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Medicaid Pediatric Dental Fraud Investigations Targeting Dentists In California, New York, Indiana & Louisiana

Categories: Health Care Fraud

pediatric dental fraud
Oberheiden & McMurrey, LLP
Former U.S. Prosecutors & Experienced Counsel

The attorneys of Oberheiden & McMurrey, LLP have been on the forefront of defending dentists and pediatric dentists against fraud allegations. The team of attorneys at Oberheiden & McMurrey, LLP that represents dentists and pediatric dentists from across the country include:

  • Former Medicaid Investigators
  • Former Assistant United States Attorneys in Charge of Civil Healthcare Investigations at the Department of Justice
  • Former U.S. Prosecutors in Charge of Criminal Healthcare Investigations at the Department of Justice
  • Experienced Defense Counsel

The government has drastically increased civil and criminal prosecutions of dentists and dental clinics with an overwhelmingly population of Medicaid patients. The core allegations are that dentists and pediatric dentists have provided unnecessary dental procedures, or those that failed to meet the normal standard of care, for Medicaid patients and in particular for Medicaid pediatric patients.

Background

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) started to intensively investigate irregular billing activities of dental clinics across the United States. From the first wave of audits and investigations it appears that the government considers four states so-called outlier states, where alleged billing fraud in the context of Medicaid dental clinics is particularly present. These states are California, New York, Louisiana, and Indiana. The general criteria for the research study included general dentists, oral surgeons and orthodontists who provided services to 50 or more children in the year 2012. The OIG used the following billing measures to identify dental providers with questionable billing who were extreme outliers when compared to their peers.

  • Average Medicaid payment per child served.
  • Average number of services provided per child per visit.
  • Average number of services provided per day.
  • Proportion of Medicaid children who received fillings.
  • Proportion of Medicaid children who received extractions.
  • Proportion of Medicaid children who received stainless steel crowns.
  • Proportion of Medicaid children who received pulpotomies.
  • Proportion of Medicaid children who received advanced behavior management, e.g. restraints.
  • Average Medicaid payment per child served.
  • Average number of services provided per day.
  • Average number of services provided per child per visit.

Valuable Medicaid Services

Medicaid is the primary source of dental coverage for children in low-income families and provides access to dental care for at least 37 million children.

Dentists who participate in Medicaid provide much-needed access to dental services for children in this program.  When children lack such access, untreated decay and infection in their mouths may result in more complicated and expensive dental and medical interventions later in life.

Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit requires States to cover all medically necessary dental services for children 18 years of age and under.  Medicaid dental services must include diagnostic and preventive services, as well as needed treatment and follow-up care.  Diagnostic services may include x-rays of the mouth; preventive services may include cleanings, topical fluoride applications, and dental sealants.  Dental treatment covers a wide range of services such as fillings; tooth extractions, crowns, oral surgery, and pulpotomies, which are often referred to as “baby root canals.”

California Dental Investigations

California’s Medicaid policy allows for twice yearly diagnostic and preventive services for children covered by Medicaid, along with limited services for orthodontia.  The State allows these orthodontic services only for assessing and treating children with handicapping malocclusion, cleft palate, and craniofacial anomalies. A provider must receive prior approval from the State before providing orthodontic treatment to a child. California has several systems in place to oversee Medicaid pediatric dental claims.  These self-assessing checks include:

  • Review for frequency of services allowed;
  • Use of an automated system for periodic utilization reviews; and
  • Random test sampling to include patient file review.

Questionable billing/outlier red flags (total of 329 dentists, 6 orthodontists):

  • High payments per patient;
  • Large quantity of services per patient;
  • High percentage of patients receiving certain services; and
  • Concentration of questionable practices narrowed to five dental chains with troubled pasts, including State and Federal investigations.

The government takes the position that several hundred dental providers in California have engaged in abnormal billing patterns. Investigators from the Medicaid Fraud Control Unit, the Department of Health and Human Services, the Office of Inspector General and other law enforcement agencies are currently investigating, auditing, and subpoenaing records to build their case against California dental providers. Overpayment requests, intense auditing, or even a formal investigation from the U.S. Attorney’s Office are likely increasing. Dental providers in California have to be on alert. In light of this climate of investigation, we recommend to discuss billing compliance with experienced attorneys to make sure that an audit does not turn into a formal investigation.

Dental providers in California may contact the former U.S. prosecutor and former Medicaid investigators of Oberheiden & McMurrey, LLP for a free and confidential consultation, including on weekends.

Louisiana Dental Investigations

Louisiana’s Medicaid policy allows for twice yearly diagnostic and preventive services for children covered by Medicaid, as well as covering medically necessary treatment services.  Louisiana has specific criteria for types and frequency of covered services.  Additionally, the State requires dental providers to seek prior authorization before performing most dental treatments outside of routine diagnostic and preventive services.  During the review period, Louisiana covered dental services on a fee-for-service basis.  This program transitioned to a managed care format on July 1, 2014.  Louisiana has several systems in place to oversee Medicaid pediatric dental claims.  These self-assessing checks include:

  • Review for proper payment of claims;
  • Confirmation that services were provided by an enrolled Medicaid dentist;
  • Confirmation that all Medicaid guidelines were met in terms of frequency and prior authorization; and
  • Random test sampling to include patient file review.

Questionable billing/outlier red flags:

  • High payments per patient;
  • Large quantity of services per patient;
  • High percentage of patients receiving services;
  • Concentration of questionable practices narrowed to two dental chains; and
  • Prior disciplinary action by the State Board of Dentistry.

The findings raise suspicions that certain dental providers may be billing for services that are not medically necessary or were never provided.  They also raise concerns about the quality of care provided to these children.  Additionally, almost a third of the providers with questionable billing worked for two chains.

