Showing posts with label Dental Scams. Show all posts
Showing posts with label Dental Scams. Show all posts

Wednesday, November 19, 2014

Mechanisms of Dental X-ray Scams

clip_image002By: Michael W Davis, DDS

Dr. Michael W. Davis maintains a private general practice in Santa Fe, NM. He chairs the Santa Fe District Dental Society Peer-Review Committee. Dr. Davis is active in dental care for disadvantaged citizens. His publications are on ethical issues within the dental profession, as well as numbers of clinical research papers.


November 19, 2014

Frequently, the media, non-dentist investigators, and the public ask me, the methods and means of swindles played out with dental x-rays. Most incorrectly assume, that patients are simply given excess numbers of unnecessary radiographs, to increase billing statements.

Both the insurance industry and Medicaid generally pay 100%, for the costs associated with dental x-rays. These third party payers have limits on the frequency and types of radiographs, which they will cover for benefits under their contracts with dental providers. Most dental insurance carriers have computer-generated algorithms, which are triggered when excessive x-rays are taken. Moneys are then not paid out, or immediately recuperated, in the next insurance payment cycle.

Medicaid oversight is generally more lax. However, there is a very real risk with dental x-ray over-billing, that this will be caught by Medicaid oversight mechanisms, even as incompetent as they usually are. Generally, large sums of Medicaid over-payments are generated, and regulators chase down very large sums, well after the fact (“Pay-&-Chase”). Often, only pennies on the dollars are returned to taxpayers. However, it represents a scam with some element of downside risk. As dental Medicaid fraud has become an accepted business model with in the dental industry, swindlers desire to minimize or eliminate regulatory risk.

Today, large interstate corporate dental providers retain former state and federal dental investigators. These corporate dental providers, which are usually beneficially owned by the private equity investment industry (Wall Street parties), have a good idea of which forms of fraud will be potentially investigated, and which methods of fraud will fly under the radar. Regardless, the corporate beneficial owners always retain licensed doctors acting as nominee owners (sham-owners), to assume any potential regulatory liabilities.

Most commonly, we observe the following forms of dental scams with dental radiographs.

Unbundling of X-ray Services

The American Dental Association (ADA) has established a clinical coding system called, “Common Dental Terminology” (CDT). Numerical codes are designated for nearly every possible dental service. This system is updated annually. Every insurance carrier and Medicaid will establish fees for each dental service, for which coverage is provided under their program. One such dental service is called a “complete series of radiographs”, which has a set fee, and CDT code number.

The scam involves taking a fair number of x-rays on a patient, and charging out for these multiple individual radiographs with multiple different CDT codes, to a sum greater than the fee, for a complete series of radiographs. This dishonest billing is termed unbundling.

Upcoding of X-Ray Services

Many pediatric dental patients, especially those with short attention spans, and who physically move about frequently, are unable to sit still long enough for a panographic x-ray (very large radiograph, approximately the size of a small loaf of bread). Thus, two occlusal radiographs (these approximate the size of a playing card) are often substituted. Cheats will frequently take a standard sized periapical x-ray (approximately the size of a domino), and turn it 90-degrees, and misrepresent that radiographic service, as an occlusal x-ray, and not a periapical radiograph, which it truly is.

This scam is usually played out, when the CDT code fee for an occlusal radiograph is more than a periapical radiograph. Since the only way to catch this fraud is with a physical auditing of the patient records, it’s easy to get away with. 

Non-Diagnostic Quality X-rays

When dental providers bill for x-ray services, they are assumed to bill for diagnostic quality x-rays. Any reasonably qualified doctor should be able to view the radiographs, and use that data to assist in generation of a patient treatment plan with their total examination. A patient treatment plan is generally an essential and required part of any patient record. Further services (fillings, crowns, extractions, root canal therapies, etc.) provided to a patient are based upon the patient treatment plan, and diagnostic quality x-rays.

When a doctor utilizes non-diagnostic quality radiographs (x-rays with processing errors and distortions, incorrectly positioned x-rays, etc.) to generate a patient treatment plan and provide clinical services, the patient and third party payer may be cheated. Not only is it unlawful to bill for the non-diagnostic quality radiographs, but also dental services delivered based upon these x-rays may represent malpractice and/or fraud.

Again, this form of malpractice/fraud is difficult to catch, without an on-site patient record audit, or physical examination of the records. Once patient records are subpoenaed for a civil or criminal legal action, a Medicaid audit, or a state dental board administrative law complaint, we commonly see non-diagnostic quality x-rays to be the unreasonable standard-of-care, for an unfortunate subset of practitioners. Too frequently, we see very extensive patient care (multiple steel crowns, pulpotomies a/k/a baby root canals, extractions, etc.) based on non-diagnostic x-rays and a very sketchy patient treatment plan.

