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?”.

 Conclusion
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.


Wednesday, November 05, 2014

Nearly 100 Indiana dentists found to have questionable billing in HHS Report

Capture

 

Feds: 95 Indiana dental providers have questionable billing

Marisa Kwiatkowski, marisa.kwiatkowski@indystar.com 7:01 a.m. EST November 5, 2014

A federal report released Wednesday found questionable billing practices by 94 dentists and one oral surgeon who treat Indiana children on Medicaid.

Those providers received about $30.5 million in government funds for pediatric dental services, according to the report by the U.S. Department of Health and Human Services’ Office of Inspector General.

Federal officials did not cite specific dentists or clinics in the report, but said the findings demonstrate the need for improved oversight of pediatric dental services paid by Medicaid in Indiana.

Officials studied claims paid by Medicaid in 2012 for such dental services and focused on those who served more than 50 children.

Two-thirds of the dentists cited in the report for questionable billing worked for four dental chains. Three of those chains have been the target of state and federal investigations, according to the report.

Read the entire story here

 

 

HHS Report - Indiana Questionable Pediatric Dental Mediciad Billing November 2014

 

Monday, October 27, 2014

Torture Chambers-with free sweatshirt!

It’s 10 years later.

Excerpt from Uncle John's Bathroom Reader-The World's Gone Crazy (May 2010)
TORTURE CHAMBERS--WITH FREE SWEATSHIRT:

In 2004 twenty dentists in California Central Valley area were accused of defrauding the state Medi-Cal health system of $4.5 million by performing unnecessary—and cruel—dental work. To lure low-income patients, these dentists went to homeless shelters, shopping malls, and schools and offered gift certificates, sweat-shirts and electric toothbrushes.  The patients were then given unnecessary dental work, including root canal.  Some dentists were accused of holding crying children down in the dental chair and using straps on elderly patients.  Then they charged outlandish amounts of money for the work and sent the bills to Medi-Cal.  "In every single one of the 300 files we checked, " said an official, "we found fraud.".  In 2008 the two lead dentists in the scam were sentenced to one year in jail and forced to repay $3M.

 

Torture Chambers and a sweatshirt-excerpt from Uncle John's Bathroom Reader-The World's Gone Crazy-May 2010

 

 

 

 

 

 

 

 


The Dentist’s were:

1. Steve Sangmoon Ahn, 41, of Fullerton
2. Hoon Young Chang, 34, of Anaheim Hills
3. Wen Hsiang Chou, 46, of Alhambra
4. Anthony Halili Galvan, 42, of Dublin
5. Eduardo Sabater Gerodias, 36, of Modesto
6. http://www.dbc.ca.gov/public/dds46799_20060907_dec.pdf 37, of Reseda
7. Keith Yoshikuzu Komaki, 58, of Anaheim
8. Ricky Hung-Tak Lam, 35, of Antioch
9. Rahim Mesbah, 49, of Modesto
10.Duc Sy Nguyen, 33, of Milpitas
11.Sang-Hyuk "Sean" Park, 35, of Merced
12.Luis Alexandrino Pinto, 42, of Irvine
13.Rodolfo Poscablo Ravanera, 57, of Oakland  DEAD
14.Behnam Rostami, 48, of Stockton
15.Williams Defreitas Saraiva, 60, of Irvine
16.Seyed Mohamed Tarifard, 58, of Stockton
17.Tri Duy Vu, 32, of Sunnyvale
18.Shiyu Wang,44 of Alameda
19.Faruk Cenap Yetek, 43, of Pleasant Hill
20.Kyon Maung Teo, 42, Hatch Dental clinics in Ceres, Stockton and Modesto

Attorney General Charges Central Valley Dentist and 20 Others in $4.5 Million Medi-Cal Fraud Scheme

October 2008-

Intentional Harm as Dentists profiteer in California

December 5, 2008

California Dental Board Decision regarding Dr. Kyon Maung Teo

Thursday, October 16, 2014

Small Smiles now under direction of former Small Smiles Employee gone rogue: Ron Montano, Hero Dental Management and Adventure Dental and Vision.

If you are seeing more commercials for Adventure Dental and Vision lately it’s not an accident.  Check the phone number, it’s actually Small Smiles clinics.

Hero Dental Management is the new FORBA/Church Street Dental Management/CSHM and many Small Smiles clinics are now under the umbrella of Hero taking the name Adventure Dental and Vision.

Ron Montano broke out on his own and created Hero Dental Management and clinics operating as Adventure Dental just like Drs. Pham and Tran broke away and created NCDR and Kool Smiles.

Tuesday, September 30, 2014

It’s September 30, 2014

Today is the deadline for CSHM to have divested in all of the Small Smiles clinics.  Have they? Have the simply rebranded?

I don’t know.

Monday, September 29, 2014

DD Marketing, Small Smiles Dental Centers: Double dipping?

In 2003 while dental centers owned by the DeRose family were coming under fire for abusive dental treatment of children, by North Carolina investigative reporter, Stuart Watson, South Carolina was gearing up to  not only allow the clinics to operate in the state, but also let the taxpayers foot the bill for the clinics advertising while it lured children to the torture chambers. School districts signed contracts with DD Marketing agreeing to pay them $48K per year plus 20% commission, and DD Marketing would work their hardest to recruit advertisers to assist in generating income for the schools.  By August 2003 the South Carolina school district was locked in a lengthy and complicated contract with DD Marketing.

