What Dentists Need to Know About Medicaid Fraud & DentQuest Audits

Oberheiden P.C. Represents Dentists and Oral Surgeons in DentaQuest Audits and Investigations

Is DentaQuest auditing you? Did you get a letter from CMS requesting patient files? Are you a defendant in a whistleblower lawsuit or criminal case? Did fraud investigators stop by at your practice? Are you worried that the Medicaid Fraud Control Unit might be scrutinizing your practice? Are you concerned that you might lose your dentist license or even go to jail because some services were billed but not performed or (arguably) not medically necessary? Is your documentation “thin” and missing X-ray images?

You Found the Right Law Firm! Dentists have become prime targets of overzealous auditors and law enforcement. Unfortunately, too many doctors still underestimate the potential exposure healthcare audits, patient board complaints, and fraud investigations carry. This article will present a few examples of recent dental Medicaid fraud investigations to illustrate the scope and forcefulness of investigations into dentists by the Attorney General’s Office, the U.S. Attorney’s Office, the Office of Inspector General, and the FBI.

• Nick Oberheiden, Founder
• Joe Brown, Former U.S. Attorney & Former District Attorney
• Aaron Wiley, Former Assistant United States Attorney (DOJ Healthcare)
• Amanda Marshall, Former U.S. Attorney (DOJ)

We Don’t Let Bad Things Happen to You. In cases across the country, the Oberheiden P.C. attorneys have realized that many escalations are entirely avoidable—as long as you, the targeted dentist, pediatric dentist, or oral surgeon seek effective and proven help the moment you become aware of a potential case. It is at this early stage, when you receive a letter, or a patient threatens to turn you in, when you can best control a smooth outcome of the case.

Oberheiden P.C. Has Helped Dentists from Across the United States

Oberheiden P.C. attorneys have resolved a substantial number of cases in which dentists were accused of fraud. Dentists from across the United States have sought the help of our attorneys to navigate through a challenging audit, to avoid referrals to law enforcement, or to handle an already advanced matter. If you are in a situation where you are concerned about your license, your reputation, or your career, give us a call. We will not waste your time and senior attorneys, many who joined us straight from the U.S. Justice Department, will answer your questions—free of charge and absolutely confidential.

• Medicaid Investigation v Dentist. Oberheiden PC represented a dentist under a rigid Medicaid audit. Our defense approach resulted in no criminal charges filed against our client. The dentist kept his license.
• Medicaid Investigation v Dentist. Oberheiden PC lawyers successfully defended a dentist accused of Medicaid fraud and healthcare fraud and abuse. Our representation resulted in no indictment being filed against our client. The dentist kept his license.
• Medicaid Investigation v Dentist. Oberheiden PC attorneys successfully represented a dentist against allegations of Medicaid Fraud due to the dentist office’s billing practices. Our defense efforts resulted in no client liability. The dentist kept her license.
• Medicaid Investigation v Dentist. Oberheiden PC attorneys defended a dentist under a criminal Medicaid audit. Our attorneys avoided any civil or criminal charges. The dentist kept her license.

Oberheiden P.C. will not let you down. Call us today to discuss your audit or your situation with experienced attorneys and a network of dental law defense lawyers.

What Is Dental Medicaid Fraud?

Medicaid Fraud involving dentists, in simple language, is a form of healthcare fraud that is typically investigated by the Medicaid Fraud Control Unit (MFCU), the FBI, and the Office of Inspector General in combination with other state and federal agencies. Medicaid Fraud can be a state law violation, or, more severe, a federal offense. The general is 18 U.S.C. 1347. Pursuant to this statute, a person is guilty of healthcare fraud if the following conditions are met:

1. The defendant knowingly and willfully executed or attempted to execute a scheme to defraud a healthcare benefit program or obtain money or property from a healthcare benefit program by means of false or fraudulent pretenses, representations, or promises;
2. The defendant executed or attempted to execute the scheme or plan in connection with the delivery or payment of benefits, items or services under the healthcare benefit program; and
3. The defendant acted with the intent to defraud the healthcare benefit program.

Put our highly experienced team on your side

Dr. Nick Oberheiden

Founder

Attorney-at-Law

Lynette S. Byrd

Former Department of Justice

Brian J. Kuester

Former U.S. Attorney
Former DA

John W. Sellers

Former Senior Trial Attorney
U.S. Department of Justice

Local Counsel

Joanne Fine DeLena

Former Assistant U.S. Attorney

Local Counsel

Joe Brown

Former U.S. Attorney & Former District Attorney

Local Trial & Defense Counsel

Amanda Marshall

Former U.S. Attorney

Local Counsel

Aaron L. Wiley

Former Federal Prosecutor

Local Counsel

Roger Bach

Former Special Agent (OIG)

Michael Koslow

Former Supervisory Special Agent (FBI)

