The Whole Tooth: Dental Fraud and Whistleblowers

No area of health care seems to be free from fraud these days, and that includes dental care. Like doctors, most dentists are upstanding professionals, caring for their patients’ comfort and doing their best to restore health. But, also like a few doctors, sometimes dentists manipulate the system for their own financial benefit. These False Claims Act (FCA) fraud cases involve children, as Medicaid generally pays only for dental care supplied to those under 18 (dental care for adults on Medicaid is on a state-by-state basis and is limited in scope). Around 37 million children obtain dental care through Medicaid, and the fraud is undoubtedly in the hundreds of millions annually. A study by the federal Office of Inspector General (OIG) concerning California pediatric dental services discovered that, in 2012 alone, questionable billing by dental providers amounted to roughly $117.5 million.

How is Dental Fraud Committed?

Unscrupulous dental care providers have a multitude of ways in which they can line their own pockets unlawfully. Commonplace types of dental fraud are:

• Performing and billing for procedures that are not necessary, including tooth extraction
• Billing for services not performed
• Paying kickbacks for patient referrals
• Submitting claims using the Medicaid number of another dental provider
• Performing services without a family’s consent
• Using unlicensed staff to assist, such as an X-ray technician who isn’t certified
• Billing for the dentist’s services when the procedure was done by a hygienist or dental assistant
• Procedures done by a dental assistant when the dentist was out of the office
• Insufficient or fraudulent information on charts and other documentation, such as altering dates of service
• Performing substandard work and billing for it
• Billing for a higher standard of procedure than was performed (“upcoding”)
• Billing separately for procedures that are generally performed in one office visit (“unbundling”).

Dental fraud is often suspected by the government when:

• Each day the dental professional provides an exceptionally large number of services
• A high percentage of procedures involve extractions, pulpotomies, and stainless steel crowns
• A general dentistry practice serves an exceedingly high proportion of children.

Orthodontics care, which is restricted in various ways and can be more complex, are one additional area that receives scrutiny for possible fraudulent activity.

Whistleblower Cases

Recent Medicaid history includes a number of False Claims Act qui tam (whistleblower) cases that were successfully settled because someone blew the whistle:

• January, 2010: FORBA Holdings LLC, a dental management company, settled for $24 million, plus interest, resolving allegations that it billed state Medicaid programs for unnecessary procedures done on children insured by Medicaid. Procedures included “baby root canals” (pulpotomies), crowns, extractions, administering anesthesia that included the use of nitrous oxide, and unnecessary fillings and sealants. The federal share of the settlement was $14.3 million. Three qui tam suits initiated the cases, and the whistleblowers will jointly receive more than $2.4 million, based on the federal settlement. This case was especially disturbing because of treatment considered by professionals to be cruel and unethical.
• June, 2015: An Atlanta dentist settled a false claims case for almost $325,000 in which it was alleged he fraudulently billed Medicaid for tooth extractions and for procedures done by a dental assistant when he was not in the office. In this qui tam case, the whistleblower received an appropriate share of the settlement.
• April, 2008: Heartland Dental, Inc., agreed to settle with the U.S. government for $1.35 million because of allegations that dentists new to the practice issued prescriptions before they were registered with the DEA, which generated more income for Heartland. Heartland also settled for $1.65 million over allegations of improper billing to Illinois Medicaid. The whistleblower received $412,000 as her share of the federal settlement.

Blowing the Whistle? We Can Help You with Your Next Step.

If you think you have the facts needed to bring a whistleblower case, the experienced whistleblower attorneys at the Louthian Law Firm can review your case and help you file the appropriate disclosure statement. Under some circumstances, the government will intervene, or join in your lawsuit.

Your chances of succeeding are greater if your whistleblower claim is substantive, clear, and to the point. Because of this, meeting with a qualified whistleblower attorney can increase your chances of winning.

The Louthian Law Firm can help you form your claim so that the government will be more inclined to intervene in your case; government intervention can sometimes increase the chances of recovering reward money. Even if the government decides not to intervene, it could still be a good idea to pursue your case without government involvement. Our strong support system can assist you through every step of the process.

For a free, confidential evaluation of your case, call the Louthian Law Firm today at 1-803-454-1200 or, if you prefer, you can fill out our online contact form.