What are the “Powers That Be” saying when it comes to Medicaid dental fraud and overtreatment?

Below are select excerpts from the transcript and powerpoint slides of a January 2015 CMS Learning Lab Weninar entitled “Advancing Program Integrity for Medicaid Dental Programs: Federal, State and Stakeholder Efforts”.  The Webinar was held by Medicaid-Chip State Dental Association’s (a must check out website) Lynn Douglas Mouden, DDS, MPH, Chief Dental Officer with the Centers for Medicare and Medicaid Services (CMS), (also associated with a host of other organizations). Speakers included:

First, John Hagg, Director of Medicaid Audits, Office of Inspector General, US Department of Health and Human Services, John.Hagg@oig.hhs.gov. His presentation begins on page 3.

Second, Meridith Seife, MPA, Deputy Regional Inspector General, Office of Evaluations and Inspections, Meridith.Seife@oig.hhs.gov, 212-264-2000. Her presentation beings on page 5, about 2/3 the way down the page, and; 

Third, Linda Altenhoff, DDS Chief Dental Officer with the Office of Inspector General, Texas Health and Human Services Commission (THHS). Linda.Altenhoff@hhsc.state.tx.us. Her part of the presentation at the bottom of page 7.

(Bios of each speaker can be found on page 2 of the transcript)

I found a few things troubling, that I’ll discuss later.

Below are the excerpts from Ms. Seife  portion where she speaks about the latest (at the time) OIG Questionable Billing Dental Medicaid Reports:

Who we are:
•The Office of Evaluation and Inspections (OEI) conducts national evaluations of HHS programs from a broad, issue-based perspective.
•We are working on a series of studies evaluating Medicaid pediatric dental services in selected States.

So why are we looking at Medicaid dental services? Well, as I'm sure many of you know, in recent years, there have been a number of high-profile cases where certain dentists and dental chains were found to have engaged in some extremely abusive dental practices. Although such cases represent an extremely small number of bad actors, they can have truly devastating effects on children. Dentists have been found guilty of routinely extracting healthy teeth, performing unnecessary pulpotomies, or putting stainless steel crowns on teeth that didn't need them. Obviously our primary concern is that no kid should ever have to endure unnecessary treatment, or that treatment that doesn't meet basic standards of care. But this can also have a significant impact on taxpayers as well.

The primary goal of our evaluations was to use Medicaid claims data in a way that could accurately identify dental providers who exhibited patterns of questionable billing. We're doing this currently in four states. In 2014 we issued reports on providers in New York, Louisiana, and Indiana. And our California report will be issued early this year. Although we were somewhat limited in doing these studies in only a few selected states, we hope that these reports will serve as a model for how other states can use their Medicaid data to identify potentially problematic providers in their Medicaid programs, and, hopefully, to target their resources more effectively in looking at those providers.

So I've already referenced, a few times, this idea of questionable billing, but I haven't really defined what it means. It's based on a type of analysis that the OID has done in other parts of Medicare and Medicaid, but this is the first time we've applied such an analysis to dental services. What is it? It's really just a method of determining certain billing patterns that are significantly different from one's peers.

We base these analyses on certain key measures that we developed in consultation with numerous experts. We spoke with law enforcement officials who specialized in working dental fraud cases. We also spoke with dental experts in state Medicaid agencies and CMS. We also received a tremendous amount of help from experts within the AAPD and that ADA.

Once we developed these measures, we then analyzed Medicaid's claim data in each state to identify extreme outliers or questionable billers, as we referred to them in our report. Specifically, we use these measures to identify providers who received extremely high payments per child, provided an extremely large number of services per day, provided an extremely large number of services per child per visit, and/or provided certain selected services, such as pulpotomies and extractions, to an extremely high proportion of children.

Once we developed these measures, we then analyzed Medicaid's claim data in each state to identify extreme outliers or questionable billers, as we referred to them in our report. Specifically, we use these measures to identify providers who received extremely high payments per child, provided an extremely large number of services per day, provided an extremely large number of services per child per visit, and/or provided certain selected services, such as pulpotomies and extractions, to an extremely high proportion of children.

Just to give you a sense of what those outliers look like, here is an example of a questionable billing analysis on average Medicaid payments per child by individual dentists. As you see, the vast majority of dentists are clustered around the median and mean amount, with an average payment of about $200 per visit. But, of course, way out towards the left, you start seeing outliers that are very different from that amount. For example, you can see that one outlier was paid over $1,100 per visit on average.

