Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare outpatient dental services billed on dates of service from January 1, 2017 – December 31, 2017. Below are the review results:

Background

The Office of Inspector General (OIG), under report A-06-16-05003, dated March 2017, found that 542 out of 600 dental services in the six stratified random samples did not comply with Medicare requirements. Based on these results, the OIG estimated that the six Medicare contractors improperly paid providers an estimated $9.7 million for hospital outpatient dental services that did not comply with Medicare requirements.

Reason for Review

In response to the OIG report, the CMS tasked Noridian, as the SMRC, to conduct medical review. The SMRC will medically review claims to determine if the dental service was eligible to be paid by Medicare and meets all other applicable requirements, based upon submitted medical documentation. Medicare generally does not cover hospital outpatient dental services, but these services may be covered under rare circumstances.

Common Reasons for Denial

• Excluded Service
  • The Social Security Act (SSA), Title XVIII, Section 1862(a)(12) indicates that Medicare does not cover services, “where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services”. The documentation submitted did not support a covered service/condition.
• No Response to the Documentation Request
  • CMS Internet-Only Manual (IOM), Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Missing Documentation
  • CMS IOM, Publication Publication 100-08, Chapter 3, Section 3.2.3.8 (C) relays that “If the submitted documentation includes defective,… the reviewer shall deny the claim as not meeting the reasonable and necessary criteria.” The documentation submitted was not sufficient to support coverage criteria.
• Signature Requirements Not Met
  • CMS IOM, Publication 100-08, Chapter 3, Medicare Program Integrity Manual, Section 3.3.2.4 requires services be authenticated by the persons responsible for the care of the patient. The documentation submitted lacked required signatures.
• Rendering/Billing Error
  • CMS IOM, Publication Publication 100-08, Chapter 3, Section 3.6.2.5 requires review contractors to deny a claim if it was determined that the service “Was not delivered or provided to the beneficiary, or not provided as billed.” The documentation did not support the service billed as being rendered.

References/Resources

•  Social Security Act (SSA), Title XVIII, §1862(a)(1)(a), (a)(7) and (a)(12). Exclusion from Coverage and Medicare as a Secondary Payer
• SSA, Title XVIII, §1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• 42 Code of Federal Regulations (C.F.R), 411.15(i). Services Excluded from Coverage
• 42 C.F.R., 410.32(a). Ordering diagnostic tests
• 42 C.F.R, 410.32(a)(3). Ordering diagnostic tests-Application to non-physician practitioners
• 42 C.F.R, 440.100. Dental Services
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150. Covered Medical and Other Health Services
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 140. General Exclusions from Coverage
• CMS Product No. 10050. Medicare & You 2018. November 2017. Centers for Medicare & Medicaid Services

Last Updated Jan 28, 2022