Missing X-Rays

This too often comes down to three possible situations, none of which are good. The doctor claims the x-rays have gone missing. Patient records are assigned a responsible custodian for ownership. In most states, this is a licensed doctor. In other states, a corporate dental service organization may be assigned ownership, and treating doctors have specific and limited rights to access patient records (Again, a dangerous situation for patient rights. Also, potential for a corporate dental provider, to blackmail employee dentists’ testimony, when the corporate model of dental practice is outside the norms of the dental industry, involving fraud as an overall business model. “If you talk doctor, we’ll throw you under the bus, just like we did with the current defendant.”).

Missing records, inclusive of dental x-rays, does not bode well for defendants in civil or criminal malpractice or fraud cases. A judge will most often make a ruling, which casts a negative inference, upon subpoenaed and non-produced discovery material. Records not produced are deemed to negatively impugn defendant(s). 

The third possibility is that the dental radiographs never existed, in the first place. Yes, billing statements were generated for dental x-rays, but these services were not provided. Extensive treatment plans and other dental services were provided, all without supportive dental x-rays. A good question for plaintiff’s attorney to ask a defendant/doctor at deposition may be, “Are you related to Superman, because you must have x-ray vision?”.

Scams involving dental x-rays may be somewhat more complex, than many assume. Implications for malpractice and/or fraud go far beyond the radiographs themselves. Auditors, investigators, policy makers, legislators, leaders in organized dentistry, and the public must be alerted, to these common frauds played out in the dental industry. The crooks aren’t simply a handful of small-time dentist bunco operators. These swindles go directly to the heart of unregulated corporate America, which beneficially owns many of these disturbing dental clinics. The public interest must supersede the interests of all others, when it comes to our nation’s healthcare.

Tuesday, September 16, 2014

Mechanisms of Dental Sealant Scams

By Michael W. Davis, DDS"Dr. Michael W. Davis maintains a private dental practice in Santa Fe, NM. One day per week, he assists at a dental clinic focused on disadvantaged children and adults. Dr. Davis chairs the Santa Fe District Dental Society Peer-Review Committee. He is also an active member, in the New Mexico Dental Association House of Delegates, which drafts legislation relating to public protections in dentistry. Dr. Davis also serves as an expert witness, in dental legal cases. He may be reached at:

Mechanisms of Dental Sealant Scams
By: Michael W. Davis, DDS
September 16, 2014

Dental sealant scams have been a mainstay hustle, in unethical dental practices for numbers of years. The insurance industry terms this dishonest and unlawful activity, “upcoding”. It’s a highly lucrative and successful play, especially in Medicaid settings, because it costs nothing from the patient, and there’s no pain or discomfort generated. Here’s how it works.

The crooked doctor etches the tooth’s enamel surface with an acid gel, which has no dental caries (dental cavity). The tooth may or may not have a stain, which certainly doesn’t require clinical restoration (filling). Next, they place a flowable resin-composite into the tooth’s pits & grooves. This is a tooth-colored material, which lacks physical properties of strength and wear resistance. Manufactures never recommend flowable resin-composites to be used in high physical stress areas, like the chewing surfaces of teeth. Basically, the clinician has delivered the service of a dental sealant.

However, unlike a preventive service like a sealant, this “service” is billed out as a resin-composite restoration. Not only does this activity generate more billable fees, but also each surface the flowable resin-composite contacts generates additional billable fees. While a preventive dental sealant may command in the neighborhood of a $35-40 fee, a multiple surface resin-composite restoration will produce a fee ranging from $85-170. The only real limitation is the greed of the dishonest dentist.

Sometimes, the doctor may actually roughen the enamel surface, for better adhesion of the restoration (in reality, a sealant). However, because of the compromised material used, a general lack of adjusting of the patient’s occlusion (the manner in which teeth bite together), and the rush to maximize production under a challenging Medicaid fee schedule, this form of restoration has a compromised longevity. The compromised longevity is yet another moneymaker, in that these “fillings” require frequent replacement.

When I’ve audited Medicaid patient records, it’s rare to actually see any radiographic evidence of tooth decay on teeth restored like this. (On review of x-rays, there’s no indication of any prior tooth decay.)  Further, once these teeth are restored, there’s still no evidence of these restorations entering dentin (Dentin is the tooth structure under enamel, which is a qualifier for a definitive dental restoration, under most Medicaid and insurance programs).

One exception is “preventive resin restorations” (PRRs), which are not a covered service under most insurance and Medicaid plans. Under magnification, and using micro-air abrasion or a fissurotomy bur, the doctor selectively removes only the caries-affected enamel. PRRs do not command an equal fee for restorations, which enter into dentin. However, that won’t stop an unethical dentist for charging, for the more lucrative service.

