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October 1, 2015

Improper Payments for Hospital Outpatient Dental Services

Background

The Office of Inspector General (OIG) identified that Medicare contractors (National Government Services (NGS) and CGS Administrators, LLC (CGS)) paid providers in Jurisdiction 15 (Kentucky and Ohio) the second highest reimbursement amount of all jurisdictions for hospital outpatient dental services from January 11, 2011 through October 31, 2013.  Based on this finding, the OIG conducted an audit to determine if the services were eligible for Medicare payment.

OIG Review and Findings

  • The OIG review was performed during the period of February through December 2014.
  • The OIG reviewed a stratified random sample of 100 outpatient hospital dental services with a diagnosis not related to cancer or physical trauma that were paid during the period of January 1, 2011 through December 31, 2013.
  • The OIG determined that 97 of the 100 claims reviewed were ineligible for Medicare payment.
  • The OIG identified that tooth extractions and tooth socket repairs, usually in preparation for dentures, accounted for 89% of the hospital outpatient dental services paid in error.

The complete report (A-06-14-00020) was published on July 28, 2015 and is available to the public on the OIG websiteExternal Website.

Review Results

Based on the recommendations of the OIG, CGS:

  • Recovered the unallowable payments
  • Implemented system edits to ensure payments for outpatient hospital dental services comply with Medicare requirements
  • Is providing the following reminders and resources related to Medicare coverage of outpatient hospital dental services

Hospital Outpatient Dental Services

Medicare generally does not cover hospital outpatient dental services.  Under the general exclusion provisions of the Act, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth (e.g., preparation of the mouth for dentures) are not covered (§ 1862(a)(12)).  Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.

For hospital outpatient dental services to be covered, they must be performed as incident to and as an integral part of a procedure or service covered by Medicare.  For example, Medicare covers extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw, but a tooth extraction performed because of tooth decay is not covered.

Resources

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