Chris Quick

Former Special Agent (FBI & IRS-CI)

Ray Yuen

Former Supervisory Special Agent (FBI)

Examples of Recent Dental Medicaid Fraud Cases

• A dentist from Missouri pleaded guilty to his role in a scheme to defraud Medicaid. According to the plea agreement, the dentist submitted claims to Medicaid for reimbursement for services that were never provided. The dentist used his Medicaid eligible patients’ personal information on the claims submissions to make the claims appear legitimate. As part of his guilty plea, the dentist is required to surrender his dental license and must pay $200,000 back to Medicaid.
• A Pennsylvania dentist was ordered to surrender his dental license after pleading guilty to defrauding Medicaid. According to the plea agreement, the dentist would bill Medicaid for duplicate procedures performed on patients. The dentist would perform a legitimate dental procedure on a patient, but then use the patient’s personal information to bill for the same procedure several months later. As a result of these duplicate billings, Pennsylvania Medicaid paid out more than $1.5 million. The dentist was ordered to pay the $1.5 million back to Medicaid as restitution.
• A man from New York pleaded guilty for his role in a scheme to defraud Medicaid. According to the plea agreement, the man worked at a dental office where he pretended to be a licensed dentist. The man would pay $25 to Medicaid eligible individuals to come into his office and give him their personal information. The man would then use that personal information to bill Medicaid for dental procedures that were never performed. As a result of the scheme, Medicaid paid over $2 million.
• A dentist from Missouri pleaded guilty for his involvement in a scheme that defrauded Medicaid. According to the plea agreement, the dentist would give patients plastic mouth-guards, similar to the ones worn by athletes. The dentist would buy the mouth-guards from local sporting goods stores. The dentist would then bill Medicaid for these mouth-guards as if they were a “speech aid prothesis.” The reimbursement the dentist would receive from Medicaid for these “speech aids” was $700. As a result of the scheme, Medicaid paid the dentist $165,000.
• A dentist from California was indicted for his alleged role in a scheme to defraud Medicaid. According to the indictment, the dentist would use his patients’ personal information and then submit bills to California’s Medicaid system for dental procedures that were never performed. The patients who had their information used were unaware of the dentist’s actions. Through the indictment, the dentist was charged with six counts of healthcare fraud and two counts of aggravated identity theft.
• A dentist from South Carolina pleaded guilty for his role in a scheme to defraud Medicaid. According to the plea agreement, the dentist engaged in up-coding almost all of the procedures he performed at his office. The use of up-coding allowed the dentist to receive much higher reimbursement rates from Medicare because it appeared he was performing much more complex procedures than he actually was. The dentist also admitted to prescribing opioids to patients he knew did not need such drugs. As a result of his scheme, the dentist was sentenced to five years in prison.
• A Michigan dentist pleaded guilty for his involvement in a scheme that defrauded Medicaid. According to the plea agreement, the dentist was excluded from billing Medicaid for services, so he used the identifying information of another dentist to submit bills to Medicaid. The scheme was ultimately uncovered when the dentist’s billing specialist noticed the discrepancies in the office billing. As a result of impersonating another dental professional, the dentist caused over $1.7 million in fraudulent claims to be paid by Medicaid.
• A dentist from Oklahoma pleaded guilty for her role in a scheme that defrauded Medicaid. According to the plea agreement, the dentist billed Medicaid for services she did not perform. To try and conceal the fraud, the dentist falsified patient records to make it seem the un-performed services actually had been rendered. As a result of her involvement in the scheme, the dentist was sentenced to 18 months in prison and must pay over $375, 000 back to Medicaid as restitution.
• A Hawaii dentist pleaded guilty for his role in a scheme that defrauded Medicaid. According to the plea agreement, the dentist was billing Medicaid for procedures that were more expensive than he actually performed. In some instances, the dentist billed Medicaid for procedures that were not performed at all. As a result of his plea, the dentist will no longer be allowed to participate in Medicaid and must pay Medicaid $35,000 in restitution for the fraudulent services he claimed he performed.
• A dentist from Idaho pleaded guilty for his involvement in submitting fraudulent bills to Medicaid. According to the plea agreement, the dentist submitted bills to Medicaid for the surgical removal of teeth, when in fact the teeth had been removed non-surgically. Surgical removal of a tooth has a much higher reimbursement rate from Medicaid than a non-surgical removal. As part of his plea agreement, the dentist will pay over $7,000 in restitution to Medicaid as a result of the false billings.

