Pediatric Dental Medicaid Fraud

The False Claims Act incentivizes whistleblowers to report dental fraud and other types of health care fraud to the U.S. Government. The Justice Department rewards individuals who come forward through the FCA with a percentage of the government's recovery. If you have evidence of large-scale fraud by a dentist or orthodontist, please call 1-800-590-4116 to speak to one of our whistleblower lawyers about reporting the practice to the Justice Department.

Medicaid Fraud by Dentists

Medicaid typically pays for early detection and treatment of dental health problems for Medicaid beneficiaries through at least 18 years of age. Although each state differs, this dental care covers roughly 37 million children (primarily for kids of low-income families). Coverage for diagnostic services and preventative care typically includes x-rays, preventative cleanings, fluoride, and dental sealants. They also cover a number of treatment options including fillings, tooth extractions and pulpotomies (baby root canals). States may extend eligibility for the care through the age of 21.

Orthodontic services are generally covered where they are medically necessary and prior authorization has been received by the provider (where required by the state). To review medical necessity, the State reviews documentation such as an orthodontic treatment plan, x-rays, facial photographs, and a Handicapping Labio-lingual Deviation Index (HLD). The Medicaid Manual requires a total HLD score of at least 26 points or a valid exception. Among the conditions that may warrant orthodontics are a handicapping malocclusion, cleft palate and craniofacial anomalies.

Medicaid payments for pediatric dental care have unfortunately not escaped the overall problem of health care fraud.

– providing services that are not medically necessary
– failing to meet professionally recognized standards of care for children
– insufficient documentation for the services provided
– providing services without the families consent
– unnecessary tooth extractions
– failure to disclose prior criminal conviction on licensing application.
– use of unlicensed staff to perform dental procedures (such as taking dental x-rays)
– billing for services by a dental assistant when the dentist is not in the office
– upcoding of dental services – seeking payment for more expensive levels of services than were actually performed.
– unbundling services – billing Medicaid separately for additional treatments performed on patients that return on a separate day for it at the request of the dentist when those services are typically provided in one office visit

How Serious is the Problem?

After Texas saw a sharp increase in payments for orthodontic services by Medicaid, a 2015 study by the Office of Inspector General at the Department of Health and Human Services found nearly $200 million in funds wrongfully paid out to providers for these services in three years.

An OIG study of pediatric dental services among general dentists and orthodontists in California in 2012 found questionable billing by providers charging $117.5 million for services in 2012. The studies found that the dental professionals practices involved a large percentage of children compared to other practices and included a high number of certain procedures.

Given these studies, the amount of fraud in this area in probably in the hundreds of millions of dollars a year. Dentists aren't generally among the largest providers committing fraud because they have a limited number of patients that they can personally see in a day. There generally also aren't large chains of dental providers (such as in nursing homes or home health agencies) stealing hundreds of millions across their company. However, when they do bilk the government and taxpayers, they are also performing unnecessary dental services on poor children (the typical Medicaid dental patient) – which is pretty despicable.

Fraud Risk Factors

The U.S. Government looks at a number of factors in order to suspect dental fraud. These factors were published in an OIG report a few years back. They include:

– an extremely large number of services provided per day
– general dentistry with an extremely high proportion of children
– a high percentage of stainless steel crowns, pulpotomies and extractions.

If your dental practice has some or all of these risk factors, and you suspect fraud, please contact us.

How to Report Dental Fraud

The False Claims Act allows individuals with evidence of health care fraud by dentists, orthodontists and dental practices to report it to the Department of Justice. More than half of the states have a similar procedure to report Medicaid fraud for investigation by the state Attorney General.

To discuss reporting fraud by a dentist or orthodontist to the U.S. Government, please call our whistleblower attorneys at 1-800-590-4116 for a free, confidential consultation.

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