Process for Conducting Audits
•Audit Notification Letter / Entrance Conference
•Define: Audit Objectives, Scope, and Methodology
•Data Collection and Analysis
•Exit Conference
•Draft Report
•Auditee Comments
•Final Report

So, before I get into what we found, I do want to make just a few brief points about our methodology. One of the biggest challenges in conducting this type of an analysis is to be sure that you're comparing similar peer groups. Obviously you don't want to compare a general dentist in private practice with an oral surgeon working in a hospital setting. So, first, we separated out general dentists from other selected specialties. And once we grouped each peer group appropriately, we then established key thresholds for each of the measures.

These thresholds were established using a statistical method that's known as the "Tukey method." For the more statistically inclined among you, it basically calculates values that are greater than the 75th percentile plus three time its interquartile range. For those of you that are not statistically inclined, it's simply a way of identifying really, really extreme outliers. It also does this in a way that takes in the overall distribution into account. It means that you will not just be taking the top ten billers on a particular measure, it has to be significantly different from the norm. As a result, in a number of case, we found no outliers at all for a specific measure.

I should emphasize that this analysis does not confirm that a particular provider is engaging in fraudulent or abusive practices. Some providers may be billing extremely large amounts for perfectly legitimate reasons. Our position is simply that these providers are significantly different enough from the norm that it warrants further scrutiny.

So, using those measures, we identified a number of dental providers with questionable billing in each of the states we looked at. In total, we identified 151 providers with questionable billing, and Medicaid paid these providers over $56 million for pediatric dental services in 2012.

Questionable Billing Examples:
New York :
•Dentist averaged 16 procedures per child, compared with a statewide average of five.
•Dentist extracted the teeth of 76 percent of children he treated, compared with a statewide average of 10 percent.
Louisiana:
•Three dentists each provided an average of 146 or more services per day, compared to an average of 27 services for other dentists in the state.
16.

We also found that a significant proportion of these questionable billers were concentrated in certain dental chains. As many of you know, systemic problems within specific chains is a concern to many policymakers. In the three states we've reviewed so far, between one-third to more than half of the questionable billers worked for certain dental chains. Many of these chains had been previous investigated for providing services that were medically unnecessary or that failed to meet professionally recognized standards of care.

AAPD Behavior Guidance Symposium Nov 2013

According to the American Academy of Pediatric Dentistry, their Behavior Guidance Symposium “kicks” off today at their headquarters in Chicago.  I can simply not believe I was not invited to this event!  I should pay much closer attention to their event schedule in the future.

Frankly, I’m not sure why the AAPD even has the event, since apparently the AAPD and their “policy and guidelines” are of little value.  According to testimony from ethically challenged dentists involved in various malpractice lawsuits across the nation, he policy and guidelines are mere “suggestions”.

Attending the event will  garner you Continuing Education credits.  With the massive number of dentists working in the Medicaid dental mills, you would think they would need a venue such as McCormick Place or the United Center instead of the Westin Hotel.

Dental coalition pressures HHS for a report on sugar-sweetened beverages and it’s affects on oral health.

A coalition of associations and groups have joined together to ask Health and Human Services Secretary, Kathleen Sebelius to commission a report to evaluate the scientific community’s literature and research on sugar-sweetened beverage consumptions affects on oral health.  Story posted at the ADA website.

Why? Do they think someone is lying about sugar being bad for your teeth?

If you google “evaluation of oral effect of sugar-sweetened beverages” I believe you will find this study has been done numerous times! One as late as 2009, heck it’s only 2012. Has sugar changed that much?

Maybe there is a legitimate reason for this request, I’m no expert, nor do I pretend to be. Sound a bit stupid to me, don’t we all know sugar is bad for oral health? Or are we not teaching this anymore?  Maybe this is just something to keep HHS and Kathleen Sebelius’ busy so HHS is not digging into the massive fraud and abuse happening in dentistry today?

Naw, I’m probably wrong, as usual.

No doubt, the American Academy of Pediatric Dentistry (AAPD) is concerned about our children’s oral health, after all they are in front of Congress on a “regularly scheduled basis” with their hand out, telling lawmaker more taxpayer dollars are needed to give children “access to care” so these cavities can be treated as soon as possible. We all know children’s, teeth are highly susceptible to rot over sweets, right?