Investigators from the Medicaid Fraud Control Unit, the Department of Health and Human Services, the Office of Inspector General and other law enforcement agencies are currently investigating, auditing, and subpoenaing records to build their case against Louisiana dental providers. Overpayment requests, intense auditing, or even a formal investigation with the involvement of the U.S. Attorney’s Office are possible. Dental providers in Louisiana may want to discuss billing compliance with experienced attorneys to make sure that an audit does not turn into a license suspension or formal investigation.

Dental providers in Louisiana may contact the former U.S. prosecutor and former Medicaid investigators of Oberheiden & McMurrey, LLP for a free and confidential consultation, including on weekends.

New York Dental Investigations

New York’s Medicaid policy allows for twice yearly diagnostic and preventive services for children covered by Medicaid, along with limited services for orthodontia.  The orthodontia treatment cannot be for mere cosmetic purposes but must meet the Medicaid criteria of a “severe handicapping malocclusion.”  This type of malocclusion occurs when a child’s teeth are so far out of position that he or she cannot engage in normal activities—such as eating and talking—without difficulty.  It is commonly associated with other medical conditions such as Down syndrome, muscular dystrophy, or craniofacial anomalies such as a cleft lip or palate.  A provider must receive prior approval from the State before providing orthodontic treatment to a child.

During the review period, New York’s Medicaid program made a transition from fee-for-service to managed care.  January-July 2012 operated under fee-for service.  After July 2012, most dental services were offered through managed care. Orthodontic services were offered through managed care after October 2012.

Questionable billing/outlier red flags:

  • High payments per patient;
  • Large quantity of services per patient;
  • High percentage of patients receiving certain services; and
  • Concentration of questionable practices narrowed to single dental chain with troubled past.

The findings raise suspicions that certain dental providers may be billing for services that are not medically necessary or were never provided.  They also raise concerns about the quality of care provided to these children.  Additionally, the concentration of questionable billing practices was narrowed to a single chain that had settled lawsuits in the past for billing unnecessary medical procedures and failing to meet the thresholds for standard of care.

In addition, a recent OIG audit found that providers inappropriately billed for orthodontic services provided to 43 of 100 sampled beneficiaries in New York City, totaling an estimated $7.8 million in inappropriate reimbursement.  These services were provided without the required preapproval or they were simply never provided.  These inappropriate billings occurred due to lack of appropriate documentation or oversight.

Investigators from the Medicaid Fraud Control Unit, the Department of Health and Human Services, the Office of Inspector General and other law enforcement agencies are currently investigating, auditing, and subpoenaing records to build their case against New York dental providers. Overpayment requests, intense auditing, or even a formal investigation with the involvement of the U.S. Attorney’s Office are possible. New York Medicaid dentists should discuss billing compliance with experienced attorneys to make sure that an audit does not turn into a license suspension or formal investigation.

Dental providers in New York may contact the former U.S. prosecutor and former Medicaid investigators of Oberheiden & McMurrey, LLP for a free and confidential consultation, including on weekends.

Indiana Dental Investigations

Indiana’s Medicaid policy allows for twice yearly diagnostic and preventive services for children covered by Medicaid, as well as covering medically necessary treatment services.  Indiana has specific criteria for types and frequency of covered services.  Indiana also allows dental providers to use “behavior management” techniques when treating children.  Behavior management may range from soothing an uncooperative child to using physical restraints, such as a “papoose board,” to stabilize the child.  Dental providers must document the reason for the use of behavior management in the medical record and provide evidence that the child required more management than was reasonable and necessary compared to other children of the same age.  According to the American Academy of Pediatric Dentistry (AAPD), physical restraints should be used only when less restrictive methods are not effective and should not be used frequently because they have the potential to produce physical or psychological harm.  During the review period, Indiana covered dental services on a fee-for-service basis. Indiana has several systems in place to oversee Medicaid pediatric dental claims.  These self-assessing checks include:

  • Review for proper submission of claims;
  • Confirmation that all Medicaid guidelines were met in terms of frequency and certain time intervals; and
  • Use of algorithms to flag unusual billing patterns such as upcoding or overutilization.

Questionable billing/outlier red flags:

  • High payments per patient;
  • Large quantity of services per patient;
  • High percentage of patients receiving certain services; and
  • Concentration of questionable practices narrowed to four dental chains with troubled pasts, including State and Federal investigations.

The findings raise suspicions that certain dental providers may be billing for services that are not medically necessary or were never provided.  They also raise concerns about the quality of care provided to these children.  Additionally, the concentration of questionable billing practices was narrowed to four chains, three of which have been under investigation by State and Federal authorities.

State and Federal authorities have likely increased their investigatory efforts into Medicaid pediatric dental fraud in Indiana since this 2012 study.  If you or your practice find yourself the subject of a similar investigation, please call our office today.  We have experienced defense attorneys that know how to defend against these cases.

Schedule a Free Consultation with Experienced Defense Attorneys Today

If you are operating a dental clinic or pediatric dental clinic in California, New York, Louisiana, Indiana or elsewhere and want to discuss a voluntary compliance audit by former Medicaid investigators or have general questions about pediatric dental investigations, then please contact our team directly, including on weekends. All consultations are free and absolutely confidential.

  • Nick Oberheiden has successfully represented healthcare medical providers, business owners, public officials, physicians, and lawyers in healthcare prosecutions across the United States. Dr. Oberheiden is the managing principal of Oberheiden & McMurrey, LLP.

Call us today and speak to one of our experienced attorneys directly. We are available to discuss your situation in a free and confidential call, including on weekends.

Oberheiden & McMurrey, LLP
Compliance – Litigation – Defense
(800) 810-0259
(214) 469-9009
www.federal-lawyer.com
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