Dental Value-Added Services—Molina Healthcare
Learn how the AI-generated research projects were createdOverall Conclusion
Molina did not consistently submit dental value-added services encounters with the correct financial arrangement code, which may affect the accuracy of FSR data and the computation of capitation rates and potential experience rebates.
Source Document
Audit Scope
September 1, 2022 through August 31, 2023.
Key Findings Summary
Molina did not consistently submit dental value-added services encounters with the correct financial arrangement code. 13,654 of 23,303 encounters (59%) were coded as payable dental services (financial arrangement code 04) instead of value-added services (financial arrangement code 11), totaling $560,777.
AI-Assisted
AI Scope Summary
This audit assessed whether Molina Healthcare submitted dental value-added service encounters in accordance with requirements, covering September 1, 2022, through August 31, 2023, and found a significant noncompliance in coding that could impact FSRs and capitation; future audits should validate corrective actions, HCBS member identification practices, and cross-check retrospective adjustments to ensure continued compliance.
AI-Generated Insight
An inspection identified a systemic misinterpretation of the requirement to use FAC 11 for value-added dental encounters, with 59% miscodings totaling $560,777. The vendor DentaQuest and Molina plan corrective actions including retrospective adjustments, improved HCBS member identification, and ongoing monitoring, with target completion by April 30, 2026.
Audit Objectives
Determine whether Molina Healthcare submitted encounters for dental value-added services in accordance with applicable requirements.
Audit Findings (1)
Molina did not consistently submit dental value-added services encounters with the correct financial arrangement code. 13,654 of 23,303 encounters (59%) were coded as payable dental services (financial arrangement code 04) instead of value-added services (financial arrangement code 11), totaling $560,777.
Recommendations (5)
Implement controls to verify it reports STAR+PLUS dental value-added services encounters with the correct financial arrangement code.
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.