A sealant scam is difficult to pull off, with private pay and dental insurance patients. Here are the reasons why.

Whether the patient (or their parents) pays the full amount, or simply a lesser-required co-payment, they have “skin in the game”. They feel a pinch in their pocketbook. If these “fillings” fail to hold up, which is virtually guaranteed, patients will complain. They may complain to the doctor, the state dental board, professional peer-review, a civil attorney, their insurance company, or their employer who purchases the dental plan. They are also highly likely to discontinue services with an unethical doctor, who provides this disservice.

By contrast, Medicaid patients have no skin-in-the-game. They pay nothing. They absolutely rejoice, when a dentist places a large “filling”, which doesn’t require Novocain (local anesthetic), and never hurts. They have no concern; this “restoration” is replaced or repaired every 2-3 years. This creates an ever-renewing financial annuity, for a crooked doctor. 

Further aiding the dishonest doctor is the abysmal to nonexistent oversight provided by Medicaid regulators. While dental insurance auditors are very well aware of this common dental scam, Medicaid auditors are generally clueless. I seriously don’t know if Medicaid auditors are mostly corrupt, lazy, or stupid. Regardless, I don’t have the time or energy, to broker fools.

So far, I’ve focused on the role played by dishonest dentists. Numbers of corporate dental clinics also play this fraudulent game on Medicaid. These dental service organizations (DSOs), which purport to limit their supervision to non-dental activities, misrepresent the reality. They are active in instructing doctors, on how to cheat the system. The private equity investors, clinic managers, and fraudster doctors all dip their collective beaks, in taxpayer largesse. This represents corporate fraud on a massive interstate level. Unfortunately, since the victims are disadvantaged Medicaid beneficiaries and US taxpayers, regulators generally sit on their hands, or hide under their desks.

In conclusion, misrepresentation of dental sealants as resin-composite fillings is not a “billing error”, as some dental crooks would have you believe. These “fillings” are often placed upon specific teeth, and surfaces of teeth, not covered under a Medicaid program for sealants. These are intentional misrepresentations to deceive the Medicaid program, for one’s financial gain at taxpayer expense. This represents violations to the Unfair Trade Acts and False Claims Acts (both state and federal), which is fraud. Fraud is not malpractice, and a doctor’s malpractice insurance generally doesn’t cover for acts of fraud. Acts of fraud often carry both civil and criminal penalties. Financial penalties are generally treble (3X) damages.

We already have state and federal legislatures, which have enacted powerful laws onto the books. The problems primarily lie with worthless regulators. They are unwilling to enforce existing laws, to protect the disadvantaged and taxpayers. Government regulators too often serve as enablers, for white-collar criminal activity.

From my perspective, I hold Medicaid auditors and regulators to equal culpability, as the actual violators. By ignoring their lawful responsibility to enforce the rule of law, regulators give criminals a tacit green light. Sadly, this green light perpetuating dental Medicaid fraud has been frozen on “go”, for many years.

Friday, August 22, 2014

Golly Gee..this is just shocking! NOT!

Anyone what to take a guess who the employs these unnamed dentists?  Kool Smiles and ReachOut have operations in Louisiana….just saying…


Feds look at Louisiana dentists for kids on Medicaid


Associated Press August 20, 2014

NEW ORLEANS — About 5 percent of the Louisiana dentists treating children under Medicaid may be padding their numbers, overcharging, providing unnecessary treatments or even harming children, according to a federal study released Wednesday.

Auditors for the Department of Health and Human Services checked 512 dentists and 41 oral surgeons. Twenty-six dentists and one oral surgeon — paid a total of $12.4 million for pediatric dental work in 2012 — billed for extremely high numbers of children or amounts of money or showed other possible excesses, according to the report from department inspector general's office.

Some of the bills may be legitimate but they warrant scrutiny, said a copy of the report provided to The Associated Press before its general release.

"Some of these cases are pretty alarming," said Calder Lynch, chief of staff for Louisiana's Department of Health and Hospitals. He cited doctors with high numbers of fillings and "baby root canals," or pulpotomies. According to the report, one dentist billed for 31 procedures, including 13 pulpotomies, four fillings and 10 stainless steel crowns on one 3-year-old — all during the same visit.

Lynch said he believes many of the dentists described in the audit are among more than 20 his department is already investigating. It recently hired a second dental technician to go over records and will check all 27 people as soon as the federal department sends their names, he said.

That list was "still going through internal processes" Tuesday "but will most certainly be provided," Janna Raudenbush, spokeswoman for the Office of Inspector General, said in an email.

State Medicaid Director Ruth Kennedy wrote in a July 24 response included with the report that, as a result of the study, DHH hired Managed Care of North America on July 1. The company will manage dental benefits under Medicaid and the state's Bayou Health program — an insurance-based model that covers 900,000 of Louisiana's 1.4 million Medicaid recipients, mostly pregnant women and children.