Heck Bernie Sander’s recently introduced yet another bill to appropriate more money to treat children who they say go to bed at night with “sippy cups” full of Coke.

The issue is so terrible says the AAPD and the Pew Institute that thousands upon thousands of private equity owned corporate dental clinics have spread across the US faster than a Colorado wildfire. All paid for by the taxpayer and all to combat the cavity crisis this country has had since the beginning of time.

Some states such as Texas have doubled their reimbursement for procedures needed to treat these specific problems.

In an effort to end this crisis, the AAPD has turned a blind eye to highly questionable treatment of children’s cavities by dentists, and in many cases have endorsed such treatment – papoose boards, risky sedation etc.

Organizations pleading for the study are:

• American Dental Association (ADA)
• Academy of General Dentistry, (AGD)
• American Academy of Periodontology,

Inside Edition investigates papoose board use in dentistry

For some kids a trip to the dentist can be a traumatic experience. But just imagine what it might be like strapped into a cocoon-like restraining device called a papoose board that is sometimes used to immobilize children at the dentist's office.

They're smiling today, but eight children say they were strapped into a papoose board while visiting the same dentist for routine work.

They're all patients of Dr. Edward Dove. Dr. Dove has a huge pediatric dentistry practice in Southern California and his commercials are specifically targeted to kids like a friendly Saturday cartoon show. But these kids' parents say their experience was nothing to smile about.

"He hit me on the head and said, ‘You better shut your mouth,' four-year-old Abigail Webb told INSIDE EDITION's Chief Investigative Correspondent Lisa Guerrero.

"He strapped me down on a papoose board and I started crying and he kept slapping my cheeks," said six-year-old Tyler Catalfamo, another patient of Dr. Dove.

Dr. Dove says he uses the papoose board properly, after sedating the youngsters.

Read the full story here at Inside Edition

 

When there is news about dentistry in the media, the American Dental Association issues a Red Alert.  Here is the ADA Red Alert issued after the “Inside Edition” story about the use of papoose boards aired April 26,2012. And the ABC Chris Como report about Florida’s children access to dental care; It’s in a “crisis”. Link to ADA Red Alert

Inside Edition and ABC World News Media Stories

"Inside Edition" airs segment on the use of papoose boards

"Inside Edition," a nationally-syndicated newsmagazine show aired a story April 26 about dentists' use of papoose boards during dental treatment. As a result of this rather sensational segment, parents of young children under your care may ask if you use a papoose board in your practice.

Scary–On the one year anniversary of Jenny Olenick’s death, anesthesia dentistry is on the rise.

On the one year anniversary of Jenny Olenick’s death, Medscape posted, what I refer to as “Anesthesia Media Blitz II”. Since early March, the AAPD and other associations have released various press releases promoting putting children to sleep to perform dental procedures. The Medscape article is the second round. Medscape could have posted a story on the hazards of such practices, but didn’t. I’m not saying it was on purposely, however, I’ve learned seldom are stories published without reason.

Visit msnbc.com for breaking news, world news, and news about the economy

   

MedScape

April 6, 2012 — Pediatric dentists cannot find enough dentist anesthesiologists to meet the needs of their patients, according to a survey of pediatric dentists published in the spring 2012 issue of Anesthesia Progress.

The survey responses differed somewhat by region, sex, and years in the specialty, with 20% to 40% of participants saying they currently use a dental anesthesiologist and 60% to 70% saying they would use one if one were available.

The demand for dentist anesthesiologists has been increasing in recent years in pediatric dentistry, according to a separate survey of dental anesthesiology program directors published in the same journal.

"The trend in the past has been that many dentists provided [both] anesthesia and dental care," coauthor James Jones, DDS, chair of pediatric dentistry at Indiana University in Indianapolis, told Medscape Medical News.

Now, many pediatric dentists would prefer to concentrate on the dentistry while someone else focuses on anesthesia, he said. "We're realizing that it's a safety issue."

Dr. Jones said researchers at the university had become aware of the need for anesthesia in their patients because they provide service to a lot of low-income patients who need extensive dental work of the type that often requires general anesthesia.

To see what other pedodontists were experiencing, they sent out emails to all 2586 active board-certified pediatric dentists who are members of the American Academy of Pediatric Dentistry and who made their email addresses available, asking them to participate in an online survey.

