Mass. dentist accused of $250K in Medicare fraud
December 12, 2011 -- SmileCenter, a dental office in Plymouth, MA, received at least $253,519 in unallowable reimbursements from MassHealth, the state's Medicaid program, according to the state auditor's office.
Most of the billing was for orthodontic services performed by a dentist who did not possess the required accreditation, State Auditor Suzanne Bump stated in a press release.
According to MassHealth regulations, dentists who practice orthodontics must complete a minimum of two years of training in a specialized program administered by the ADA.
SmileCenter's sole dentist, who is also its sole proprietor, did not complete such a program, but still billed and received $201,509 from MassHealth for orthodontic services.
As a result of the investigation, MassHealth will terminate SmileCenter's specialty as an orthodontic practice, transfer its members for treatment to other dentists, and seek restitution, according to the state auditor.
The review of the $1.2 million SmileCenter received from MassHealth for dental services between 2007 and 2010 cited a pervasive pattern of excessive treatments, duplicative payments, and payments for services that were possibly never performed, officials said.
Due to lack of control, SmileCenter was able to bill MassHealth for more than $40,000 in unallowable fluoride treatments, oral examinations, and pain treatments that violated rules. In one example, SmileCenter performed 27 fluoride treatments in a 24-month period for a single member who was caries-free. According to guidelines set by the American Academy of Pediatric Dentistry, SmileCenter should have provided no more than four fluoride treatments. In a sample of 30 MassHealth members, 61% of the 272 claims for fluoride treatment were unallowable, totaling $4,008.
The investigation also revealed 35 instances of SmileCenter billing twice for the same procedure.
The auditor recommended that MassHealth recover the identified money and called on SmileCenter to reform their billing procedures relative to MassHealth.
The audit is the latest review of the Medicaid program, which now accounts for one-third of the entire state budget. In fiscal year 2011, MassHealth paid a total of $267 million in dental claims.
