Pediatric Dental Investigations in Detroit

Detroit is seeing an increase of government investigations into pediatric dental clinics. Like other parts of the country, federal law enforcement in Detroit has begun to approach dental clinics with allegations of overpayments, billing fraud, and violations of pertinent Medicare and Medicaid rules. Audits, subpoenas, and investigators trying to interview clinic personnel are the seen tools of investigations. If your clinic has a substantial Medicare or Medicaid component, you should read this article to see how former Medicare prosecutors and former Medicaid agents may be able to help you before the case goes to the U.S. Attorney’s Office or out of control.

OIG Investigations of Pediatric Dental Clinics in Detroit

The Medicare program is the federal healthcare program for the elderly and disabled, the Medicaid program is the federally funded, state proctored, healthcare program for low-income families and children. Since each program typically provides coverage to a different set of patients, the services covered by either program varies; for example, dental services are covered under the Medicaid Program. As a result of this difference, about 37 million children are provided access to dental care through the Medicaid Program.

Detroit is one of seven cities in the United States that is under considerably higher scrutiny for healthcare fraud. In fact, the U.S. government has established special task forces to investigate and prosecute Medicare and Medicaid fraud in Michigan and in Detroit. Recent prosecutions show that this effort to combat fraud continues to increase. One of the agencies driving pediatric dental investigations is the Department of Health and Human Services (HHS) and the Office of Inspector General (OIG). Together with the Federal Bureau of Investigations (FBI) and the Department of Justice (DOJ), these agencies use analysis techniques to identify aberrant billing levels in healthcare “hot spots” and targets these suspicious billing patterns, as well as emerging schemes and schemes that migrate from one community to another. Although Medicaid is a state program, the federal government still has oversight authority to monitor program violations.

Specifically in Detroit, OIG and HEAT have begun to focus attention on the Medicaid-centric pediatric dental services. In support of this increased scrutiny, OIG has conducted studies of these services in California, Indiana, Louisiana, and New York to compare services between general dentists and orthodontists. Under general dentists, OIG analyzed four specific services; filings, extractions, stainless steel crowns, and pulpotomies (also known as baby root canals). For orthodontic services, OIG looked at the number of children receiving orthodontic services from any one provider. With each provider type, the studies identified the national average then identified providers who were outliers (75^th percentile plus 3).

Excessive billings for the services raise concerns that dental providers may be billing for services that are not medically necessary or never provided. There is further concern that, if these services are being performed at the rate, they are billed that children may be harmed. OIG’s reasoning is completely rational. If one was to look at the results of the study through the prism of common sense, it does appear odd that so many children, presumably with baby teeth, would need extractions, crowns, root canals, or orthodontic devices.

The initial study performed for New York identified twenty-three general dentists and six orthodontists as aberrant. These providers were paid over $13 million in a single year. A third of these providers were linked to a dental chain that had settled lawsuits for providing medically unnecessary services to children. The second study in Louisiana identified twenty-six dentists who were paid over $12 million in a single year with a third of the providers relating to two different dental chains. The third study found 94 general dentists associated with four dental chains who were paid over $30 million in a single year. The final study in California identified 329 general dentists and six orthodontists who were paid over $117 million in a single year. Half of the dentists identified worked for dental chains, with most of those dentists working for five chains, two of which had been the subject of State and Federal investigations.

Detroit Dental Clinics on the OIG Radar

Based on their study, OIG issued several recommendations. First, OIG recommended that State’s increase the monitoring of Medicaid dental providers. Associated with this, OIG has also suggested that states focus on the same services they did in their studies. Providers should know that there are multiple state agencies that have authority to review their practice. Providers should expect to receive visits from the State Health and Human Services Commission, the state Dental Board, and MFCU. While the first two agencies look at the appropriateness of services and the safety of patients, MFCU units are criminal investigative units with the authority to use subpoenas, search warrants, surveillance, and other techniques that implicate a provider’s constitutional rights.

Because so many of the suspect providers identified in the OIG study relate to dental chains, they recommend a focus on dental services provided through these large chains. Several chains identified in the OIG study had been previously investigated for fraudulent activity. Providers should remember that dental chains can cross states and; as a result, multiple law enforcement jurisdictions. The HEAT concept was created to handle multi-jurisdictional healthcare fraud cases. It was also designed to address schemes that migrate from one location to another. OIG’s dental study involved three states (California, New York, and Louisiana) that are also existing HEAT target locations. OIG’s study identified dental chains in these states that were also operating in other HEAT locations; such as Detroit and Dallas. HEAT will likely begin to scrutinize the same dental services in other active HEAT cities. Providers in Detroit, Dallas, Chicago, and Tampa who bill many fillings, extractions, pulpotomies, or crowns should understand that law enforcement will increase the number of investigative resources expended in their cities to quash the rise of pediatric dental fraud.

Finally, OIG recommends States act against these aberrant dental providers. This action is separate from HEAT’s activities and includes more administrative actions. Administrative actions providers should be aware of are actions against their dental license, recoupment of monies for claims paid in error, and revocation of their Medicaid billing number. Even if a pediatric dentist is experiencing a criminal investigation or administrative action, they should consult a law firm that has experience with all levels of review.

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Dr. Nick Oberheiden

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U.S. Department of Justice

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Former Assistant U.S. Attorney

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Amanda Marshall

Former U.S. Attorney

Local Counsel

Aaron L. Wiley

Former Federal Prosecutor

Local Counsel

Roger Bach

Former Special Agent (OIG)

Gamal Abdel-Hafiz

Former Supervisory Special Agent (FBI)

Chris Quick

Former Special Agent (FBI & IRS-CI)

Kevin M. Sheridan

Former Special Agent (FBI)

Ray Yuen

Former Supervisory Special Agent (FBI)

Dennis A. Wichern

Former Special Agent-in-Charge (DEA)

A Team of Experienced Defense Attorneys

Oberheiden P.C. consists of former Medicare and Medicaid fraud prosecutors with significant experience in fraud prevention and healthcare fraud defense. Our attorneys not just offer the experience of hundreds, if not thousands, of healthcare investigations to our clients; because of the many years our attorneys have spent in leading positions with various U.S. Attorney’s Offices, we are also able to educate our clients about the exact process and government strategies in any type of healthcare investigation. Our combined experience of decades in charge of Medicare and Medicaid investigations helps our clients to better understand what government lawyers are looking for when reviewing healthcare data and contemplating possible criminal charges.