May 2019 Volume LIV Number 3


AAPD Offers Symposium on Medicaid Compliance for the Pediatric Dental Professionals at Annual Session

July 2012 Volume XLVIII Number 4

Approximately 150 pediatric dentists and staff attended the symposium on Medicaid Compliance for the Pediatric Professional at Annual Session on May 25, 2012. Senior Fraud, Waste, and Abuse Subject Matter Expert David Himmelreich, J.D., presented the course on behalf of Strategic Health Solutions, the education Medicaid integrity contractor for the Centers for Medicare and Medicaid Services.
Himmelreich provided an overview of Medicaid program integrity, common compliance vulnerabilities, and benefits derived from developing or improving a compliance program. Specifically, the presentation clearly clarified what documentation of medical necessity means for dental service providers. In addition, the presentation suggested ways in which written policies, staff training, dental software, and self-audits should assist you in achieving compliance with the requirements of the Medicaid program, while meeting your own expectations for providing quality dental care.
The Code of Federal Regulations 42 C.F.R. § 455.230 states that medical necessity covers "dental care at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health". Adequate documentation of medical necessity is crucial to avoid doubts about multiple treatments on the same tooth or treatment that exceeded the original treatment plan.

The seven elements of a comprehensive compliance program should include:
  • Written policies
  • Designation of an in-house compliance officer (employee)
  • Training
  • Communication (open door, anonymous reporting)
  • Monitoring and screening for exclusions (unlicensed employees)
  • Enforcing disciplinary standards
  • Responding promptly when an error is discovered
Establishing a comprehensive compliance program will self audit your practice and prepare you for a clean and worry-free experience.