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.

The False Claims Act

The False Claims Act imposes substantial penalties on doctors, hospitals and other health care companies engaged in fraud while rewarding whistleblowers for providing evidence of the misconduct to the Justice Department through a qui tam lawsuit.

Our Federal False Claims Act lawyers have guided whistleblower cases to several significant settlements on behalf of relators. Our largest unsealed cases are currently focused on kickbacks in violation of the Anti-Kickback Statute, but we have a broad base of experience across other types of Medicaid and Medicare fraud. In the pursuit of suspected frauds, we have brought cases to the attention of the government in many states, including New York, Florida, California and here in Philadelphia. In 2016, for example, we helped the federal and state governments recover $54 million from a Valeant subsidiary for kickbacks paid through speaker programs.

The law rewards whistleblowers for information with between 15 and 30 percent of the proceeds from the litigation, subject to numerous terms and conditions specified in the law. During President Obama's Administration, the U.S. paid out more than $4 billion to whistleblowers. For those not familiar with whistleblower cases, we have written a quick guide to the process.

Our False Claims Act attorneys undertake a thorough review of whistleblower evidence up front during the case evaluation process. We confirm that there is sufficient evidence of both inappropriate government billings as well as evidence of intentional or reckless conduct by the individuals in charge. We understand that no one person needs to have every piece of the puzzle and we have evaluated thousands of potential cases while honing our judgment. We also answer any questions that a whistleblower has in order to ensure that you can make an informed judgment about whether to proceed with a qui tam lawsuit.

To begin the process and get your questions answered, use our contact form or call 1-800-590-4116 for a free, confidential and no-obligation initial legal consultation from our whistleblower attorneys.

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