First recruited advertiser, was Children’s Medicaid Dental Clinics—Small Smiles Dental Centers as we know it—who contracted to pay the school district $10K so they could hang 2 x 5 foot banners in schools and adorn school vehicles with signage.  In return the school district paid DD Marketing $6K for that first advertiser—$4K monthly fee plus $2K commission.


Problem? DD Marketing and Children’s Medicaid Dental Centers, were owned by the same people. Stink? Yes! Multiply that by nearly 200 districts across the county and that’s nearly $1Mil in additional revenue and it stinks way past “high heaven”.

Small Smiles Ad Scam

Vending machines were also allowed in the schools of which DD Marketing also reaped a hefty profit; need those to keep the patient flow up at the clinics, right?
Double dipping? More like Quadruple dipping in my opinion.

Schools Welcome Ads, March 5, 2003

“Pueblo, Colorado-based DD Marketing will receive $4,000 a month to recruit business and 20 percent of the proceeds generated for the district.”
CHEROKEE COUNTY SCHOOL DISTRICT NO. 1 Minutes, March 11, 2003
“Mr. Paige Carlton - Tompkins, Kinard & Associates, an advertising and consulting service whose regional office is located in Columbia, South Carolina; Mr. Dan DeRose - President of DD Marketing, Inc.; and Mr. Mike Roumph - Vice President of DD Marketing, Inc. (DDM); made a marketing presentation to trustees. The company is located in Pueblo, Colorado and is a consulting service for marketing and advertising that works to meet the specific needs of government, public and private agencies, political organizations, corporations and individuals by developing a multi-faceted campaign to generate revenue for the client. The firm provides detailed research and analysis to develop partnerships for clients such as education, economic development, transportation, energy and natural resources, and environmental regulations.

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: MWDavisDDS@comcast.net

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.

Monday, September 15, 2014

Small Smiles Dental Centers: Countdown to Exclusion is Business as Usual

As the days count down to CSHM Exclusion from Medicaid becomes effective on September 30, 2014 I’m getting more and more reports that “lead” dentists of the individual Small Smiles clinics are “purchasing” their respective clinics. (Colorado clinics, New Mexico clinics and Indiana clinics just to name a few that have been reported.)

Since January 2010 the clinics have been visited by monitors and care continued decline to the point they were Excluded from Medicaid participation as of September 30.  Several reports from monitors found care unacceptable as dentists and staff continued to deliver substandard care as reported in the bipartisan Senate Report.

How can leaving same dentists in place improve the situation?

It is more than highly likely dentists who have been delivering the unacceptable care and treatment for years will continue with business as usual and children are still at great risk and taxpayers will continue to be fleeced.

The risk may be greater than ever.

Anyone think care will be better?

The dentists and clinic operations may not have the watchful eye of the government monitors or be bound by any Corporate Integrity Agreement with HHS-OIG.  That Agreement was made with CSHM, the management company of the Small Smiles dental centers. (another pitfall of corporate owned dentistry)

Monday, September 08, 2014

Pediatric Dental Care for General Public verses Dental Care for the Underserved

Dentists, lawmakers and regulators should be ashamed for condoning, supporting and fostering such disparity in dental care for children in America.  They should all be ashamed and disgusted! I certainly am!

General Public Dental Care for children v care for underserved

Saturday, September 06, 2014

Small Smiles in Colorado Springs, Colorado is now Front Range Smiles, PLLC–Dr. Nathaniel Conrad Cejka

The can move down the street, they can change their name to Front Range Smiles, but as long as the same employees and same lead dentist work there it’s a Small Smiles; “by any other name as they say.”

The CSHM statement in March 2014 after it was announced Small Smiles Dental Centers were Excluded from Medicaid was correct; it has no effect on the clinics whatsoever. Business as usual and now, NO oversight!

I see little difference now than when Jodi Kuhn “purchased” the clinic for $100 from previous fake owner dentist, Randall Ellis in 2013. Only difference I see is they took the time to create a new business entity and slap another dentist’s name on the documents and moved down the road. BTW, this move to the new address was in the works BEFORE the Exclusion letter was announced.  Someone should get a look see at the lease.

(Hasn’t Kuhn purchased two or three of the clinics again? Wonder what new and improved name she is using these days and how much she paid for them when she bought them from herself?)

Frankly I smell a bunch of hoodlums from Pueblo involved. Am I alone?  It’s no secret I’ve believed for a very long time the Pueblo bunch very much still has their hand in the operations of the dental clinics in Colorado. There is more evidence supporting that hypothesis than disproving it, that’s for certain.

 

Front Range Smiles, PLLC f/n/a Small Smiles

 

Don’t believe Dr. Nathaniel Conrad Cejka is a Small Smiles Dentist? He is listed as a provider at each of their Colorado clinics in Delta Dental provider book dated April 2014. (You will find other “owner dentist” Jodi Kuhn listed right along with him).

Small Smiles - Dr. Nathaniel Cejka    Small Smiles – Dr. Jodi Kuhn
1404 Cejka-delta dental-aurora 1404 delta dental-jodi kuhn-aurora
1404 Cejka-delta dental-smile high 1404 delta dental-jodi kuhn-smile high
1404 Cejka-delta dental-springs 1404 delta dental-jodi kuhn-colorado springs
1404 Cejka-delta dental-thornton 1404 delta dental-jodi kuhn-thornton