Dental Value-Added Services—Wellpoint
Learn how the AI-generated research projects were createdOverall Conclusion
Wellpoint did not consistently submit dental value-added services encounters with the correct financial arrangement code.
Source Document
Audit Scope
Scope covered September 1, 2022 through August 31, 2023, focusing on dental value-added services encounters within the STAR+PLUS program.
Key Findings Summary
Wellpoint did not consistently submit dental value-added services encounters with the correct financial arrangement code; 2,529 of 8,427 encounters (30%) were coded as payable dental services (financial arrangement code 04) instead of value-added services (financial arrangement code 11), totaling $105,942.
AI-Assisted
AI Scope Summary
This inspection evaluated whether Wellpoint properly reported dental value-added services encounters with the correct financial arrangement code (11) under the STAR+PLUS program during September 1, 2022, to August 31, 2023, and concluded that a significant portion of encounters were misclassified; future audits should assess corrective actions, ongoing code usage, and impact on risk-adjusted financial metrics and program rebates.
AI-Generated Insight
The inspection identified a systemic misclassification of dental value-added service encounters by Wellpoint, with 30% of sampled encounters coded as payable (04) rather than value-added (11), potentially affecting HHSC's financial statistics, capitation rates, and rebates.
Audit Objectives
Determine whether Wellpoint submitted encounters for dental value-added services in accordance with applicable requirements.
Audit Findings (1)
Wellpoint did not consistently submit dental value-added services encounters with the correct financial arrangement code; 2,529 of 8,427 encounters (30%) were coded as payable dental services (financial arrangement code 04) instead of value-added services (financial arrangement code 11), totaling $105,942.
Recommendations (6)
Implement controls to verify it reports STAR+PLUS dental value-added services encounters with the correct financial arrangement code.
Ensure its encounter system accurately identifies members enrolled in a STAR+PLUS HCBS waiver.
Correct the encounters and paid claims submitted with the incorrect financial arrangement code as applicable.
Review its state fiscal year 2023, 2024, and 2025 FSRs to determine whether any reported dental value-added services expenses were included in the medical expenses.
Contact HHSC Financial Reporting and Audit Coordination to receive guidance on the correction of any misreported medical expenses.
Review its state fiscal year 2026 encounters to verify financial arrangement code 11 was used as applicable until a control is implemented.