The report said the 512 dentists averaged $264 per child, but six billed for more than $663 per child.

"These dentists received more than $2,000 per child for a total of 237 children," and one was paid $8,000 for work done on one child over three visits, the report said.

"Extremely high payments raise concerns about whether these dentists are billing for unnecessary services or services that they did not provide," the auditors wrote.

Overall, the dentists averaged 27 procedures such as cleaning, extraction or X-rays per day, but three billed Medicaid for 146 or more per day. One billed for 376 services in one day, the report said.

"If this dentist spent only 5 minutes performing each service, it would have taken over 31 hours to complete all these services," the auditors noted.

The auditors also checked on specific procedures, such as extractions, fillings, stainless steel crowns and pulpotomies. On the average, the dentists pulled out teeth from 11 percent of the children they saw, but six dentists extracted teeth from at least 40 percent of the children and one did so on 70 percent of the children he treated. Dentists who filled teeth did so for one-third of the children, but one did so for 92 percent.

The audit looked at Louisiana dentists and oral surgeons who billed Medicaid for at least 50 children in 2012.

One-third of the dentists worked for two dental chains, it said. The report did not identify the chains.

The DHHS report is the second in a series of state reports; the first found similar patterns in 23 of 719 dentists in New York State. That's about 3.1 percent.

The state reports are not being done in any particular order, Raudenbush wrote.



Read more here:

Two audit reports in 2 years… Hmmm…. So they should get this done in say… the 48 years!!! Unacceptable! 

Here is wherein a major flaw in reports fall… NO NAMES! That’s why the public doesn’t know the dangers of what lurks behind the doors and criminal keep setting up another shop! Aren’t investigators tired of chasing the same damn criminals!

Thursday, August 07, 2014

Dr. Michael Davis’ Series on Dental Scams- Parts I and II


Scams played on dentists: Part 1

By Michael W. Davis, DDS, contributing writer

July 30, 2014 -- In a new three-part series, Michael W. Davis, DDS, details some of the ways dentists and dental offices are vulnerable to scams. This first part will introduce the series and discuss embezzlement and scams that are played on vulnerable employee dentists.

Dentists are played as marks for scams for several reasons. First, we are targeted because our earning potential is much higher than the general population. Traditionally, dentists have often operated in an isolationist bubble and often confer with colleagues on nonclinical matters only in unusual situations. The demanding focuses of the technical aspects of our profession often preclude us from closer examination of what may be obvious to others. We have blind spots. We are vulnerable.

Recently, courageous leaders in the dental profession such as Drs. Gordon and Rella Christensen have openly discussed embezzlement actions against them. These disclosures help dissolve any shame or guilt that other doctors/victims may carry. No one enjoys admitting they were scammed. However, open disclosures by victims help erode the smokescreen, which perpetrators depend on to pull off their scams.


Embezzlement and employee theft against an owner/doctor can take many forms. The ADA estimates about a third of all dental offices will be or have been victims of embezzlement. Experts in systems management to prevent and investigate dental office embezzlement and fraud say estimates are greater than 50%. Regardless of the exact number, these risks are very real and potentially devastating to a dental practice.

The exact method of the scam can take on enough discussion to fill several volumes of books. In a common method, the office manager, who is generally valued and trusted beyond reason, pockets office receipts. These may be cash payments from patients that the office manager writes off.

Read the Rest of Part 1 on Dr. Bicuspid



Scams played on dentists: Part 2 -- Consultants and practice brokers

By Michael W. Davis, DDS, contributing writer

August 6, 2014 -- In the second of a three-part series, Michael W. Davis, DDS, details some of the ways dentists and dental offices are vulnerable to scams. This part discusses unethical practice management consultants and practice brokers.

Who doesn't receive via email, fax, telephone, or mail a solicitation from a dental practice consultant on a weekly basis? As a young doctor, I saw many that would promise the "Million Dollar Practice." Today, those figures have grown to the $8 million, $10 million, or $12 million practice. The promises are ridiculously laughable. As the man once said, "If it seems too good to be true, it is."

A number of big-name consultants spend a great deal of time with legal actions brought forth from dissatisfied doctor clients. Using a boilerplate formula from a household name consultant has brought many a dental practice to bankruptcy or near bankruptcy. They may also have multiple endorsements from organized dentistry, which today is little more than paid advertising.

Simply because a consultant has exposure, with prolific publication of consulting articles, does not ensure his or her competency to manage the unique specifics of your dental office.

Here are some suggestions.

  1. Do a background check on former doctor clients who the consultant has served. Do they have philosophies and goals similar to yours? What were the specific objectives? Were goals met?

Read the Rest of Part II on Dr. Bicuspid