The messages bounced back from 659 of these, leaving 1927, of whom 494 completed the survey.

Participants disclosed their sex, age, years in practice, region, number of years as a diplomate of the American Board of Pediatric Dentistry, use of in-office sedation, and use of intravenous (IV) sedation. They also commented on their use of a dentist anesthesiologist.

The respondents differed in their use of anesthesiology by demographics. Thirty-nine percent of women answered "yes" to the question, "Do you use the services of a dentist anesthesiologist?" compared with 23% of men, which is a statistically significant difference (P < .01).

Only 12% of those in practice for longer than 21 years used IV sedation in their office, and only 25% of this group used dentist anesthesiologists (P < .01). Although only 53% of this group answered "yes" to the question, "Would you use the services of a dentist anesthesiologist, if available?" this percentage was not statistically significant compared with dentists who have been in practice for fewer years.

In contrast, 30% of those in practice for 5 years or fewer used in-office IV sedation, 38% used dentist anesthesiologists, and 74% would use dentist anesthesiologists if they could (P < .01).

Group practices were least likely to administer in-office sedation; solo practices were the most likely.

Practices in the Southwest were most likely to use in-office sedation. Westerners were most likely to administer in-office IV, employ dentist anesthesiologists, and use dentist anesthesiologists if they could.

Dental Anesthesiologists Address Many Needs

Dr. Jones said the finding points to a need for more training programs for dentist anesthesiologists. "I think the demand is going to increase over time," he said.

He pointed out that bringing an anesthesiologist into the office is half as expensive as taking the patient to a hospital or day-surgery center for anesthesia.

American Academy of Pediatric Dentistry Spokesman John Liu, DDS, agreed, noting that hospitals and surgery centers charge for the use of their facilities.

Dr. Liu, a clinical assistant professor of dentistry at the University of Washington in Seattle, told Medscape Medical News that pediatric dentists are in greater need of help from dentist anesthesiologists for several reasons.

First, more children are being diagnosed with behavior-related conditions such as autism and attention deficit disorder, he said.

Second, fewer parents are comfortable with having their children physically restrained through frightening and sometimes painful treatments. "The reality is that it's not an easy thing to sit through something like that," Dr. Liu, who has a private practice in Issaquah, Washington, told Medscape Medical News.

Dr. Liu also said that some state dental boards prohibit dentists from providing general anesthesia or deep sedation, even if they have completed residency programs in anesthesiology, and he thinks these regulations should be changed.

"I find it tremendously helpful to have a dental anesthesiologist, as opposed to an MD anesthesiologist, because he knows exactly what I'm doing and when I'm going to be done," said Dr. Liu. "I have used a dental anesthesiologist for more than 20 years, and I don't know how anybody manages without one."

Dr. Liu and Dr. Jones have disclosed no relevant financial relationships.

Anesth Prog. 2012;59:12-17. Full text

American Academy of Pediatric Dentistry trying to squelch “Raven’s Song” and video created to promote safety in sedation dentistry.

Twice today it’s been removed from their Facebook page.

Dental Treatment Deaths - 20 Dead Children Since February 2007

Deamonte Driver dies in February 2007, from a brain infection due to a cavity. http://deamontesdentalproject.org/. 

Since then there have been at least 20 children die during or just after dental treatment.  Those are just the ones we know about.  It is my personal belief there are three others in 2011.

The pediatric dental community stormed the halls of Congress demanding better access to dental treatment. In the process of trying to do something good, as what many times happens within the Halls of Congress, a good intention has gone terribly wrong. 

Children are dying at a lightening speed, children are being over treated with high reimbursement procedures where the money lands on Wall Street and state budgets are off the charts.  But NOT a soul, NOT ONE, from the Pediatric Dental Community has made their way to the halls of Congress demanding something be done to stop the deaths from the dental treatment its self.  1 can die from lack of treatment, 20 can die because of treatment, and we can't even get a 2 minute segment on the morning talk show to run a story sitting in their vaults.

 WTH!

ABC News has had a segment filmed and completed for well over a year.  It was to be shown on Good Morning America.

NBC News started to film a story about this in mid December 2011, the postponed it. Likely didn't plan to run it at all.  Then the next day or two, a couple of teens dies during Christmas break.  They decided to bring everyone back to NYC and film the segment the first week of January.  Not seen it yet!!

