A recent Inspector General’s report concerning alleged overbilling of Medicaid by Louisiana dentists appears to be another sign that increased enforcement against dental providers in on the horizon. The report, which had relatively narrow findings, concluded that roughly two dozen dental professionals in Louisiana are “extreme outliers” based on the amounts of their Medicaid billings. A similar OIG report was issued in March concerning New York dental providers.
Over the past several years, many dental practices have been accused of distributing kickbacks, such as gift cards, manicures and amusement park tickets, in order to lure low-income families in for examinations. Additionally, dentists have been prosecuted for allegedly providing services that were medically unnecessary or that have failed to meet professionally recognized standards of care.
Numerous dental professionals have been sentenced to prison after been convicted of Medicaid fraud. For example, a North Carolina dentist was sentenced last year to a five-month term for mischaracterizing the dentures he supplied. Additionally, a Texas orthodontist was sentenced to 50 months for letting assistants perform certain tasks without supervision.
There has also been an increase in Medicaid audits of dentists in recent years. Dental providers should make certain that the full comply with the Medicaid billing rules and regulations. Those rules and regulations can be extremely precise, as evidenced by some of the alleged fraud that has been prosecuted. In 2012, for example, prosecutors accused an Oklahoma dentist of fraud for allegedly restoring smaller portions or fewer surfaces of individual teeth than she claimed. As a result, cases can require enlisting experts to perform exhaustive examinations of dental records, such as X-rays and charts, to demonstrate conclusively that misconduct occurred.
Medicaid spent roughly $7.5 billion on dental care in 2010, a figure that has almost certainly grown since that time, especially as the program for low-income Americans expands under the Affordable Care Act. A sizable portion of those expenditures is for children, as Medicaid requires states to provide pediatric dental care but provides leeway when it comes to adults.
While many types of health care fraud are getting attention these days, experts opine that the confluence of disturbing allegations in dental fraud cases — fleecing taxpayers, harming children and taking advantage of low income families— may make such investigations or prosecutions especially attractive to government attorneys.
Over the past several years, there has been steady increase in suits by automobile insurance carriers against health care providers who treat individuals in connection with their personal injury claims. Most of these suits allege that the health care providers are fraudulently billing the insurance companies by either billing for services that were not performed or by providing treatment to the patients that is not medically necessary. With rising insurance costs, this is a litigation trend that is likely to continue in the coming years.
For example, Allstate Insurance Corporation’s filed a $6 million suit targeting allegedly fraudulent Long Island no-fault health care providers. The company says the suit is part of a larger litigation strategy, which it contends will deter fraudulent billing by health care providers and spur changes to New York’s “fraud-riddled” system. Allstate has accused several health care providers and New York businesses of billing for services that were not performed or medically unnecessary, and of funneling money, in violation of state law, to a proprietor who was not legally allowed to profit from the health services.
In New York, insurers have pushed hard — so far unsuccessfully — for a law making staging accidents to reap no-fault money a felony crime, the ability to retroactively cancel policies involving staged accidents and a law putting the onus on medical care providers to prove that the care they give is medically necessary, among other reform measures. Critics of such proposals see them as attempts to increase profits even as insurers aggressively target those seeking benefits, under a policy that is supposed to allow for quick payments to address injuries while discouraging damages lawsuits.
Insurers scored a big win in 2005 in State Farm v. Robert Mallela when New York’s highest court ruled insurers “may look beyond the face of licensing documents to identify willful and material failure to abide by state and local law” in their pursuit of allegedly fraudulent care providers. Additionally, in Allstate Insurance v. David Mun, the Second Circuit held that an insurer may file a lawsuit based on allegations of fraud without first submitting the matter to arbitration.
Other insurers, such as State Farm, Liberty Mutual and Geico, have also filed similar suits against health care providers in many areas of the country. Providers in Pennsylvania, New Jersey and Delaware have also been sued by State Farm, Allstate and Geico, among other insurance companies. These cases can be expensive to litigate, and are extremely damaging to the providers’ business. When faced with one of these lawsuits, providers should check their insurance coverage, as some policies may cover some or all of the cost to defend against these lawsuits.
