Seth Lookhart, DMD, a dentist in Anchorage, Alaska, drew a lot of negative attention in the commercial media for performing an extraction while riding a hoverboard. Now, he faces criminal felony convictions on 46 counts of Medicaid fraud and reckless patient endangerment in state court.
Lookhart initially faced multiple separate charges from the state government’s filing in April 2017. The bench ruling from Anchorage Superior Court Judge Michael Wolverton came after an extensive five-week trial. Sentencing is scheduled for April 30, 2020.
Shauna Cranford, Lookhart’s office manager, entered a guilty plea in October 2019 for pushing excessive and often needless intravenous sedation for Medicaid patients. Her sentencing is scheduled for February 3, 2020.
Costs for sedation services were not included in the $1,150 annual cap for adults in Alaska’s dental Medicaid coverage.
“If a patient was out of their Medicaid benefits, so they didn’t have anything available, we would waive that fee and they could do it with sedation, so there was still money coming in,” said former staff member Rachel Miner.
Thus, the billings generated from IV sedation services more than offset remuneration of other dental services, which were greatly reduced or eliminated. Another employee testified that a patient might be under IV sedation for up to three hours for a typical one-hour clinical procedure.
The government produced text messages between Cranford and Lookhart, with one stating, “So let’s build a practice around it, sedation, and let’s Medicaid it up.”
Lookhart’s practice alone was responsible for 31% of Alaska’s total dental Medicaid IV sedation billings in 2016.
Dental assistant Kallie Wagner testified that she was terrified being alone in the treatment operatories with patients because she lacked proper resuscitation training.
“Because that’s somebody’s life,” she said, adding that “there wasn’t anybody in the room properly trained enough or like a doctor in the room” and asking “what if something bad happened?”
Former patients testified against Lookhart. Most focused on alleged defective and improper dental care as well as on a lack of proper informed consent.
Lookhart had acquired ownership of his dental practice from two prior absentee owner/dentists, one of whom was Broc Brimhall, DMD. During that previous period, both Lookhart & Cranford were employed by Brimhall.
Cranford and Brimhall exchanged text messages indicating that state Medicaid was being charged more for IV sedation than standard insurance patients, which represented a violation to Medicaid rules. Thus, Brimhall was aware of this unlawful situation and theoretically stood to profit from it, as did Lookhart.
“To answer your question, very few insurances pay for sedation. So few that I make PPO patients pay for the sedation upfront,” Cranford texted on November 9, 2015.
“OK thanks for the clarification? Do you all charge ppo and fee for service pt’s a blanket sedation fee (ex: 600) or do you bill in the incremental times,” Brimhall responded on the same day.
“Flat rate,” Cranford replied.
“What is it,” Brimhall asked.
“$450,” Cranford said.
The state contended that the $450 flat rate for IV sedation services for non-Medicaid patients was far less than what was being billed and paid out under dental Medicaid to Lookhart. This was in direct conflict with Medicaid provider rules, which Lookhart contractually agreed to.
The Viral Video
The video of Lookhart extracting a tooth while riding a hoverboard went viral. One of Lookhart’s employees took the video without the patient’s knowledge or consent.
Lookhart rode into the treatment room on a hoverboard. He rapidly extracted the patient’s tooth with forceps while still riding his hoverboard. He then immediately exited the operatory on the hoverboard and raised his arms like a football referee signaling a touchdown.
Lookhart texted the video to friends and colleagues. In one text, he seemingly joked that providing oral surgery services while riding a hoverboard represented “a new standard of care.”
Lookhart’s defense attorney, Paul Stockler, raised several interesting issues at trial. He admittedly addressed his client’s hoverboard video activities as “stupid,” “arrogant,” and “ridiculous.” He declined to state that a crime committed.
“He came out on a hoverboard, did a simple extraction in less than five seconds, and went off. The patient wasn’t harmed, and they made a big deal about it,” Stockler said.
“It’s a complete disregard for a human being, turning her into a joke. Why? Why?” asked Alaska state attorney Joan Wilson. The concept of personal entertainment seemingly overruled patient confidentiality, patient safety, and respect for the doctor/patient relationship, Wilson contended.
Wilson then asked herself if she could deliver the state’s closing arguments while riding a hoverboard.
“I decided I couldn’t, under rules of professional conduct,” Wilson said, noting that giving arguments on a hoverboard would still be safer than performing dentistry on one.
“I don’t have a patient sitting under half my body, and I don’t have an instrument that can jab into their face if I fall,” Wilson said, comporting with the state’s contention that Lookhart had a pattern of recklessly endangering his patients.
The Defense and Prosecution
Stockler focused much of his client’s defense on attacking a flawed, defective, and confusing dental Medicaid program. He argued that a “loophole” permitted his client to bill Medicaid for patient comfort with IV sedation.
The prosecution produced state Medicaid numerical rules and codes and their definitions, which demonstrated limitations on conditions for IV sedation with dental care. The rules and appropriate applications were apparently clearly defined in the government’s initial filing.
Stockler also defended his client by pointing out Medicaid’s failed regulatory policy of “pay-and-chase.”
“I think the door was open and he kicked it in,” Stockler said. “But that should have put the state on notice to, hey, take a look at this guy and do an audit. Look at his bills. But they didn’t. They kept paying them.”
Stockler said that he was in communication with other Alaskan dental Medicaid providers who did many of the same billings as Lookhart.