3 year old Juan Quiej's and 6 year old Kyneicha Pagan death by Dr. Patrick Bamgboye, DDS - Both children Papoosed!

NEWARK — An Irvington dentist who was disciplined by the state after a 6-year-old girl died during a routine procedure eight years ago is again under investigation following the death of a second child in his care last week.

Patrick Bamgboye, 64, was still on probation for the earlier incident when 3-year-old Juan Quiej and his mother arrived at Dental Health Associates last Wednesday.

Juan, who was there to have cavities fixed, was restrained in a cocoon-like papoose to limit his movement and administered a local anesthetic, his mother said.

[FYI to investigators - There was a death much like this in NM a few years ago. Dr. Mathew Nolen, since deceased was working for Dr. Eddie DeRose at the time in the Small Smiles Dental Clinic]

Shortly afterward, the boy went limp, his lips turning blue. He had stopped breathing. He was later pronounced dead at a local hospital.

Pediatric Dentistry’s Revolving Door

We hear a lot about the “revolving” door in Washington, but seldom does anyone talk about the revolving door within agencies and professional organizations.  The same organizations that write the rules, regulations, tests, and guidelines that effect each of us in a more personal way. The same organizations that states and lawmakers trust to protect the public from harm. Chances of corruption are 100% when there are no checks and balances.

Their Publications and Studies

Looking are various websites including the American Academy of Pediatric Dentistry (AAPD), you find publication after publication, study after study, dating as far back as the early 1990’s to the present.  Just about all of them are, rewritten and republished studies that are merely mashups of their own previous written articles and studies.

Here is just one of hundreds of examples :

Journal of Dental Education – Vol. 68, Number 1

General Dentists’ Perceptions of Educational and Treatment Issues Affecting Access to Care for Children with Special Needs. 
Written by:
Paul Casamassimo, DDS, MS;
N. Sue Seale, DDS, MS;
Kelley Ruehs, DDS

Referenced:
Casamassimo PS. The great educational experiment: has
it worked? Spec Care Dentist 1983;3:103-6.

Seale NS, Casamassimo PS. Access to dental care for
children: profiling the general practitioner who treats
young and low-income children. J Am Dent Assoc
2003;134:1630-40.

If you get to looking at all the professional opinions, publications, studies, and continuing education courses concerning pediatric dentistry, the same names are there over and over.

Fox News report on Jenny Olenick’s parents suing dentist after her death. Jenny died in 2011

 

There have been 24 pediatric deaths related to complications due to dental procedures in the past seven years. This number accounts only for reported pediatric deaths. Shockingly, of the 24 pediatric deaths occurring within the seven year period, 11 have been within the last 21 months. 52% of the deaths have occurred since April of 2010! What once may have been viewed as a rarity has clearly become an epidemic. Wake-up Dr. Milton Houpt!

If you add the adult deaths, the numbers skyrocket.  If we knew the exact number of pediatric deaths and adult deaths I think everyone would be is shock!  Many are unreported as taking place during dental procedures.  Just last week I heard from a person whose friend’s husband had died in Florida just a few months ago during a dental procedure. She said the man had been dead for 15 minutes before the dental assistant brought it to his attention.  This never saw the pages of a news paper or a spot on the evening news.  There are hundreds more of these same kind of stories.  Mr. Milton Houpt ,the ADA and the AAPD do NOT want the true numbers told, it’s a $3 billion dollar a year industry!

Here is a memo sent out by the AAPD after the death of Jacobi Hill in Richmond, Virginia in 2010.

Nor does the DOCS Education program; a drive thru; weekend; three day seminar to teach dentist the fine art of sedation.  Used to help general dentists increase services and revenue streams.  A very dangerous one at that!

Someone has suggested it’s only a coincidence that the major dental agencies that set the standards and shape state rules and regulations are all located at the same address in Chicago: 211 E. Chicago Avenue, Chicago, IL 60611

American Dental Association

Academy of General Dentistry

American Academy of Pediatric Dentistry

American Student Dental Association

American College of Prosthodontists

American Association of Endodontists

and…drum roll please…..

The American Association of Dental Boards

Just a coincidence? 
The ADA owns the building and simply leases it to other organizations, no conspiracy? 

I say Hogwash!!