DENTAL MEDICAID SCAMS
A wide variety of different fraud and abuses are played out upon dental Medicaid recipients and taxpayers. These swindles only worsen as ethical providers are financially squeezed out of dental Medicaid and are replaced by scam artists.
This unfortunate circumstance was earlier demonstrated in Part 1 (click here to read), in the report by Maltsev on the failure of the former Soviet healthcare system, and on the current status of the dental program under the British NHS.
A litany of dental crooks have operated under Britain’s NHS. A single-payer system definitely does not eliminate healthcare fraud and may truly exacerbate problems.
As will be demonstrated with ensuing case examples; violators may include dishonest dentists, unlawful corporate policy and resulting actions, directives of dental service organizations (DSOs) and their private equity ownership, corrupt collusion by MCOs, and abrogation of oversight responsibility by government authorities.
Michael “Mick” Greenwald, DDS practices general dentistry in Wallingford, Connecticut.
Formerly, Greenwald was employed by a national DSO chain focused on treating the children’s Medicaid population. That entire operation was owned and controlled by private equity. Greenwald eventually served the US government in the capacity of a whistleblower, for alleged violations to state and federal false claims acts.
Greenwald has firsthand knowledge viewing the brutal experiences faced by children and parents victimized by dental Medicaid fraud. He has observed crooked dentists and dishonest DSOs, which enable and encourage violations to ethics and statutes, all to maximize dollar production. He graciously offered the following in an interview for Dentistry Today.
“One of my more recent encounters with Medicaid fraud involves a young child and a trusting mother. I should preface this with the fact that those that those on Medicaid often feel extremely limited as to their choices of providers.”
“In this particular instance, a young trusting mother went to a Medicaid provider for evaluation of her six-year old son. On the child’s initial visit, the mother was informed that her son had three small cavities and two deciduous teeth that needed to be extracted. On the initial attempt to treat the child, the child was very agitated, so it was recommended that they return for sedation.”
“The child returned several weeks later and was sedated. A full mouth series of radiographs and subsequent treatment based on the provider’s interpretation of the radiographic and oral evaluation was provided. The mother was never informed of any changes in the treatment plan. The eventual treatment consisted of 4 extractions and 8 stainless steel crowns.”
“I had the opportunity to review this case and had no concerns with the teeth that were deemed non-salvageable. Upon further evaluation of the radiographs, I was somewhat surprised that greater attention was not rendered to the radiographs. Approximately half of the radiographs were extremely blurry and not clinically acceptable.”
“The provider had many opportunities while the child was under sedation to retake the films in order to support their treatment plan. Rather than taking diagnostic films that were of reasonable quality, the provider proceeded to initiate treatment. Radiographically, each and every tooth that had received stainless steel crowns had incipient decay on one or two of the proximal surfaces.”
“In a situation like this where the patient is completely managed due to the fact that there under sedation, it would be more than reasonable and acceptable to just provide interproximal restorations, especially when in such a highly controlled situation of the patient being fully sedated.”
“The standard of care would dictate that a dentist would render care similar to those of their community, or rather, the standard of care would dictate that they would provide care to the same level similar as what another prudent dentist would provide.”
“I found the treatment to be aggressive, excessive, and quite simply a financially driven treatment plan. As you know, in most states a simple two-surface filling may provide a reimbursement rate of $40 to $60, whereas a stainless steel crown would provide reimbursement of between $300 and $500.”
“It was clear to me that not only were there multiple breaches of the standard of care, such as informed consent, adequate diagnostics, and reasonable options to the proposed treatment plan, but the treatment was excessive, unjustified, and clearly an example of an economically driven treatment plan not considering the concept of best practices,” concluded Greenwald.
Ashley Goodman, DDS is a retired general dentist and prominent dental expert legal witness, who formerly practiced in San Diego, California.
He relayed a disturbing yet fascinating story for Dentistry Today.
The patients he discusses were elderly adult Medicaid recipients. Goodman says they were upsold an “upgraded denture package” at a national DSO chain, which is owned and managed by private equity. Goodman described, “They were talked into upgrading their cases from what they were told was covered (by Medicaid) to ‘better teeth and materials,’ which weren’t covered. Sound familiar?”
“An elderly married couple went into a multi-location corporate dental office in El Centro, California attracted by an advertised “senior dental special.”
After the exam, they were led into a “consulting room” together to go over their exam findings and their case treatments with the “office manager.”
“Both patients were told that they needed new full dentures, etc., and then signed contracts for loans to pay for non-covered special better teeth and materials to be used on their upgraded treatment, for which they also signed contracts. They were then placed in separate treatment rooms where staff took impressions of their mouths.”
“Later, they related that their impressions of the case presentation experience by the dentists, and staff, especially the office manager, reminded them of a previous unpleasant experience they had had at a used car lot.”
“In the interval of less than one week, and after reviewing their previous experience together, they called to cancel their treatment and loans. The office responded that the loan had been processed and that their treatment had been initiated, with future treatments scheduled, and couldn’t be cancelled, but needed to proceed as contracted for.”
“At this point, they contacted their daughter, who happened to be a practicing attorney. After some presumed back and forth, the attorney served the office with a notice of intent to sue, along with allegations of elder abuse by the office, dentists, and staff.”
“I had been retained as a technical investigator and expert forensic witness and the attorney secured copies of the patient’s dental office records along with separate patient narratives, which were provided to me by their attorney, for my review.”
“There were several irregularities concerning the contracts, custom, and practice of the dental office business, and the professional’s prescribed dental treatment, etc., along with the allegations of elder abuse by the office and their employees toward the elderly couple.”
