Oberheiden P.C.
Former Medicare Prosecutors & Defense Counsel
The attorneys of Oberheiden P.C. have been on the forefront of defending dentists and pediatric dentists against fraud allegations. The team of attorneys at Oberheiden P.C. that represents dentists and pediatric dentists from across the country include:
- Former Medicaid Investigators
- Former Assistant United States Attorneys in Charge of Civil Healthcare Investigations at the Department of Justice
- Former U.S. Prosecutors in Charge of Criminal Healthcare Investigations at the Department of Justice
- Experienced Defense Counsel
The government has expanded civil and criminal prosecutions of dentists and dental clinics with an overwhelmingly population of Medicaid patients. The core allegations are that dentists and pediatric dentists have provided unnecessary dental procedures, or those that failed to meet the normal standard of care, for Medicaid patients and for Medicaid pediatric patients.
Background
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) started to intensively investigate irregular billing activities of dental clinics across the United States. From the first wave of audits and investigations the government considers four states so-called outlier states, where alleged billing fraud in the context of Medicaid dental clinics is particularly present. The general criteria for the research study included general dentists, oral surgeons and orthodontists who provided services to 50 or more children in the year 2012. The OIG used the following billing measures to identify dental providers with questionable billing who were extreme outliers when compared to their peers.
- Average Medicaid payment per child served.
- Average number of services provided per child per visit.
- Average number of services provided per day.
- Proportion of Medicaid children who received fillings.
- Proportion of Medicaid children who received extractions.
- Proportion of Medicaid children who received stainless steel crowns.
- Proportion of Medicaid children who received pulpotomies.
- Proportion of Medicaid children who received advanced behavior management, e.g., restraints.
- Average Medicaid payment per child served.
- Average number of services provided per day.
- Average number of services provided per child per visit.
Valuable Medicaid Services
Medicaid is the main source of dental coverage for children in low-income families and provides access to dental care for at least 37 million children.
Dentists who participate in Medicaid provide much-needed access to dental services for children in this program. When children lack such access, untreated decay and infection in their mouths may result in more complicated and expensive dental and medical interventions later in life.
Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit requires States to cover all medically necessary dental services for children 18 years old and under. Medicaid dental services must include diagnostic and preventive services, as well as needed treatment and follow-up care. Diagnostic services may include x-rays of the mouth; preventive services may include cleanings, topical fluoride applications, and dental sealants. Dental treatment covers a wide range of services such as fillings; tooth extractions, crowns, oral surgery, and pulpotomies, which are called “baby root canals.”
Dr. Nick Oberheiden
Founder
Attorney-at-Law
Lynette S. Byrd
Former Assistant U.S. Attorney
Partner
Ellen Comley
Senior Counsel
Attorney-at-Law
Roger Bach
Former Special Agent (OIG)
Steven Taylor
Healthcare Compliance Consultant
Susan Sage
Healthcare Auditor
New York Dental Investigations
New York’s Medicaid policy allows for twice yearly diagnostic and preventive services for children covered by Medicaid, along with limited services for orthodontia. The orthodontia treatment cannot be for mere cosmetic purposes but must meet the Medicaid criteria of a “severe handicapping malocclusion.” This type of malocclusion occurs when a child’s teeth are so far out of position that he or she cannot engage in normal activities—such as eating and talking—without difficulty. It is commonly associated with other medical conditions such as Down syndrome, muscular dystrophy, or craniofacial anomalies such as a cleft lip or palate. A provider must receive prior approval from the State before providing orthodontic treatment to a child.
During the review period, New York’s Medicaid program made a transition from fee-for-service to managed care. January-July 2012 operated under fee-for service. After July 2012, most dental services were offered through managed care. Orthodontic services were offered through managed care after October 2012.
Questionable billing/outlier red flags:
- High payments per patient;
- Large quantity of services per patient;
- High percentage of patients receiving certain services; and
- Concentration of questionable practices narrowed to single dental chain with troubled past.
The findings raise suspicions that certain dental providers may be billing for services that are not medically necessary or were never provided. They also raise concerns about the quality of care provided to these children. Additionally, the concentration of questionable billing practices was narrowed to a single chain that had settled lawsuits in the past for billing unnecessary medical procedures and failing to meet the thresholds for standard of care.
In addition, a recent OIG audit found that providers inappropriately billed for orthodontic services provided to 43 of 100 sampled beneficiaries in New York City, totaling an estimated $7.8 million in inappropriate reimbursement. These services were provided without the required preapproval, or they were simply never provided. These inappropriate billings occurred due to lack of appropriate documentation or oversight.
Investigators from the Medicaid Fraud Control Unit, the Department of Health and Human Services, the Office of Inspector General and other law enforcement agencies are now investigating, auditing, and subpoenaing records to build their case against New York dental providers. Overpayment requests, intense auditing, or even a formal investigation with the involvement of the U.S. Attorney’s Office is possible. New York Medicaid dentists should discuss billing compliance with experienced attorneys to make sure that an audit does not turn into a license suspension or formal investigation.
Dental providers in New York may contact the former U.S. prosecutor and former Medicaid investigators of Oberheiden P.C. for a free and confidential consultation, including on weekends.
According to the American Academy of Pediatric Dentistry (AAPD), physical restraints should be used only when less restrictive methods are not effective and should not be used often because they could produce physical or psychological harm. These self-assessing checks include:
- Review for proper submission of claims;
- Confirmation that all Medicaid guidelines were met in terms of frequency and certain time intervals; and
- Use of algorithms to flag unusual billing patterns such as upcoding or overutilization.
Questionable billing/outlier red flags:
- High payments per patient;
- Large quantity of services per patient;
- High percentage of patients receiving certain services; and
- Concentration of questionable practices narrowed to single dental chain with troubled past.
The findings raise suspicions that certain dental providers may be billing for services that are not medically necessary or were never provided. They also raise concerns about the quality of care provided to these children. Additionally, the concentration of questionable billing practices was narrowed to four chains, three of which have been under investigation by State and Federal authorities.
State and Federal authorities have likely increased their investigatory efforts into Medicaid pediatric dental fraud. If you or your practice find yourself the subject of a similar investigation, please call our office today. We have experienced defense attorneys that know how to defend against these cases.
Call us today and speak to one of our experienced attorneys directly. We are available to discuss your situation in a free and confidential call, including on weekends.
