
Some 300 Nebraska dentists received letters this spring from the state Medicaid Recovery Audit Contractor, HMS, requesting charts containing adult and pediatric billing codes for prophylaxis, Dr. Jessica Meeske told a U.S. Senate-convened panel July 9.

"Three hundred dentists in my state were hit with their first Medicaid RAC audits," Dr. Meeske said in testimony presented for the Association and describing her experience with audits, including one RAC audit. Dr. Meeske, a pediatric dentist with Medicaid patients, chairs the Nebraska Dental Association's Medicaid Committee.

"That particular billing code that they were looking at was a $22 cleaning fee, and so you receive an audit on a patient chart if you bill the state for a dental cleaning that was conducted one day less than the patient's six-month visit." After hearing the testimony, the panel moderator said, "I was struck by your example of targeting the $22 visit and whether that fits with the highest need."

Convened by the Senate Special Committee on Aging, the roundtable focused on Medicare audits but acknowledged growing concerns about Medicaid RAC audits, which began in some states in 2012. The webcast is posted at Dr. Meeske's testimony begins at the 49:32 mark. A committee staff report, Improving Audits: How We Can Strengthen the Medicare Program for Future Generations, cited issues raised by the American Dental Association about dental Medicaid RAC audits. See related stories.

RACs were created to identify and recover overpayments and underpayments made on behalf of the Medicare program and expanded to Medicaid by the Affordable Care Act. "Recouping alleged overpayments appears to be the sole goal of RAC auditors," Dr. Meeske testified. "Neither I nor any dentists I know received compliance training, nor was there collaboration with the dental community on this audit process."   

"My experience thus far with the Medicaid RAC audit process has not been positive as the audits lack transparency and an opportunity for feedback due largely to a breakdown in communication. I fear that the impact may negatively affect dental services for this population."

In Nebraska, the state's provider manual language was revised a decade ago to offer flexibility for the treating dentist in the six-month prophylaxis frequency depending on the patient's risk for decay. Current language suggests a six-month frequency but also notes that the "frequency [will be] determined by the dentist," Dr. Meeske said. "This aligns with the American Academy of Pediatric Dentistry's dental periodicity schedule for children and allows these high-risk children more frequent visits, when deemed appropriate, to prevent more serious dental issues. Up until this year, it has been a win for children enrolled in Nebraska Medicaid.

"The RAC audit in Nebraska, which narrowly focused on prophy codes with frequency less than six months, essentially removed my ability to assess a patient's risk and determine medical necessity," Dr. Meeske testified.

"Many of my colleagues just paid the amount requested as part of the audit and have opted not to serve Medicaid patients any more or take on any new Medicaid patients," she said.