Pediatric Dentist Medicaid Fraud

• A Texas pediatric dentist pleaded guilty for his role in a scheme that defrauded Medicaid. According to the plea agreement, the pediatric dentist was given a bonus from his office every time he performed certain dental procedures on children. The bonus structure was deemed to have affected the pediatric dentist’s medical decision making. The pediatric dentist also admitted via his plea agreement that he also submitted claims to Medicaid for services that he never performed. As a result of this scheme, Medicaid paid out more than $120,000 for the fraudulent claims.
• A pediatric dentist from Oklahoma pleaded guilty for her involvement in a scheme to defraud Medicaid. According to the plea agreement, the pediatric dentist admitted to up-coding dental procedures she performed on children in order to receive a higher reimbursement rate from Medicaid. The pediatric dentist also admitted to submitting claims to Medicaid for reimbursement for dental procedures she never actually performed. As part of her plea agreement, the pediatric dentist will reimburse Medicaid for the amount the program paid for the false and fraudulent claims.
• A dentist from Missouri who provided pediatric services to children has pleaded guilty to his role in a scheme that defrauded Medicaid. According to the plea agreement, the dentist admitted to performing orthotic procedures on children that were not needed. The dentist would falsify patient records to make it appear the orthotic procedures were necessary and subsequently billed Medicaid for the fraudulent claims. As part of the plea agreement, the dentist will have to pay $200,000 in restitution to Medicaid.
• A pediatric dentist in Florida pleaded guilty to charges stemming from Medicaid fraud and child abuse. According to the plea agreement, the pediatric dentist routinely billed Medicaid for services more complex than the ones he actually performed. The pediatric dentist billed for more complex procedures in order to get a higher reimbursement from Medicaid. The plea agreement also outlined how the pediatric dentist would physically abuse his child patients when he was performing services on them. As part of his plea deal, the pediatric dentist will pay over $10,000 back to Medicaid as restitution.
• A dentist from Pennsylvania who performed dental work on Medicaid eligible children pleaded guilty for her role in a fraud scheme. According to the plea agreement, the dentist submitted claims to Medicaid for numerous pulpotomies (root canals for children) that she never performed. The dentist falsified patient records to make it appear the children needed the root canals. As part of her plea deal, the dentist will have to pay $289,000 to Medicaid as restitution.
• A husband and wife from Missouri, who were both pediatric dentists were convicted by a jury of Medicaid fraud. According to evidence presented at trial, the couple would fit children with orthotain devices (which are designed to straighten teeth without braces) without getting the necessary pre-certification from an orthodontist that Medicaid requires for reimbursement for such devices. To bypass the pre-certification requirement, the dentists would bill the devices to Medicaid as speech orthosis. Speech orthosis do not require pre-certification. During the duration of the scheme, Medicaid paid out $165,000 as a result of the fraudulent speech orthosis claims.
• A pediatric dentist from Connecticut has pleaded guilty to his role in a scheme that defrauded Medicaid. According to the plea agreement, the pediatric dentist admitted to allowing un-certified dental assistants to perform procedures on children in his practice. Dental assistants are required to be certified by the Dental Assisting National Board before they are allowed to perform dental procedures. As part of his plea deal, the pediatric dentist will have to pay back to Medicaid a sum of $1.4 million.
• A pediatric dentist from South Carolina pleaded guilty for his role in a scheme that defrauded Medicaid. According to the plea agreement, the pediatric dentist billed Medicaid for the administration of nitrous oxide when in fact he never administered the gas. The scheme was uncovered when investigators realized the dentist’s office was not equipped with any nitrous oxide machines. As part of his plea agreement, the dentist will have to pay over $10,000 in restitution to Medicaid.
• A Texas based pediatric dental office has agreed to a settlement with the government to settle allegations that it engaged in Medicaid fraud. According to the settlement agreement, the Texas dental office billed Medicaid for pediatric dental services that were never provided. The dental office also is alleged to have paid low income families a nominal amount if the families would bring their children into the office to have dental work. To settle these allegations of fraud, the pediatric dental office will reimburse Medicaid $4.2 million.
• A New Jersey pediatric dentist has agreed to a settlement with the government to resolve allegations he engaged in Medicaid fraud. According to the settlement agreement, the pediatric dentist is alleged to have submitted to Medicaid for reimbursement, numerous claims for services that were not actually performed. The settlement agreement also alleges that the pediatric dentist allowed an uncertified dental assistant to perform x-rays on the child patients. To resolve these allegations, the pediatric dentist will be excluded from participation in Medicaid and will pay $90,000 in restitution.

How Can Dentists Protect Themselves Against Fraud Allegations?

By far the best way to avoid these consequences is to contact an experienced attorney early. Lawyers who have the experience you expect and deserve know how to read signs of an investigation, how to respond to an audit, and how to settle more complicated matters without you risking your license or your career. Find out how this can be achieved by calling the trusted dentist defense lawyers at Oberheiden P.C. Learn how you can protect your practice, secure your license, and move on with your life. Our proven tools have settled audits, avoided referrals to the U.S. Attorney’s Office, and saved entire careers. We are happy to do the same for you! Call Oberheiden, P.C. today at 888-680-1745, including on weekends, or inquire online. Consultations are free and confidential.