When Dentists Commit Medicaid Fraud, It’s Not All Smiles

The national Medicaid program is a social healthcare program for families and individuals with low income and limited resources. It is jointly funded by the federal government and the states and is the largest source of funding for health services for low-income Americans.

Under the Medicaid program, states are required to provide dental benefits to children, but each individual state may choose whether to provide dental benefits to adults. While federal and state Medicaid funding often is strapped, there is a growing trend of dentists who manipulate the Medicaid system with false claims in order to increase their income.

For example, in a recent case in Missouri, a group of dentists prescribed to children an orthodontic device, known as Ortho-Tain, that is designed to straighten teeth without braces and is not covered by Medicaid. The dentists, however, falsely certified to Medicaid that each prescribed appliance was a speech-aid prosthesis, which would be covered by Medicaid. The dentists billed Medicaid $695 per appliance (the maximum allowed) over a 5 year period.

The lead dentist in the scheme was charged criminally for Medicaid fraud and pled guilty. In his plea, the dentist admitted that Ortho-Tain was not a speech aid prosthesis and, therefore, needed to be pre-certified by Medicaid for approval and billed using a different orthodontic code. The dentist knew his patients did not qualify for Medicaid for the Ortho-Tain device and submitted the false claims anyway. The dentist will be sentenced in the coming months and is subject to a sentence of up to 10 years in federal prison without parole.

While this was a criminal case, cases involving Medicare or Medicaid fraud often are followed by a civil case or government-regulatory investigation. Likewise, it is also common for cases filed by qui tam whistleblowers to be investigated by the U.S. Attorney’s Office for both civil and criminal purposes.

If you or someone you know has witnessed Medicare or Medicaid fraud by a dentist, oral surgeon, or orthodontist, contact the qui tam lawyers at Rabin Kammerer Johnson for a free consultation at 877-915-4040.