Antoine Dental Center (ADC) and owner Dr. Behzad Nazari, was been placed on an administrative Credible Allegations of Fraud (CAF) 100% payment hold from Medicaid reimbursements/payments in Texas in April 2012.
CAF - Federal law defines a “credible allegation of fraud” as an “allegation, which has been verified by the State, from any source.” 42 CFR § 455.2 states that the source of these allegations may include, but are not limited to, “(1) fraud hotline complaints, (2) claims data mining, (3) patterns identified through provider audits, civil false claims cases, and law enforcement investigations. Allegations are considered credible when they have indicia of reliability and the State Medicaid Agency has reviewed all allegations, facts, and evidence carefully and acts judiciously on a case-by-case basis.
Since Dr. Nazari disagreed with this payment hold he filed a suit against Texas Health and Human Services Commission – Office of Inspector General (HHSC-OIG) —State Office of Administrative Hearings (SOAH) Docket No. 529-13-0997; HHSC-OIG Case number P20111316523848911.
On May 28, 2013 four days of hearings began where evidence from both sides was presented to the judges at the SOAH in Austin.
On August 23, 2013 both sides filed their written Briefs and Closing Arguments. They can be read by clicking the links at the end.
One Brief and Closing made perfect sense, with facts and logic along with visual aids. One sounded like a babbling idiot recounting a fairy tale. Guess which was which.
ADC and Dr. Nazari seem to think that division, and possibly the whole OIG office, is completely unnecessary.
In the ADC Brief and Closing Argument they state:
“How can the OIG support any credible aggregations of impropriety regarding HDL score sheets when the underlying diagnostic material was made available to the State and the State pre-approved the analysis that was reflected on the HDL score sheets? “
(HDL scores being the system designed to show certain criteria has been met that demonstrates a patients need for orthodontic devices such as braces).
They further argue, and I quote:
“The Prior Authorization Process was implemented to assure that qualifying orthodontic services were supported by an accurate HDL score sheet.”
I nearly blew coffee over my keyboard when I saw the word “accurate” and HDL score side by side in ADC brief — like I said, fairy tale! They later argue that the scoring is subjective. How can something subjective be accurate? Oh well…it’s over my head.
Anywho, attorney’s for Antoine Dental Centers and Dr. Nazari basically say that since the State and/or their agent had the score sheets, x-rays, pictures, and other diagnostic materials, and someone inside looked the other way, too bad, your loss is our $8M gain.
Personally, I take issue with that.
First, it wasn’t like these records and approvals were sent to someone inside the HHSC office that evaluated each case and decided whether to approve or not approve the child for braces. It was outsourced to a private company, who swore they were experts in doing this kind of thing. I believe the lasted outsource company is ACS, owned by Xerox. Let’s call it “Thing 2”. (a whole other long story). It could be another one or two, there was a shake up last March, but none of that really matters here.
It is noteworthy that ADC’s “expert” witness in this dispute with the State is , Dr. James W. Orr, the one who erroneously (or fraudulently) approved payments on many patients and who admittedly trained and mentored the Dr. Nazari of ADC on how to “utilize” (their word, not mine) the HDL scoring system, while he worked for “outsource company #1”, which I call “Thing 1”. Anyone see a conflict here? Anyone smell anything?
And, get this, Dr. Orr trained the general dentists how to exploit the HDL scoring. He trained, apparently several dentists, on how to do this. The “training” offered up by Dr. Orr took place, not in the training room at the office of Thing 1, but in the conference room of one of the attorneys now representing ADC; former dentist and American Dental Association (ADA) president turned attorney, Robert M. Anderton.
My theory is it went something like this: While working for Thing 1, Orr went out and recruited general dentists to join the Dental Medicaid Fraud Project (no, not really…but…). He brought them to a secret location; inside the office of Robert Anderton. Orr trained and mentored the dentists on how to upscore the HDL sheets and assured them no one inside Thing 1 was watching, and the ones that were didn’t care cause they get a piece of the pie too. Then Orr, returns to his desk at Thing 1 and stamps “APPROVED” on the HDL score sheets his well trained disciples submitted. It’s unclear what Orr’s part in the take was, but I would guess he was well compensated for bringing all this business on board for the company as he used the “special” training to entice the dentists to come aboard the gravy train.
I’m no legal eagle and not that bright, but I would bet if Thing 1 were sued to recover the funds their employee, Dr. James W. Orr, approved, they would though Dr. James W. Orr, and Robert Andeton under the biggest bus they could find and their “utilizing HDL score training sessions” would be front and center as proof of intentional fraud. If you haven’t you must check the blog post on Dr. James W. Orr here.
Second, it looks like the State did take a look at the materials submitted by ADC, to this third party company and approved by Dr. James Orr’s; 3 times as a matter of fact. Each time the “inspection” indicated fraudulent diagnostic materials were submitted. So is it ADC’s contentions that it’s “finder’s keepers, loser’s weepers”?
I can’t figure out if they are arguing the Office of Inspector General has a right “inspect” or not. I’m thinking that ADC’s position is “not”. Sounds like a lot of double speak to me; one of those “dazzle them with bullshit” to keep them confused type of arguments. What is obvious is they are saying that since they were stamped “approved” then “approved” it is? I swear, I would not have been surprised to have seen “though titty” in the ADC Brief.
They actually say:
“it is silly for the State to allege that ADC’s submissions and its (the STATE) own review of those submissions could amount to fraud.”
Silly, huh? Is ADC’s attorneys throwing the Thing 1 and Thing 2 under the bus? If so, so goes their expert witness, right? Are they saying there is no need for checks and balances, just checks? Sounds like it.