The state of Alaska “selectively chose to go after Dr. Lookhart because a door was open, a door that was used by every dentist,” Stockler said. “Unfortunately, Dr. Lookhart did more than everybody else combined, and so he became a good target.”
Wilson and her co-prosecutor, Eric Senta, focused their case on Lookhart’s criminal fraud and embezzlement during trial.
“It’s not just a paper crime. It’s a property crime. It’s theft. It’s embezzlement. It’s a betrayal of a program whose sole purpose is to pay for the medical needs of children, the disabled, and the poor,” Wilson said in her closing.
“I want to talk to you about the patients. But who also gets hurt like this? People who work hard for a living. People who pay taxes. Real federal taxes. Our state whose general funds make up 50% of the matching funds for medical care for dental care,” she continued.
“These are the actions and words and deeds of a petulant man-child who never thought he was going to be caught,” Wilson concluded.
A number of issues were apparently raised in the text messages between Lookhart and Cranford, other doctor owners, and his colleagues.
When Alaska substantially reduced its price-fixed fees for dental Medicaid services, seemingly the only way some providers felt they could remain fiscally viable was to game the Medicaid program—or cheat it. One may reasonably ask if the government is complicit in the flawed dental Medicaid program. Stockler certainly raised that issue.
The former owners of Lookhart’s practice had an interest because they collected a percentage of his production, which was largely a Medicaid based practice. Yet they didn’t finance his advanced education in providing patients with IV sedation services, from which they potentially stood to profit.
IV sedation services were where most of the elevated revenues were generated, especially after the state reduced other fixed dental Medicaid fees. Lookhart and Cranford went to lengths to hide their revenue derived from dental Medicaid, especially from IV sedation, from these former practice owners.
Another fascinating aspect was Lookhart’s desire to enlist other junior colleagues into his Medicaid fraud scheme, as evidenced by text communications. If he could recruit additional dental Medicaid providers into his practice, he could expand his delivery of IV sedation treatment, whether fraudulent or not. Like a growing fungus, this had the potential to corrupt added members of the dental profession.
The Profession Speaks
“Any entry level evaluation before anesthesia and/or surgery includes a benefit/risk analysis with regards to the proposed treatment. At times, more risk is warranted because of the potential benefit and absence of safer options,” said Daniel L. Orr, PhD, JD, MD, MS, DDS, former director of oral and maxillofacial surgery at the University of Las Vegas Nevada School of Dental Medicine.
“I cannot think of an instance wherein an anesthesiologist or surgeon could ethically ignore informed consent and then unilaterally adopt a plan that would make a procedure more difficult or potentially dangerous to deliver without any patient benefit,” said Orr.
“No one in dental school pointed out that this is fraud and federal fraud. It may have been mentioned but not emphasized just what a bad idea that is unless you want to wear an orange jumpsuit,” said Fred C. Quarnstrom, DDS, diplomate of the American Board of Dental Anesthesiology.
“General anesthesia has risks. The longer a patient is under general anesthesia, the more dangerous it is. Patients do not tell us the truth about their medications or diseases,” said Quarnstrom.
“General anesthesia was once described as great amounts of boredom dispersed with moments of absolute terror. It takes lots of training,” he continued.
“Even with this training, some patients will not tell you the meds they are on and why they are on them. Some patients can be quite compromised and not realize they are at risk. The stress of anesthesia can lead to emergencies you do not want to face. People do die. Admittedly, the odds of death are small, but it is 100% if it is you,” Quarnstrom said.
“Someone did not get the message that the doctor/patient relationship is sacred. You do not make it a game. This dentist had no concept of ethical dentistry,” Quarnstrom concluded.
Lookhart is now a convicted felon. Prosecutors proved their case in criminal court beyond any reasonable doubt. The life of this very bright but highly misguided doctor will forever be altered. But Lookhart was not the only party on trial.
Lookhart’s legal counsel focused on a defense that placed the failed toxic dental Medicaid program on trial too. Stockler made credible arguments that his client was far from the only abuser in the dental Medicaid program. In fact, dental Medicaid fraud and abuses are rampantly the norm. His client simply pushed the envelope further than most.
Stockler took issue with dental Medicaid’s destructive enforcement policy of “pay-and-chase,” as opposed to regular and routine audits. Such reasonable oversight would address outlier billers very early in the process. He contended such logical regulation would not allow things to get out of control, as happened with Lookhart and Cranford.
Lookhart’s and Cranford’s scheme was born from government price-fixing of clinical fees, as evidenced from their text messages. The government’s fee reduction at artificially low figures for dental Medicaid apparently gave rise to Lookhart’s and Cranford’s swindles. Again, the defense counsel made solid points that his client wasn’t a rare example but was singled out for excessive overreach.
The dental profession should also take a long, hard look in the mirror. Why do we permit the dental education-industrial complex to continuously pump out doctor graduates into a highly limited employment marketplace? New dental schools are opening, as others expand their enrollment of new applicants. Most of the employment capacity is in the Medicaid sector, which we all know is highly problematic. All the while, the average dental student load debt for recent grads is approximately $300,000 and growing.
We have important lessons to learn from the example of convicted felon Lookhart. It’s far too simplistic to view him as a villain in an isolated bubble. A series of events created a monster, many of which could have and should have been avoided.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at email@example.com or smilesofsantafe.com.