“Sometime after submitting the sworn declaration of my preliminary opinions on the case, but before I provided deposition testimony, I was contacted by the attorney and told that the case had been settled to her parent’s satisfaction, and then the settlement was sealed.”
Goodman presents a case of alleged elder abuse (a civil and/or criminal violation under California codes), possible bait-and-switch unfair trade practice violations, and alleged conspiracy to commit Medicaid fraud by charging patients for covered benefits by a Medicaid-contracted provider. Statute violations may go to the doctor-of-record, the office sales personnel, the DSO which trained staff and profited from rendered misrepresentations, and the ownership private equity company, which also profits from this business scheme.
Tragically, this dishonest business practice is not only common at this specific national DSO, but within numbers of others throughout the country. State and federal authorities do little in combating such abuses. Likewise, the managed care organization (MCO) which administers the senior couple’s plan under state contract was also apathetic.
David Snodgrass, DDS is a practicing pediatric specialist dentist in Hermitage, Tennessee. Snodgrass offered Dentistry Today an extensive overview of serious misconduct and abuses by a MCO operating in Tennessee. To follow is only a small segment of that interview.
Snodgrass demonstrated significant collusion, between this MCO and state officials, all designed to lower state costs at the expense of disadvantaged Medicaid-eligible children and drastically limit dentist providers’ participation. Snodgrass offered a detailed narrative which was supported by court case exhibits.
For purposes of this report, the identity of the MCO was withheld.
“The MCO established two entirely separate sets of recruited providers, (1) key providers and (2) risk-pool providers. Most dentists, especially the risk-pool providers, seeing TennCare patients in 1998, had no idea that this MCO had secretly negotiated contracts with individual dental providers and that these contracts reimbursed some providers more than others for their dental services.”
“They defined Key Providers as those providers (1) in high elected positions within the Tennessee Dental Association; (2) those providers with important political connections; (3) and/or those providers in high needs and underserved rural areas in which access to care was a must for the MCO in order for them to obtain the state’s contract.”
“Each key provider had his own personally negotiated, “special deal” (as was described by the CEO of the MCO in court documents) individual contract or payment schedule known only to the MCO and that key provider. Their reimbursement percentages were negotiated individually by contract and kept totally private between the provider and the MCO. Per the terms of their contracts, key providers were to be paid first before risk-pool providers.”
“All other providers were referred to as Risk-Pool providers. Risk-Pool providers were to be paid last. Risk-Pool providers were not politically connected and generally served the metropolitan populations, an area where there were many other dentists to serve as Medicaid providers.”
“The MCO also introduced and implemented a smoke-and-mirror fee schedule to confuse state legislators into thinking that the providers were being adequately compensated for their services. They presented to state legislators a so-called ‘allowed fee per procedure’.”
“The allowed fee made it appear as though dentists were being paid more for their services than what was actually occurring. Their published allowed fee represented 65% of a dentist’s usual, customary, and reasonable (UCR) fees. The true payment to the dentists represented only 70% of this allowed 65% fee.”
“The MCO referred to this as their “Global Budget” fee. This meant that unless you had one of these special, secret contracts (deals) with the MCO, which guaranteed you (x) percentage of your usual fee, your reimbursement rate was going to be about 35% (Global Budget fee) of your UCR.”
The situation described by Snodgrass served to disincentivize Tennessee dentists from Medicaid participation. The program was deceitful and duplicitous.
Factions of the Tennessee Dental Association and state government colluded with this MCO, in dirty dealing to a majority of Tennessee dentists.
None of these activities were in the best welfare of disadvantaged Medicaid children.
Fortunately, all was exposed in public record court documents.
Unfortunately, too little actually improved in a timely manner, if at all.
Steven G. Mautner, DDS used to practice general dentistry in New York City before relocating to practice in Margate, Florida.
Mautner relayed for Dentistry Today a few of the more “creative” Medicaid schemes he has witnessed.
Mautner stated, “I knew of one owner in New York who told his associates to bill out two gingivectomies a day regardless of whether they were needed or not.”
One can only imagine the pressure upon young dental graduates with a mountain of student loan debt, who are placed in such a negative ethical position.
Basically, associate dentists are told, “If you don’t cheat, you won’t eat.” Moreover, disadvantaged patients, many of whom lack much formal education or English as a first language, received unnecessary oral surgery of dubious clinical value at taxpayer expense.
Mautner continued, “Another Medicaid practice I know in Florida paid a guy, per patient recruited to the practice. This gentlemen would drive through communities with Medicaid patients and offer patients cash to go to that Medicaid dentist.”
This activity represents a clear violation to the federal Anti-Kickback Statute. It is unfortunately all too common, to payoff Medicaid patients with cash or retail gift-cards, to incentivize them to obtain dental treatment. This lawless behavior has been successfully prosecuted, but far more needs to be done.
CONCLUSION – PART 2
Our dental Medicaid program is rife with fraud and abuses. Moneys defrauded could reasonably go toward healthcare for the needy. Playing in this massive scheme are dishonest dentists, greedy MCOs, elements of the private equity industry, and corrupt and apathetic government officials.
Part 3, the conclusion, will examine a variety of solutions. Enacting answers to better assist our disadvantaged populations accessing quality dental care will not be easy. Too many of the Medicaid stakeholders are entrenched and fully committed to accessing easy money.
Disreputable stakeholders have often forced out caring, compassionate dentist providers.
Empathetic government and MCO personnel have been battle-hardened into a cold apathy, by the cynical self-serving attitudes of their superiors.
ABOUT THE AUTHOR
Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation. Davis also currently chairs the Santa Fe District Dental Society Peer Review Committee. He can be reached at MWDavisDDS@Comcast.net.