Again, I have to point out that the State didn’t approve them, but good ole Dr. Orr and his former employer – Thing 1 — certainly did, and Dr. Orr trained the dentists how to get the most Medicaid buck for the bang. Thing 2 simply continued with the ole family tradition.
ADC also states:
“Whether the State’s agent (Thing 1, along with Dr. Orr and Thing 2) properly performed its review and a pre-approval responsibility is irrelevant.”
Really? I think this is implying the “tough titty” theory.
Another one of their cockamamie theories on why ADC should get the money they defrauded released and back into their grubby little hands; as well as why no one at HHSC-OIG should question their falsified (alleged of course) HDL score sheets is this:
Only the Texas State Board of Dental Examiners has the jurisdiction to question whether any dental services was medically necessary or not.
The Brief acknowledges that HHSC-OIG has the power to “take administrative action” when dentists violate the program requirements as set out in the provider manual. Well, hell, this “payment hold” IS that administrative action! Hells bells, the hearings about this are in the State Office of Administrative Hearings! Geez!
Here are some other notable statements in the Brief:
“The payment hold was originally levied on the allegation in the original complaint, and it is appropriate for this court to require the OIG to defend its original claim.”
I’m guessing they really don’t want that, since I highly suspect Dr. Nazari would be visited by Federal Marshals or at least hearing from the local district attorney.
“The OIG maintains burden of proof”.
Well, choose a side, damnit. Either OIG has authority, which would include burden or not!
“A false statement of fact is an untrue, deceptive or misleading statement concerning a past or present fact.” In my opinion would include all 32 pages of this Brief. (yes, it’s 66 pages in length but after page 33, it attachments.)
To determine whether the statement is fact or opinion, (what about fiction) courts consider the specificity of the statement, the parties’ relative level of knowledge, and whether the statement related to the present or future.”
Here is where they run into problems; none of the dentists involved in this case, including the former employee of Thing 1 and expert witness, Dr. James Orr is an orthodontist!! That’s right, Dr. Nazari and his teacher/preacher, is NOT an orthodontist. Dr. Nazari didn’t even hire an orthodontist until 2006.
Next they go into about 20 pages of ectopic eruption of teeth, what it is, and what it is not and what one non-orthodontist might think it is, compared to what a real orthodontist thinks it is, what I might think it is, and what you might think it is. Basically, it is what they say it is, when they say it’s this or when they say it’s that.
To sum this thing up:
- Office of Inspector General is not needed, nor is its Medicaid Fraud Control Unit(MFCU) because only the TSBDE has the authority to determine proper treatment. (hmm..wonder why TSBDE wasn’t taxed with approving or not approving the HDL score sheets?
- Even if falsified HDL score sheets were submitted and approved, finder’s keeper’s. What Dr. Nazari seems to have found is $8,104,875.75 in 3 year time span between 2008-2011. He only has two offices!
- Just because ADC averaged 106 new patients for braces a month before the 2011 patient record “inspection” and only 10 per month after that means nothing.
- Ectopic Eruption is subjective but only if related to fraud allegations, otherwise it’s what Dr. Orr or whoever submits material requesting payment, says it is. Further, they know payment for braces and such is strictly for “severe handicapping malocclusion”.
To·ma ·to - To·mah·to
- We fooled one Administrative Law judge with this BS, so now what we say is so. Kind of like the ectopic eruption theory.
- Ok, so our expert is NOT really a qualified expert, don’t pay any attention to that teeny weeny meaningless factoid. He took a correspondence course a few years ago. And since we say he is the HDL Scoring God that means it is so and should not be questioned.
- Forget Dr. James Orr use to testify for the State where he found nearly 100% of score sheets fraudulent. We can pay more than the State; not sure why. Basically our funds are only limited to the amount in the Treasury.
- Forget that ADC has been under investigation 3 times, since 2007. Non of them have been resolved, cause we need to milk the cow a bit more.
- The MFCU of the OIG, and especially Jack Stick has nothing really important to do and, they all watch way too much local news. This insights them to rush to the office early each day and brainstorm; trying to find fun and exciting activities to fill their otherwise mundane day. One day the Texas MFCU actually put names in a hat and drew Antoine Dental and Dr. Nazari to filly fart around with, figuring that would keep them occupied for the next few years. Idol hands are the devils workshop, right?
- The highly unqualified Dr. Nazari, who is NOT an orthodontists, but a pharmacist/general dentist wants the money sent to him, pronto.
[Dr. Nazari used to be a pharmacist, from 1991-Nov 2011. Wonder what happened there?]
The Texas Office of Inspector General (OIG), created in 2003, was tasked with the responsibility of monitoring and investigating allegations of fraud and waste in the Medicaid program. Inspector being the operative word here and the word that ADC apparently isn’t happy with. It’s not the Office of “Wink Wink” General or the Office of “No one is looking” General, it’s the Office of I N S P E C T O R General.
Don’t forget, you’ll want to read both Briefs. I suggest starting with Antoine’s.
Transcripts of the May 2013 Hearings
- ADC vs. State of Texas — Day 1
- ADC vs. State of Texas — Day 2
- ADC vs. State of Texas — Day 3
- ADC vs. State of Texas — Day 4
- Transcript of Oral Deposition of Dr. Irwin Ornish – Expert Witness for ADC
August 23, 2013 Briefs and Closing Arguments
1. To examine carefully and critically, especially for flaws.
2. To review or examine officially.
1. One who is appointed or employed to inspect something.
2. A police officer ranking next below superintendent.